Pink Hats 27: Deju Vu

 
Christmas parties in the first two years of medical school tend to be few and far between, or so it was in Jessie's experience. There just wasn't the time. The last week before the holidays was dedicated to exams and if you had time to party, you slept instead. It's tough and everyone knows it.

Actually being able to put on a dress or at least something other than scrubs and spend a social evening -- unless she was on-call -- with her "working family" was one of the perks Jessie loved about Maine Med. She'd gone through residency with several of her classmates and established friendships among the medical staff that she cherished. A rumor circulating about an attending position opening up once her fellowship was complete had been confirmed by the departmental director, and she was considered a shoe-in for the job. Christmas parties at Maine Med promised to be a feature in her life for years to come.

This year was going to be special for a lot of reasons, not the least of which was an occasion to formally announce her engagement to Bob. The truth is, there was scarcely a soul who didn't know already, thanks to the hospital grapevine. Good news travels like wildfire, especially when Halley Henry is the one with a match. Jessie and Bob spent the afternoon following his proposal with the twins and gave Halley the "Go" command she'd been waiting for. By the following Monday, neither one could walk the hospital hallways without running a gauntlet of congratulatory handshakes and hugs.

Fresh powder had fallen in the White Mountains off and on the week before the Saturday evening event, so Bob and Jessie drove up to Pleasant Mountain ski area near Fryeburg. Jessie skied while Bob spent the morning learning the ins and outs of snow boarding. After a few runs alone, she joined him on the beginner's slope.

"Why, if it isn't Shawn White!" she said, teasingly. "Can I have your autograph, pretty please?"

"Baby, you can have my autograph and anything else you want. I am footloose, fancy free, and all yours!"

She laughed and said, winking, "I can think of a lot of ways to take that."

"I'm sure you can, but this is the bunny slope and that means G rated. With the twins around, you better start getting used to that, Dr. and almost Mrs." he said, winking back.

"Only during the early evening hours -- after they're asleep, anything goes." she said, sidling close and raising her eyebrows.

"I think...I've created...a monster," he said, eyes wide.

"You have no idea. Now come on, you hot snow rider you, show me your stuff!"

Yogi Berra said it, this is like deja-vu all over again.

(Creative Commons image of Shawnee Peak by bobtravis via Flickr)

The White Coat Brigade

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

"Wait a minute, that means me."

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

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

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

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

(Creative Commons image by Kids_Safari2 via Flickr)

Warm Days and Woodchucks

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

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

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

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

(Photo copyright 2014 by the author)
    

Like Walking on Water

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

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

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

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

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

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

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

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

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


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

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)

Doctors and Spirituality: Nothing is Etched in Stone

On the premise one agrees spirituality is important to medicine, as I argued in yesterday's post, that's only where the story begins. There are even more questions to be raised about its management in the clinical setting. For example, who is best qualified to inquire about spirituality and, besides, isn't it an end-of-life issue? What if a patient asks their physician to pray with them and s/he is an atheist? These are real concerns and as a minister on the cusp of medical residency, I'd like to offer a perspective.  

Customarily, religious or spiritual preference is noted in the intake interview and becomes part of a patient's chart. Whoever does the intake should ask, at least generically, about the significance of religion, faith, or spirituality. During times of stress, changes of life, or when treatment decisions can be affected by religious beliefs, it's especially appropriate for the physician to broach the subject. When patients come to the clinic, they anticipate seeing a doctor they know and have come to rely on. The doctor-patient relationship provides an ideal basis for talking about what health or illness means to them, personally. As I define it, such conversations reflect "spirituality" in its most basic sense.  

Naturally, you'd assume spirituality to be an end-of-life concern but it surfaces at other times as well. For instance, couples who have been relatively uninterested in religion often express a desire to reconnect with family religious traditions when a newborn enters the picture. As a first-time pastor, I discovered young children in the home was associated with parents attending church regularly. Family atmosphere, the potential for children to learn moral principles, and social contact with other parents were important factors in the decision to become involved. Midlife is another time when spirituality may take on new significance. The point to remember is, spirituality and relating -- intrapersonally and interpersonally -- go hand in hand, and most of us are best at both while we're still breathing.

The question of qualifications is one that has far less importance for spirituality than the practice of medicine. Doctors are accustomed to referring patients when a specialist would be better qualified to be of help. Spirituality, however, doesn't require technical expertise to be addressed meaningfully. Patients don't expect their physician to be a theologian. What they expect is consideration, respect, and empathy. If we can't provide these qualities, we've got far bigger fish to fry than whether we can explain why bad things happen to good people. And for the record, even ministerial folk have a hard time with that one, if they're honest about it. As long as we stay in touch with our humanity, we've got all the qualifications we'll ever need.

Well, then, what about physicians counseling with integrity when their own convictions concerning spirituality are at odds with patients'? While statistics indicate physicians who are fairly comfortable bringing up spirituality tend to be persons of faith, there's absolutely no reason why this should be considered necessary or even advantageous. For one thing, it's not about what we as physicians believe or disbelieve, anyway. For another, there are a number of potential points of disagreement with patients, including music, politics, caffeine or decaf, none of which require us to alter our convictions to be medically effective. In any case, introducing spirituality into the conversation is never an occasion for us to persuade, convert, or pontificate.

Admittedly, possessing a spiritual orientation may seem helpful, but it can also create problems. The innocent presumption that you know what a patient is talking about since you're able to identify with their experience may result in failing to ask follow-up questions. Conversely, patients may withhold information believing a common experience tells you all you need to know. In situations like these, having no spiritual orientation or one that differs from your patient can be an advantage because it requires us to explain ourselves rather than err by relying on assumptions.

Finally, in the matter of praying with patients, I'm reminded of a wonderful line from the film, Oh, God (1975). John Denver's character asks God (George Burns) if they might just talk now and then, to which God says, "You talk, I'll listen." If a patient should ask their doctor to pray with them, whether or not they are persons of faith, offering to listen reverently while the patient prays is spot on. If they should ask you, as their doctor, to pray on their behalf, there is no harm in gently explaining your convictions should they differ from your patients'. By telling the truth you maintain your integrity and confirm your trustworthiness. Furthermore, your honesty tells your patient that you value them too much as persons to pretend to be someone other than who you are. The result could very well be a much stronger bond between you.

Admittedly, in this essay I haven't gone anywhere near the truly difficult and painful spiritual/ethical issues of blood transfusions and Jehovah's Witnesses, abortion, or faith-based objections to teenage birth control and HPV vaccination. My interest has been on what you might call "bread and butter" spiritual concerns, but demonstrating respect, empathy, and truthfulness is essential in any situation involving religion or spirituality. We struggle, do our best, make mistakes, fall down and get back up, mindful that where spirituality is concerned, nothing is etched in stone. 


(Creative Commons image by john-norris via Flickr)

Why is Spirituality Important to Medicine?

 
That's a good question. Why is it? Well, to try and formulate what I hope will be an equally good answer, we should begin by defining our terms, though I'll tell you right off, precise definitions are elusive. "Spirituality" can suggest devotion to a particular religious tradition, but often as not, it refers to something that has little or nothing to do with organized religion. It may signify a feeling of relatedness to something and/or someone greater than ourselves or express the way a person conceives of their life unfolding. It may describe a personal sense of meaning and purpose or the conviction there is no purpose, that life is a series of random events possessing no more significance or predictability than the numbers drawn in the lottery. "Spirituality" literally can mean almost anything; it all depends on how we use the word.

Sigmund Freud called religion and by extension, spirituality, a "universal obsessive neurosis," inferring it was associated with psychological ill-health. His most famous student, C.G. Jung, disagreed and considered spirituality essential to a patient's well-being. Individuation -- the process of achieving fully conscious self-realization -- could be nurtured by a spiritual orientation as well as psychotherapy. But instead of relying on the doctor and patient relationship, spirituality activates archetypal images residing in the unconscious that enable us to feel grounded and genuinely connected with the deepest aspects of ourselves, a process some call "soul work." Unlike Freud, it wasn't the practice of spirituality that troubled Jung; it was its neglect that created problems requiring psychiatric help.
 
Jung gave considerable attention to Christian images and theology in the development of Depth Psychology, but he also drew on other forms of spiritual expression, including Hinduism, Islam, and the study of alchemy. In the I Ching, for instance, Jung discovered a useful instrument for revealing his own unconscious motivations. He regarded the symbols that recur throughout the I Ching, religion and mysticism as comprehensible images of a mature and fully integrated self.

If we think of spirituality, therefore, as the expression of a powerful desire or need that, when adequately addressed, leads to a feeling of wholeness, we can begin to let go the notion that spirituality must be opposed to science and reason. True, spirituality is irrational in the sense that it's an intuitive process, but irrational doesn't equate with anti-rational. It simply means spirituality "knows" in a way that sidesteps reason or logic. We call this relying on "flashes of insight."

You could say, intuition operates like saltatory conduction in the brain and spinal cord. Some nerves, particularly the longest ones, are wound about with a substance called myelin, making them look like a string of hotdogs placed end to end. An electrical signal travels along a nerve by leaping between the spaces between one "bun" and the next until it reaches its target. This type of signaling is much faster than the stepwise transmission employed by nerves that don't require "rapid transit" for communication. Similar cognitive leaps characterize intuition, though we may have to retrace our steps in order to explain to others how we "arrived at the station," so to speak.

Quaker philosopher Elton Trueblood described post-WW II America as "the cut flower generation," and identified its critical existential problem as disconnection from its psycho-spiritual roots. Cut flowers look very nice in a vase, but they don't survive very long that way. Spirituality can be understood as an intuitive effort to find one's place in the universe, to put down roots and establish a sense of belonging.  

Although most people probably think about seeing a doctor or psychiatrist when they feel ill or they've got a problem, medicine is moving toward a model that promotes health and wellness. You take your car to the mechanic for regular maintenance, why wait until you're sick to see your physician about health maintenance? If your doctor is an osteopathic physician or psychiatrist, attending to the mind-body-spirit triad lies at the heart of their medical philosophy. "Spirit," like "spirituality," can mean many things, but as physicians, recognizing and cooperating with its presence means we wish to promote wholeness, a type of wellness that touches a patient through and through, that improves their quality of life and the lives of those around them. 

(Creative Commons image by NA dir via Flickr)

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 70s and couldn't imagine doing it "at my age." 

You'd think I'd have gotten enough practice, after six years, that answering questions like his wouldn't require much reflection. To a certain extent, that's true, except that 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, or 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)

It's the People, Not the Place

If I were to say it's harvest time, you might glance at the calender and wonder if I didn't need some of the chemical dependency treatment I've been trying lately to provide, except for one thing. My hayfield is getting its first buzz-cut of the year. In a couple of months, we'll get one more "cutting," before the growing season settles in for a long winter's nap. All of this means the sound of a tractor engine is added to the bird songs coming in my study window, blending with the rhythmic inhalation-exhalation cycle of sleeping dogs. These are the sounds of Maine mid-summer mornings I love best.

They are especially nice when heralding the onset of a three day weekend. I know, you thought I couldn't wait to get to the psychiatric unit each morning, what gives? Well, Saturday morning reverie like this feels like pushing yourself back from the table after a holiday meal with family and close friends, a meal with all the trimmings that satisfies like no other. The past four weeks I've tucked in with a huge napkin draped over my shirt and my plate has overflowed.

If I were called in, I'd be glad to go, but that's not going to happen. Students don't have "call" on this rotation, so I'm spared the necessity of being available, though like I say, I wouldn't mind. One of the docs has the duty this weekend and he'll cover the adult, child-adolescent, and chemical dependency units. Basically, he needs to touch base with every patient once in the course of 72 hours and take care of emergencies and new admissions. But I remember my first night on-call during pediatrics and this is his first weekend in the same role, only with more responsibility, and it's easy to commiserate. Besides that, he's a really nice guy whom I've enjoyed getting to know.

That holds true for everyone I've worked with thus far. I realize I've said this before, but it's hard to say too often. I'm truly grateful for the generosity these people have demonstrated, how they've taken me in as a quasi-staff member, overlooking my occasional and predictable mistakes, and accepted my efforts to do well with appreciation. For all the reasons I'm not looking forward to the end of this rotation, the people I've worked with are at the top of my list.

I think the reason for this comes about from a paid employment history that includes two hospitals. I've been a member of a treatment team where people are counting on me to do my job. Medical students are permitted certain tasks but none of them are essential in the sense that, in your absence, there is no one else available to do them. On this rotation, however, the entire staff, from the unit secretaries to the physicians, have not only treated me like someone they enjoy having around, they've taken my contributions seriously. They make me wish this hospital had a psychiatric residency program.

One of them, a social worker, does something no one else has ever done -- he insists on calling me "Doctor." Not "Student Doctor," but Doctor in the same way, with the same tone of voice he uses when speaking with the psychiatrists. I told him one evening, as he was preparing to leave and I was still at the computer, writing progress notes, that getting into medical school had been a struggle and staying in was a full-time job. Even though I had no legal right to the title, it meant a great deal to hear him use it. He ducked his head, smiled, and said I deserved it. That blew me away.

I'm not sure I deserve anything, really, but working with folks like him makes me realize, when it comes to being happy, more than anything else, it's the people, not the place.


(Creative Commons image of the Joint Medical Group by Defense Images via Flickr)

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)

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)

Surviving Board Exams Revisited

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

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

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

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

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

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

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

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

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

(Creative Commons image by ross6606 via Flickr)

Family Doctors -- The Default Psychiatrist

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

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

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

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

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

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

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


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