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) 

Graduation: Catching Up at Last

If the road to hell is lined with good intentions, I was well on my way yesterday, having fully intended to write and yet finding my brain utterly exhausted from the events of Saturday. To say graduation was memorable is so far from the truth as to almost be a lie: it was more like a dream and I was living it. Truthfully, though, Sunday morning I was almost certain it had been precisely that. It wasn't until I took the dogs out for their walk and looked in the car for my sunglasses, that I noticed the box my robes had come in. "Well, guys," I said, "I guess I wasn't dreaming, after all."

It sure felt like it and I'm sure it stems from the fact that I've never had any absolute assurance I'd make it this far. Not that I was a doubter, like Hero Boy in The Polar Express, who wanted proof of the existence of Santa Claus before committing himself to believing. I knew in my "heart of hearts," as my mother used to say, the obstacles and difficulties I'd encountered along the way would only make graduation sweeter. But still in all, our demons have a tendency to haunt us in the darkness of night, especially before exams, whispering wickedly, You're a fraud -- you're in over your head -- if you were meant to do this, it would be easier. 

Martin Luther, the 15th century church reformer, said the Devil was exquisitely sensitive to humor and the trick to banishing him lay in laughing in his face. I've wondered if that's a skill we must learn to employ and if so, medical school has given me a lot of practice.I was definitely laughing Saturday, along with my classmates, when my best friend placed my doctoral hood round my neck backwards. It wasn't intentional; he'd been handed it backwards and the rest will go down in Hooding Ceremony history. But what better way to thumb my nose at all those demons?

All the same, there is a tender, albeit bitter sweetness to graduation, that comes from having to hold off being called "doctor" a bit longer. I've gone through the exercises and taken my Osteopathic Medical Oath, but with rotations yet to complete, I won't hold my degree in hand until later this year. Like a teenager who is neither child nor adult, I'm in a liminal space. I'm no longer entirely a student, but then again, I'm not entirely a doctor. Thankfully, however, I'm closer to one than the other and the confidence I've gained from standing shoulder to shoulder with my graduating classmates, pledging my life, loyalty, and sacred honor to the practice of medicine and the care of patients, will see me through.  

To my beloved entering classmates, nearly all of whom preceded my graduation in 2010, I can truly say, look behind you, the footsteps you've been hearing are mine. I'm catching up at last.        

(Photo of the author and graduating classmate and friend Dr. Joseph Scott, copyright 2012, all rights reserved) 

Internal Medicine: One Week Down

Third year clinical rotations are great opportunities to discover what you don't know. For instance, I thought, like many other well-intentioned medical students, that "internal medicine" was concerned with illness conditions too severe for the family practitioner to manage. You referred to an internist when the waters were swirling and you didn't want your patient going under a third time. Oops, there goes another of my misconceptions. Internal medicine means simply the practice of adult medicine. Family docs treat families, pediatricians are all about kids, OB/GYN's manage women and babies, and psychiatrists -- well, they try to keep everything on an even keel, how's that? Except family docs treat adults and pediatricians may treat young adults, so that throws simplicity out the window.

Once upon a time, internal medicine would have been my first rotation, but as it stands, I've spent time in a rural family practice (loved it), pediatrics (really loved that), and psychiatry ("you make me feel like dancing, I wanna dance the night away" ~ Leo Sayer). I've also done a stint in osteopathic manipulative medicine (a wonderful experience) which, for us DO types, ties pretty much everything together. I guess I've come back to where I might have started.

So, what kinds of things can you encounter in IM? The same ones you do in kids, the kids are just bigger, is all. And there are some you don't as much. Heart disease is more common in adults, hypertension and the effects of lifestyle -- alcohol, drugs, overwork. Cancer, clearly something the world would be far better off without, is there, too. Adults have responsibilities and being sick means being under stress, which only complicates the healing process. Internal medicine (and pediatrics and family medicine and...) is one part physical and two parts psychological and spiritual. People who are sick need hope. Come to think of it, so do the rest of us.

Where do I see my assigned patients? Since this is a hospital-based rotation, the inpatient unit, ICU, and rehab. If one of them is undergoing a procedure, I'll follow along to observe and learn and provide moral support. You see, students possess in relative abundance, something the residents and attending physicians have in short supply, i.e. time. We also have some measure of freedom about how we choose to use it. Talking to patients, forming a relationship, is one of the best uses of our time. If you've never been a patient yourself, or even if, like me, you have, this is a chance to find out what it's like for them to be in their shoes. Moral support may seem small in comparison to writing treatment orders, but from the patient's perspective, it's huge.

It's also important to spend some of that "abundance" talking to nurses and not simply about the patients you have in common. Nurses know things, things you want (and need) to know, too. When you're trying your heart out to do well, to develop some measure of competence, and to avoid doing anything that should never be done in the first place, having staff members who watch your back is priceless. Besides, it makes life more pleasant and we can all use some of that.

I mentioned in a previous post how I wanted to learn more psychiatry in the course of learning internal medicine. One week down, I think it's impossible not to. Osteopathic physicians are intent upon finding the person in the midst of their illness. Patients aren't problems to be solved, though their condition may pose many, nor are they incidental to what we do like a spot on an X-Ray that turns out to be a clasp on a hospital gown. They're the why for all of medicine and any occasion to work them teaches something about why they tick the way they do. I suppose you could say I'm learning how to keep them ticking as healthily and hopefully, as long as they can, before the clock strikes twelve.


(Public Domain image of Downtown Bangor, ME via Wikipedia)

You Only Live Once

To be completely honest, I've rocked back and forth between remiss and downright absent-without-leave more often than not these past three weeks. And for that I sincerely apologize. The intellectual drain of rotations is as severe as the physical strain and it's getting so that weekends are my only time to contemplate writing. I do fantasize about it at other times, but usually when something cute, wonderful, or memorable has occurred, by the time I'm home, my mind is lucky if it can say, "Huh?"

Now, this condition is not uncommon. Most of my friends are tap dancing around their mid to late 20s and when one of them comes home, so slow and heavy are the footfalls up the stairs, you'd think they were summiting Everest. Rotations are tough and residency is tougher. I've got pals here from my entering class in psychiatry, surgery, and internal medicine and they're the pudding's proof. Tired R All of Us.

But there's more than that and I'm thoroughly enjoying the dormitory environment here in the "osteopathic ghetto," as I've christened it, since the apartments in our converted house are occupied by my classmates. Barely a knock before opening the door to shout is about as polite as we get.

About week ago, a few of us spent Friday evening playing Guitar Hero, a serious challenge, I discovered, for those of us who really know what to do with a six string. The game is about counting but we want to get down with the rhythm and be "big rock stars and live in hilltop houses, drivin' fifteen cars," even if the audience is only electronic and fame and fortune as fleeting as a flip of the switch.

Oh yeah, that's right, you read it here first, Beggar plays Guitar Hero and will again -- first chance he gets. I may have a hard time getting my brain to think in the evenings, but chasing that neon rainbow? Hey, you only live once.


(Creative Commons image by Kermitz72 via Flickr; I Wanne Be a Rock Star, words and music by Nickleback)

A Word of Thanks

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

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

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

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

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

The Last Day of My First Rotation

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

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

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

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


(GNU Free Documentation image via Wikipedia)

Wrappijng Up My First Rotation

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

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

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

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


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

Making a Difference

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

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

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

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


(Photo copyright 2011 by the author)

Osteopathic Psychiatry: It's Time to Smell the Roses

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

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

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

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

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

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

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

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

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

(A follow-up essay may be found here)


(Public Domain image via Wikipedia)
 

Rotations: Day Two

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

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

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

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


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

Rotations: The First Day

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

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

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

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

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


(GNU Free Documentation image via Wikipedia)

When Lady Luck Turns Her Back On You

Well, at long last I'm on the brink of clinical rotations, my first being scheduled to begin next week. Four weeks of osteopathic manipulative medicine in private practice followed by four more of community medicine at a different location, and so it goes, one after the other. I will most certainly graduate on time, in the sense that I'll walk across the stage with my graduating class, knowing members of my entering class will be in the audience. They've had to wait a long time for me to join them and that moment will represent a triumph for us all.

However, since I'm beginning rotations later in the academic year, this means I'll have to complete a few after graduation. As a result, while I'll go through the ceremony, actually completing medical school will have to wait a bit. It happens; I'm not the first nor will I be the last. For some students, the art of medical school begins at the point where their education departs from the well-beaten path. Incidentally, this is also the point at which medical school becomes, or at least ought to become, a character-building experience. Whether it does so or not depends on the person, as does most everything in life. There's nothing automatic and there are no guarantees.

One thing happens or another and the first thing you know, your scheduled graduation is postponed by a year and what your fellows will accomplish in four, you'll do in five. Then you try to run the blockade of board exams and another year gets tacked on for good measure. Finally you find a way through that smokescreen and begin rotations. That's where I am now.

The extent to which you can call any of this "character building" seems like a joke when it's coming down on top of you. Your only goal is to survive. If you can manage it with a modicum of self-esteem intact, you've come a long way, baby. You tell yourself every hurdle overcome is one closer to getting you where you wanted to be in the first place. And that's not a lie. Even better, it gradually dawns on you that every one has the potential to bring you closer to others when their path diverges in the wood and circumstances decide which fork they're going to take, whether they like it or not.

If there's anything I've gotten from my own experience it's the opportunity to be grateful for those connections. As you may have guessed or long suspected, I'm not one of those who prefers the company of persons who have no idea what it's like to bang your head against a wall to that of those who do. I like people who've faced their demons and have the scars to prove it. They have a depth which makes me feel strengthened and enlivened from being in their presence. There's a lot of experiences I've felt I could have done without, but in the long run, the fact that they've created friendships with people like I've just described, makes me realize there are worse things than having Lady Luck turn her back on you.


(Creative Commons image entitled "Lady Luck" by Emily Raw via Flickr)

All I Want for Christmas

Well, I’m back on my patio for two more nights and then it’s off to Maine. It was odd, driving back to Champaign, Illinois this evening, knowing I had little more to do than write, pack, and say goodbye to new friends. 

Now that my exam is finished, there’s really no reason to be here, but I still feel rather like I’m leaving home. For one thing, this apartment has been home for eight weeks that have seemed more like eight months. I have an idea I’m going to need several posts to sort it all out.

In the meantime, I’d like to begin tonight by offering a sincere word of thanks to everyone who has stopped by these past weeks to see if I’d posted anything new or if not, to read something old. It was very affirming and truthfully, I took it as supportive, and have appreciated it very much. As much as I've wanted to write and thought about it, as my exam date drew closer I could do little else but study.

It wasn't exactly what you'd call a strategy, but I think it was a sound one, even though results won't be available until mid-December. As tortuous as that sounds, it’s the fate of all medical students, whether they take the osteopathic Comlex or the USMLE. And no matter how well you think or hope you may have done, there is really no way to know with any certainty until scores are mailed. Every test has easy questions, harder ones, and those that seem impossible, so the outcome is always up in the air.

What I can say, in retrospect, is I felt better prepared than ever before. A very good friend from my entering class, who is now a family medicine resident in central Maine, has told me he knew he was ready for boards when he couldn’t stand to open another book. Two days ago I can safely say, I knew exactly what he meant. I’d taken a formal practice exam, done well, and despite being so consumed with study that even this morning I was looking over viral infections once more, I was eager to be done.

My father would say, it’s all over but the shouting, and I hope it's exactly that way. I’m so ready to begin rotations, to see real patients in a real healthcare setting, to make mistakes and learn all that I don’t know. Passing will be the best thing and Santa, if you’re reading this, just know that's about all I want for Christmas this year.

(GNU Free Documentation image via Wikipedia)

Medical Boards and More: A Father's Perspective

Two days away from my original "second date" with our osteopathic medical board exams, it's also Father's Day and I'm wondering what my dad would have to say. Knowing him (and me), probably several things (like father, like son), but I have no doubt he'd begin with, "Don't worry, I've prayed about it and you're going to do fine."

My father wasn't always "religious," you know. If he were here to tell you, he'd admit freely he had little use for religion and even less tolerance for ministers as a younger man. But it wasn't age that changed him, it was the awareness that the vertical dimension to life is as significant as the horizontal one. After my mother died and he was diagnosed with pre-leukemia, his faith grew immensely, so if he said he prayed for you and you were going to be all right, he was certain even if you weren't.

After providing encouragement (encourage was his favorite word) and reassurance, he'd say, "Now, that doesn't mean you don't need to buckle down, just don't make yourself sick in the process. Have some fun, even if it's only for an hour a day." From someone who rarely practiced the principles of a balanced life, this alone is huge. He learned a lot from his illness, things he wished he'd known years before, but he also knew regret could be poisonous, so he focused on the present and lived for the future.

As far as my decision to push back my exam date an additional thirty days to reinforce my preparation is concerned, I can hear him: "Don't beat yourself up. You took a long, hard look at where you were, where you wanted to be, and said, 'I'm not quite ready.' Better over-prepared than under. Being honest with yourself instead of covering up the truth for the sake of pride or what other people think, is the first step toward getting things right." I couldn't have said it any better.

Finally, he'd remind me why I got into medicine. "I knew all along you were cut out for the ministry, just not the pastorate or at least not forever, but you had to sort that out for yourself. Some things no one can do for us. Not even fathers and sometimes, especially not fathers; it's all part of growing up. You found your place -- you were my 'doctor' when I was on my death bed, remember? So go ahead, fulfill your calling. Be the person you were meant to be."

My father will have been ten years gone this November 5th, but many of the words I've put in his mouth he actually said at one time or another, in one way or another. I was watching the movie Transformers the other evening and in the scene where the main character's father wishes to buy his son a clunker for his first car, I was reminded of the way my father handled a similar situation. I'd just got home one afternoon -- in November, interestingly enough -- from college when he took me to a local dealership saying he'd found a car, a 1966 Mustang that I've written about previously (see 10/13/09).

My point is, dad consistently remembered what it was like to be me, even when I managed to forget. He taught me that stability is a value to be nurtured in myself and discovered in others. He also taught me nothing can replace it -- not looks, money, intelligence or influence. Someone who can be relied on in a pinch is worth more than a million promises from someone who never shows up. And dad always showed up. So, today I'm remembering the stability and encouragement he'd pass along as easily as one might take keys from their pocket, as though he had a pile stashed somewhere and was ready to hand it over without a second thought.

Happy Father's Day.


(Creative Commons image by loswl via Flickr)

Graduation: Wishing to Remember

Well, as my father used to say, it's all over but the shouting. The majority of members of my entering class are now, and ever will be, Doctors of Osteopathic Medicine. For all of us who were present at graduation, it was truly a triumph -- everything we've shared and suffered together has paid off in spades. It's hard to know where to begin this morning, because at one point yesterday I thought I must have gathered enough material for a week's worth of posts, and it may just turn out that way.

Two things, however, are perched at the forefront of my mind and it's probably best to start with them. One advantage of being an usher at these ceremonies is, you usually have your selection of the best seats. In my case, I was able to choose one right next to the steps that led onto the stage where hooding was to take place. As a result, I had the privilege of shaking hands with every one of my classmates as they passed by.

With each, memories of our first year came unbidden. Sitting in lecture with a future colleague who initially wanted to be a family doctor. Since then, he's come to love psychiatry with a passion that rivals mine, and we've formed a warm and lasting bond. Three with whom I spent long hours bent over a cadaver and so many others whom I've touched and who have touched me in OMM lab. In some cases, we cast aside formality like crumpled paper and hugged and kissed freely. I wouldn't have been anywhere else in the world.

Near the end of the ceremony, my classmates stood to take their osteopathic oath and I stood with them off to the side of the auditorium. I couldn't have sat at a moment like this, my legs wouldn't have permitted it. We've gone through too much, shoulder to shoulder, to merely be an observer. Like Stephen Hopkins, delegate from Rhode Island at the Continental Congress, who wished to remember the faces of the signers of the Declaration of Independence, I wanted to see the faces of my friends as they spoke. I, too, wished to remember.

As family members gathered round during the reception that followed and I was introduced to parents and siblings, it felt unusually familiar, almost as though I was meeting members of my own family for the first time. And it only makes sense, since coming to medical school for me, has been like coming home. Later, as I walked to my car, one of my classmates passed with his fiance, and he waved a roll of nondescript cardboard in the air that could have been photographs or a movie poster, but it wasn't. "There's one of these with your name on it, don't forget," he said with a grin.

It was his diploma and he's right, there is.


(Photo by the author, copyright 2010)

An Intimate Conversation with the Adam's Apple

It's doubtful anyone would seriously use cricothyroidotomy in a song lyric -- I guess we can't have everything. Still in all, there is such a thing as poetic justice, since a cricothyroidotomy can save a life by creating an airway when it's impossible to do so by intubating, i.e. inserting a breathing tube into a patient's trachea. This is what handsome, daring TV docs do with a switch blade borrowed from a gang member, sterilizing both the knife and their patient's neck with a splash from a bottle of Jack Daniels another gang banger conveniently has in his pocket.

If you feel around the thyroid cartilage located midway from your chin and the base of your neck, you'll feel a little peak. Move your fingertip downward and you'll feel a little space followed by another ridge below that. The space is precisely where Dr. Young and Handsome makes his incision, following it by inserting the barrel of a pen, a hollow coffee stirrer, or whatever the prop guys think will make women swoon from week to week. It's an intimate conversation with the Adam's Apple.

Anyway, this what I learned to do today -- perform a cricothyroidotomy. How to make women swoon was apparently taught in another group and naturally, I missed out on that one. Nevertheless, it was exciting for me to learn a procedure because, for one thing, I know very few of them and for another, in psychiatry we rarely do them. Surgeons get scalpels, hemostats, clamps, and all kinds of neat things to work with, but in psychiatry, our primary tool is ourselves.

True, we have medications, but unlike those who are new to the field and presume psychiatric illness can be cured with a swift turn of the pen on the ever-ready prescription pad, veterans know psychiatry to be, probably, the most interpersonal of medical specialties. We can't repair broken hearts with a new valve like our cardiothoracic surgical counterparts. And even though our incisions are bloodless, they cut deeply, and healing takes time. Lots of time and lots of patience.

Psychiatry is still medicine, however, and particularly so in osteopathic medicine where we take the mind-body interface seriously. The challenge is to maintain an awareness of the presence of one while treating the other. This is why I enjoy learning the skills of physical medicine -- they work on the larger context of the organ I know the best and frequently realize I understand the least. People are incredibly complicated and yet, as the Psalmist writes, "fearfully and wonderfully made." There's no end to what you can learn and every day brings forth something new.


(Psalm 139:14; Creative Commons image via Wikipedia)

OMM: Touching the Picture and the Frame

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

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

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

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

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

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OMM: A Rite of Passage

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

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

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

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

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


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

Is There an Osteopath in the House?

So, tonight, I'm off to dancing lessons and I have to tell you, I feel a little self-conscious about it. Now, to be sure, anyone else who's going to be there (aside from the instructors) knows about as much as I do, which is next to nothing, so I'm in good company. Ordinarily, I'd be particularly nervous about learning something that involves muscle coordination, but medical school has actually helped in that regard.

As osteopathic students, we're taught techniques that fall under the rubric of Osteopathic Manipulative Medicine, which means we work with the body to diagnose and treat certain kinds of illness conditions. We learn how to be sensitive to changes in muscle, skin, and the various other tissues that make up the body, and how they influence one another. It's just one more tool in the kit to help us help patients, but it's also helped me gain a sense of confidence about using my hands in ways I'd never done previously.

As a result, I don't think feeling uncoordinated is going to be a major problem this evening, though one never knows. Placing your hands in the proper position to correct a muscle spasm is one thing, getting your feet to cooperate with dance steps is, no doubt, another. This is one time when a little OMM from one of my classmates to help me relax might be what the doctor ordered.

In lieu of that, I'll try to remember to breath and avoid injuring anyone's phalanges (the bones in the feet that correspond to the fingers). On second thought, I've got an idea: why not simply get my head examined? I mean, I've gotten through life thus far without having to trip the light fantastic (much), do I really want to alter my track record now? I know, stop making excuses, I'll be fine. You're probably right. I suppose the worst that can happen is someone will step on my toes and then I'll really need OMM. I'll let you know how it goes tomorrow.

In the meantime, just in case, is there an osteopath in the house?


(Creative Commons image by William Hamon (aka Ewns) via Flickr)

A Blessing in Disguise

Every now and then, the student loans really bug me. Not that I mind paying for an education -- someone has to do it. Nor is it the actual cost because a good education ought to be more costly. It's that I've had to pay to get the kind of education I've received over time. And it's at that point I try to stop grousing, because not only has it been my choice, it's been a blessing in disguise.

For example, as a result of having had to study philosophy, I've learned there is more than one way to ask a question. I've also learned the answers often depend less on the question itself than the disposition of the questioner. In other words, someone predisposed to see life only in terms of what can be demonstrated and empirically evaluated, is not going to be very satisfied by answers that defy quantification. But that limits their understanding because measurement depends on the tools you use and not everything can be measured by the same standard.

The anthropologist, Claude Levi-Strauss said, "The scientist is not a person who gives the right answers, s/he is one who asks the right questions." Somewhere along the line I think we've gotten away from this. I don't know if it was the threat of the Bomb and the end of the world as we know it or just the inherent ambiguity of life, but instead of looking to science to help us refine the questions, we seem to expect it to provide all the answers. And when it doesn't, instead of searching for another way of addressing the questions, we treat them as though they were the wrong ones to ask in the first place.

When Andrew Taylor Still, the founder of osteopathic medicine, declared the patient-as-person was an integral unit composed of body, mind, and spirit, he opened Pandora's Box. As long as medicine had only to deal with the body, science alone was more than adequate to the task. But once we decide there is an integrative principle involved we're thrust into the realm of phenomenology. Descartes, the French Enlightenment philosopher who might be regarded as the spiritual father of the scientific method, is a fine guide as long as we're content to misconstrue the nature of reality. Once we open the door to complexity, things change radically.

The true scientist resists approaching every problem as though it was a nail and all that's needed to beat it into submission is a large enough hammer. A person can do a lot of damage with a hammer, if they're not careful. One of my favorite maxims is, "He who has never traveled thinks mother is the only cook." If all we've ever learned is one way to think, we're going to be in big trouble when we run up against a recipe mom never heard of.


(Image via Wikipedia)