Medical School Without a Doubt

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

"Yeah...no doubts, though."

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

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

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

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

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

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

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

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

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

(Creative Commons image of Eric Liddell via Wikipedia)

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)

Look, Mom, I Passed!

This morning dawned chilly in my neck of the Maine woods and it's about time we had a blast of Canadian air to remind us it's December. I have yet to get my Christmas tree, but that's on the list for this week.

If a picture is worth a thousand words, the one I've included of Rocky Balboa says it all. I'm overjoyed to share the news that I finally passed my boards exams! A not-so-subtle subject line in an email from the Dean last night alerted me to check the exam web site once again and am I ever glad I did.

How do I feel? Like 40 pounds has been lifted off my chest and shoulders. As I've said before, boards are an unusual species of critter. No matter how hard you study, how well you feel prepared, how positive you are once you're done, it's really quite impossible to have any assurance that you've passed. There are questions that absolutely must correspond to the answers you've selected and there are others that defy prediction. Because of the inherent uncertainty involved in such a broad-based and wide-ranging examination, only Professor Trelawney, who teaches divination at Hogwarts, could possibly know the outcome. And I think she might even regard it as the ultimate challenge.

As a result, you never can quite relax until scores have been reported or at least that's been my experience lately. Now, however, the whole world looks brighter, as though someone cranked the rheostat up from medium to high. What comes next? Well, as far as medical school is concerned, rotations are on my horizon beginning in January. I don't know where I'll be working but I have a vague idea of what I'll be doing. To begin with, there will be two weeks of family practice right here in Southern Maine. After that, your guess is as good as mine, but I'll let you know as soon as I know.

Beyond this, there are the holidays of course, and I'm writing at last, after a long dry spell this fall. If it seems as though I'm spending quite a bit of time with Pink Hats and a Mack Truck, it's because I'd like to finish this series before rotations begin. I'm thoroughly enjoying the way this story is unfolding and while I have an idea how it will end, there are no guarantees. I may end up as surprised as you. So, please accept my thanks for your support and encouragement as well as my appreciation for all your well wishes these past months. They have paid off in spades.


(Creative Commons image by hsuanwei via Flickr)

What Makes It So Good

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

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

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

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

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


(Photo copyright 2010 by the author)

With Outstretched Hands

In your heart, you already know ~ Zen saying

Yesterday's Red and Rover cartoon depicts Red telling Rover about his holiday homework assignment. He was supposed to make a list of things for which he was grateful on Thanksgiving. All he needed was one word and it filled the entire page: Rover. I'm the same way. Give me a morning like this where my dog is lying on his bed next to my chair and the cat warming himself in the sun by the window and I know what I'm grateful for.

Some things are not so easy to appreciate and getting to the point where we can express gratitude for them may leave friends or family wondering if we've lost our marbles along the way. For instance, failing boards once was tough, twice bordered on downright demoralizing. However, the eight weeks I spent at the PASS Program were redemptive, they put medicine together in ways I could scarcely have imagined and my gratitude for Dr. Francis and the friends I made, overflows.

Redemption means more than putting a positive spin on things. It often entails self-forgiveness and I don't know about you, but that doesn't come second-nature to me. Letting myself off the hook for stupidity and stubbornness is frequently the last place I look for peace, even it's the best place.

Sometimes it helps to accept it from the hands of another. One of the things that helped me immensely in Champaign was the refusal of the staff to accept the verdict I had imposed on myself. I drove down there towing a virtual U-Haul trailer filled with regret, self-criticism, and fear over the possibilities of facing failure once again. And I wasn't alone. It seemed like everyone had a variant of my story to tell.

While no one could provide absolution, I experienced it nonetheless. I'm not certain when or how it arrived on my doorstep, but over time I just felt better. There was hope; I hadn't screwed the pooch so badly that I may as well pack up my toys, go back to Colorado, and spend the rest of my life hoping nobody ever asked me if I'd thought about going to medical school. There was hope because others had found it and could show me where to find it for myself.

I don't think it would be reasonable to say I'm grateful for those two failing grades because the truth is, I could do without them both. But I'm getting better at forgiving myself for them because there's so much more ahead of me than behind me. Does that make sense? There will be obstacles to overcome because of my mistakes but they're not insurmountable. It's kind of like what St. Paul once said, "Letting go of what is past, I press on with outstretched hands toward the goal of my high calling." On this Thanksgiving Day, I'm grateful for those who have helped me let go of the things that held me back so I can reach forward once again.

(Creative Commons image by Dominic's pics via Flickr)

Discerning the Patterns

Only a week ago I was sitting on my patio in Champaign, Illinois, wrapped in a blanket against the cold, studying clue words in the final push before my board exam on Tuesday. Since then, I've been thinking about the take-home points from the past eight weeks and asking myself how they might apply to medical education at large. The trouble is, the PASS Program is so unique in its approach and effective in its delivery, an application of its principles might necessitate completely revamping the way we train medical students. Some would say that's an idea whose time has come. Rather than engage that debate, I'd like to simply allow the lessons I learned to speak for themselves.

One of the first things you discover upon arrival is, every staff person has either been a practicing physician or is applying for residency. This means they've had to sit for boards and thus, know what it's like to have been in shoes that pinch as tightly as yours. The element of personal experience creates fertile ground for establishing an empathic relationship that is instructive, encouraging, sometimes therapeutic, and very, very human. Some are graduates of the Program and know first-hand how to use its principles successfully. They're battle-hardened veterans, we're green recruits; they've been under fire and know how to survive; we do our best to pay close attention.

Now, despite having the initial four weeks of lecture feel like our first two years trimmed down to the essential of the essentials, the learning atmosphere at PASS is devoid of the competitiveness often associated with medical school. Partly, this is due to the fact that we've all completed our required courses and our common goal is to pass boards. But even in the classroom and small group sessions, if a student is stumped, the watchword is, "Can someone help so and so out?" No one tries to beat anyone else to the punch in the hope of gaining the instructor's recognition or approval. Support is taken seriously because so many have experienced failure and we're here to learn from and overcome our failures, not reenact them.

The material is the silent partner in the whole process. We've all been exposed to an overwhelming amount of information in medical school and I'm not sure a great deal can be done about that without doing damage to what we're about. However, the PASS Program focuses on what is truly high yield, for boards as well as rotations. And that's a surprise. Most of us thought we were going to address board exams exclusively; lo and behold, we're also being trained to be more effective in the clinical setting.

How the material is presented is as important as its content. Many, including yours truly, come to Champaign thinking their frustration with boards is due to a defect in memorization skills. We're informed on the first day that our problem stems from a basic misunderstanding of the nature of boards. They aren't intended to test what we know, but rather what we can use. Our mistake was in assuming memorization was the best way to prepare. It's far better to understand the material because then it becomes a tool for problem-solving rather than a reason to go hunting for Alka-Seltzer.

The metaphor that has stuck in my mind in this regard relates memory to enzyme functioning. Enzymes break big chemicals down into smaller ones so the body can use them for energy and to promote health and well-being. But every enzyme has a limit; it can only do so much work before it hits the wall. I can identify with that. So, once the enzyme is working at maximum capacity, the only way to get it to do more work is to increase what we call the substrate concentration. Basically, this means we add more chemical so that it competes for spots on the enzyme where it can be broken down.

How does this apply to memory? Well, it seems that short-term memory or RAM, to borrow from computer lingo, is like an enzyme: it has a maximum capacity. Once you've gotten it loaded down with facts, figures, statistics, and who knows what all, it's full. To remember more, you have to start forgetting a few things and that's what happens when a person prepares for a test. They've studied for days and they think they're ready at last when that pretty young medical student from Colorado (sorry, I have to give the honor to my home state) comes along and whoops! there goes a few hundred facts. Our guy asks her out after the test and there goes another few hundred. Next day he walks into the lecture hall and his mind is as blank as a slate and he wonders what happened.
The way to combat this normal state of affairs is by making connections, discerning the patterns and relying on useful and reliable concepts that provide the framework for learning. In this way, the instructors at PASS teach us how to reduce our obsessive reliance on rote memorization and replace it with understanding. In itself, this isn't revolutionary, but the way it is applied makes it feel that way.

You see, pattern recognition is one of the primary ways the brain processes and stores information. Take vasculitis (inflammation affecting the veins and arteries), for example. Once you've discerned the general pattern that characterizes this condition, the individual types of vasculitis can be identified by clue words specific to each. A memory tool? You could call it that but I'd say it's more like using an enzyme to break down a complicated system of disease categorization into a form that makes sense. Research scientists might cringe at the thought, but they don't have to take medical boards and neither do they have to stand at a patient's bedside. If all of this sounds simple, it is, and that's the beauty of it. "Simple" may be less impressive but if it renders a concept more accessible on an exam or in a clinical situation, isn't that the whole point?

Don't get me wrong, the Program isn't a Stupid's Guide to Medical Boards Exams. I came away with a notebook filled with notes and lecture material to the tune of some 500 pages. It's four solid weeks of eight hours a day worth of hard work. My classmates and I went home at night weary and bleary-eyed , as did our instructors who were on the job long after we were eating dinner. The additional four weeks I spent studying, trying to absorb and integrate what I'd learned, was invaluable and I feel safe in saying I'll still be doing that very thing for months to come.

There is another element in the PASS Program and it's not, strictly speaking, academic; it's pastoral. Failing to succeed at boards can shake a person's confidence and damage their self-esteem. You put your heart and soul into preparing for what you fear may be the exam of your life, you get your score report and it reads, "Sorry, Charlie, Starkist only wants the best tuna." Is there ever a time when a medical student feels lower? I doubt it. They know this at PASS, many of the faculty having had their own run-ins with failure and frustration, and so they place recovery of faith in yourself, your intelligence, and your ability to tackle boards and medical wards at the forefront. When you arrive, you feel battered, black, and blue. When you leave, the bruises have healed and you're ready to ask, what's next. Treating students like persons and whole ones at that, is the most osteopathic thing they do. And most of them are MDs.

How about that?!

(Photo of the PASS Program Center copyright 2010 by the author)

Getting Off the Interstate

Paths cannot be taught, they can only be taken. ~ Zen Saying

Or to put it another way, "Get off the interstate, Ben Stone." Okay, I'll admit that sounds a bit like loose associations, what we in the psychiatric business call the disconnect between one thought and another that can signify altered mental status. But considering my state of mind late this past Thursday evening, anything's possible.

I'd been driving since 11.00 AM, having gotten away from Champaign slightly later than planned, as usual. I wanted to drop by the PASS Program center and say goodbye to Dr. Francis, his staff, and friends I'd made and with whom I intend to remain in touch. That done, I stopped at the local Meijer department cum grocery store to load up on Diet Code Red Mountain Dew, a favorite since living in Boulder. Trouble is, only the high octane version (with sugar) is available in my neck of the Maine woods. Nor can I obtain the excellent beers from The New Belgium Brewing Company in Ft. Collins, Colorado, up here and I was delighted to find both at Meijer's.

Reminiscent of the film Smoky and the Bandit, I was going to "smuggle" Diet Code Red along with some 2 Below and Fat Tire Ale across the country with me. Meijer was fresh out so I grabbed the beer and stopped in Kankakee, a town south of Chicago and memorialized in Arlo Guthrie's City of New Orleans. There I emptied the shelves of a K-Mart and Kroger grocery, making good my escape with seven boxes of calorie-free nestled in the back of my CRV.

Now, you should know the previous night had been a restless one. The excitement of going home coupled with ambivalence about leaving my comrades in arms made sleep elusive. I realize I often use military metaphors to describe the way medical students feel about one another, but it makes a great deal of sense, and every student with whom I've shared the notion has agreed. Medical school and the confrontation with board exams are so intense they create a bond that is difficult for "non-veterans" to comprehend. I don't know any better way to describe it.

Anyway, somewhat sleep deprived and just shy of twelve hours later, I found myself in what I believed to be Akron, wondering who moved Cleveland in the last eight weeks. The next morning, the night hotel manager explained I had missed the turn for Cleveland and was forty or so miles from Akron in a little borough named, appropriately enough, Streetsboro. In response to my blank look, he offered to call his mother -- the police dispatcher -- for reliable directions.

"The dispatcher is your mother?" I asked.

"Yep, been that for 30 years," he said, proudly, "and if there's a route anywhere around here, she knows about it."

Feeling like I'd just become a participant in an insider trader scheme, I thanked him and a half-mile later, walked into a Denny's like none I'd ever seen before (photo). Usually, America's restaurant is a dimly-lit collection of booths and tables under a modified A-frame roof. This one was a throwback to a 50s diner, the only difference being, instead of Elvis and Jailhouse Rock, the overhead was playing an updated version of Girls Just Want to Have Fun. What happened to Cyndi Lauper or is that too 80s?

In another time, the name on my waitperson's tag might have read Dotty or Flo and the cook would have been a cigar-chewing, t-shirt clad, Army vet known simply as "Sarge" with the tattoo of a heart emblazoned with the word "Mom" on a muscular forearm. She had the personality and physical proportions for a Dotty, but he was a young guy whose demeanor suggested he might slip out for a drag on a joint when no one was looking. It didn't matter because the food was great and the coffee good enough to make the Starbucks Christmas blend I'd had the day before seem more like warm water poured over a rock. I took a travel mug full with me and drained the last drop wishing it would refill with a wave of my hand and a casually spoken hokus pokus.

All too soon I was heading north toward Erie, PA with the Cleveland Clinic on my left and a gorgeous sunrise on my right (photo). What started out as a mistake in the night had turned into a wonderful morning. The surprises that await once you get off the interstate.


(Photos copyright 2010 by the author)

Home at Last

To borrow a line from the last line of Tolkien's The Return of the King, I'm back. Home at last. From Champaign to near Cleveland on Thursday, then Cleveland to Maine yesterday. That's not as bad as the trip out, Maine to South Chicago in one long trek. Honestly, I wasn't trying to set any speed records or prove I could still do at (muffled words) years that I could have at half my age; it was more by accident than design. I haven't told you that tale? Well, shame on me.

I left on the Friday before classes were to begin and thought I'd drive until I got tired, stop, and start up again the next day, more or less aiming for Indiana. By the time I got to South Bend, home of Notre Dame University and the South Bend fishing tackle company, I was ready to hit the sack. Finding an available room, however, was nearly as difficult as coming up with the cash called for by even a no-tell motel, one of the "We'll leave the red light on for you" variety. And why was that, you may ask? It was a Notre Dame football weekend.

Did it occur to me to check the football schedule? Nope, and if it had, do you think I would have considered this to pose a problem? Right again. My Boy Scout training, i.e. Be Prepared, failed me -- don't tell any of my former Scouts, please, they'll never let me live it down.

The night manager of a Micro-Tel told me the cold, hard facts of life: the best deal I was going to find would closely approximate Saturday's Power Ball Lottery jackpot and require the license and title to my first born as proof of my credit-worthiness. Off-season opportunities to make a buck were too good to pass up and free enterprise being what it is, the cost of a bed rose accordingly. Having neither won the lottery (yet) nor had a first born with me I could offer as collateral, I headed on to Chicago.

The lights of a Super 8 loomed near the cutoff for Highway 57 South, my lifeline to Champaign, and I took that as a sign. The bed was incredibly comfortable as was its counterpart in the Super 8 my roommate and I shared in Peoria, and four hours later I was sipping coffee and channel surfing the car radio in Illinois corn country, while munching maple oat muffins for breakfast that I'd brought with me for the occasion.

The adrenaline that powered my trip West was a fond memory on the way home. All I wanted was to be bowled over by ninety pounds of Yellow Labrador charging through the door and every "now" I could think of wasn't soon enough. I had hoped to get as far as Buffalo when hunger and cognitive decline, aka sleepiness, took over and I ended up spending the night in what I took for Akron, Ohio. It wasn't Akron, but that story is for another post. It's a good one, though, so stay tuned.


(Public Domain image of Notre Dame Fighting Irish logo via Wikipedia)

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)

Brothers in Arms

It’s early Sunday morning, the last of my Sunday mornings (for now, at least) on this penthouse perch overlooking the expanse of grass – less than a park, more than a yard – that abuts Neil Street and ends where the Champaign mall parking lot begins. My first two “patients” were also perched on the power line that is my waiting room until a few moments ago. I was about to invite them in for our session when one flew off in a huff, followed by the other an instant later. As they flew by I could have sworn I heard the first exclaim, “I told you, I don’t need to see a shrink!”

The second, a distinctly female voice, trailed behind like the Doppler effect created by a passing train whistle fading in the distance, “Oh yes, you dooooooooo…”

I should be studying and will be very shortly, but I don’t want to lose this brief onset of reverie, surfacing alongside the weariness that’s been dogging me the past few days. We’re (my roommate and I) nearly at the end. Tomorrow evening we’ll drive west to Peoria, the nearest available testing site, register into a motel, and try to keep one another sane and relaxed until Tuesday, test day, dawns.

We’ve commiserated, complained, and cursed, all the while trying to contrive every possible way to cram concepts and clue words into our brains over the past eight weeks. We were friends before we arrived, but the stress of war has turned us into brothers in arms and Tuesday we’ll march into the face of the enemy, side by side.

(Creative Commons image by Puddles via Flickr)

Recharging Me

"Not everyone is as mono-maniacal as you." ~ Donatello Moss

Before we go any further, I should tell you, Donatello Moss aka Donna, is not a real person, but she ought to be and in some world, she probably is. In ours, she's Dr. Watson to Josh Lyman's Sherlock Holmes in the syndicated program The West Wing, which you can still see on Bravo. If I was in Maine, my dog and I would be munching breakfast together while getting our daily dose.

The line I've quoted comes from the opening scene of one of the final episodes in which Josh is suddenly becoming aware of all the romantic pairings that have developed during the presidential campaign he has been directing. Enter Donna, who has a gift for remaining human when Josh has become so hyper-focused that he misses the details of daily life. Every now and then he has a meltdown and it takes someone else to remind him to take a vacation once in a while.

I hate to admit it, but I'm very much the same way and maybe you are, too. Perhaps that's one reason I love The West Wing so much: Josh's character is a mirror of my own proclivity to overlook the obvious. For instance, lately I've gotten so engrossed in what I'm attempting to do out here that I haven't permitted myself the pleasure of sitting on the patio with the computer and writing about the experience -- at least on anything resembling a regular basis. I've treated my sanity-saver as a luxury and the truth is, as the demands on us increase, the more things like this become necessities.

But it's hard to see them as such, especially when we regard every moment devoted to self-nurturing as one taken away from the task at hand. Sooner or later, however, the inner well runs dry and we become touchy, irritable, and resentful. Even those of us in the helping professions have limited reserves and that's oh-too-easy to forget when the stakes are high and we're under the gun.

Unfortunately, in the same way we can't make up for several days of sleep deprivation by getting a single good night's sleep, making up for self-deprivation can't be done in one fell swoop. It takes time and that's just the way the universe works. I know, it sucks. We'd all like to believe our internal battery recharges automatically, but there has to be a power source. Even when a person has a spiritual connection, they can't assume it will do for them what they can only do for themselves.

So, here I am, it's 40 degrees in the shade, but like my cat who is no doubt sitting on his window ledge at this very instant, watching the squirrels scamper for late-season acorns, I've found a warm spot in the sun. An hour ago I was feeling pretty anemic, but now there's a little tingle down inside. I'm betting even the Ever-Ready Bunny needs an occasional carrot and today, this one is mine.


(Creative Commons image by Ben+Sam via Flickr)

The Clubhouse Turn

It's been a long time since I've had roommates and the past four weeks have involved some adjustment. The kitchen in our apartment is large enough for two to cook, three to socialize, and on those occasions when all four of us (and we're big guys) crowd in at once, it approximates a mosh pit. We have individual bathrooms, thankfully, and our schedules vary sufficiently that coming and going is never a problem. But it's the conversation that I've come to appreciate the most. I've missed my classmates the past few months and being able to talk with like-minded souls at the drop of the hat has been really nice.

Since classes begin early here, around 7.15 AM, late night conversations are restricted to the weekends, but their detritus may last for days and stirring oatmeal in the morning can just as easily stir up concerns about insurance, patient care, and when is potassium at its greatest concentration in the cardiac cycle. Life and school intermix as smoothly as coffee and Splenda in my cup.

Sitting out here in my airy third floor patio perch this morning, the sun is already warm and it will hit near 90 before the day is out. Contrast that with Maine where fall is in full bloom and my dog will take his walk this afternoon along a lane enshrouded with pine needles and temperatures in the upper 50s. I've noticed colors are starting to slightly shift toward the yellow end of the spectrum and the high cirrus clouds I associate with autumn are streaming by more and more frequently.

I've come to really value mornings out here for the chance to maintain some sense of flow. As in medical school, it's terribly easy to become so engrossed with material we're reviewing that one loses track of time. Tunnel vision is our common opthalmic disorder and everyone is infected. Being able to disconnect for a few minutes reminds me that I do have another life and in a few weeks I'll return to it. My dog and I will take his walks together, he and the cat will curl up next to me for naps in our chair, and I'll build a fire in my study to take away the chill before settling down to write.

Those weeks before rotations begin in January are going to be a blessing. The last few have been wonderful, overwhelming, intense, and enlightening. The ones to come, the ones intervening between Friday's final lecture and my exam, are going to be devoted to interacting with my physician-tutors, practicing exam-taking skills, and wrapping my head around all that I've learned. It's not exactly the home stretch -- more like the clubhouse turn -- but it's going to be good and sometime or another, I don't know when exactly, I'll write about it -- thanks for bearing with me through all of this. For now, as usual, it's back to the grind. Have a good day.


(Photo copyright 2010 by the author)

No Offense, Nick (Nolte)

"You remind me so much of Nick Nolte," she said, "only when he was a lot younger and sexy." I was surprised, genuinely flattered, and thanking her, said so. I've been told I look like a lot of things, some printable, some not, but never Nick Nolte.

He's what women called a "hunk" not too long ago and much as I may have fantasized about achieving hunkiness, considering myself in his class strikes me as borderline delusional. Coming on the heals of a recent birthday, as it did, the "younger and sexy" part of her comment was, well, let's just say it was really nice.

In his later years, my father was distinguished, at least according to my mother, and I think she was right. As a young man he was all of tall, dark, and handsome. Where those genes went in the crossover phase of meiosis when his half of my genetic code was being hammered out, I'll never know. I got the one for height but the rest went AWOL and have been missing ever since.

It's especially welcome to get a compliment like hers when you crawl out of bed in the morning, look in the mirror, and wonder what on earth you were doing to yourself between lights out and sunup. I mean, you thought you were dreaming, right? Some days I have to wonder.

Admittedly, it was tempting to ask which Nolte she had in mind. Was it the romantic Prince of Tides (1991), rough and tumble 48 Hours (1982) with Eddie Murphy, or the football player from North Dallas Forty (1979)? But that didn't seem polite, nor did I want to risk it. At this point in my life, I'm grateful when someone vaguely contemplates using the adjectives "young" and "sexy" in the same sentence where I'm concerned. It doesn't happen often and I've learned not to look a gift horse in the mouth. Besides, no doubt the day is coming when she's going to decide I look like the older Nolte and for that, I'm in no hurry. No offense, Nick.


(Creative Commons image by Alan Light via Flickr)

You Have Just Been Empowered

Putting my experiences in the PASS Program into words is becoming a work in progress. At first, I expected most of my posts would be diary entries, rather like those of my great, great, great maternal granduncle who was a circuit-riding Methodist preacher in the 1850s. Imagine the delight my ministerial self felt at discovering the daily grind to be more akin to revelation than mere reporting.

Of course, that's what makes it so difficult to verbalize, which explains why anytime you ask a question of a theologian, hoping for a multiple-choice type answer, you're likely to get the equivalent of an essay. The nature of the subject matter renders a yes-no response too simplistic to be meaningful. By the way, this is also a good reason to question any minister who presumes s/he can unveil the mysteries of the universe in three easy-to-follow steps.

Which brings me back to my original problem, namely, making sense of my experience here and why it is turning into a work in progress. If they were teaching a method, you ought to be able to order the CD and workbook for only $19.95 plus shipping and handling. But that's not what this place is about. We're learning how to think and that's a different animal altogether.

One of the things I'd hoped to do in my posts was discuss how it feels, being an older student, in an environment like this. Age, however, isn't a factor at all. While, as usual, I'm probably the oldest student here, as far as my driver's license is concerned, there are several others who've been around the block as well. Most are in their 20s and 30s, but our intention isn't to determine who's qualified to be a doctor by virtue of their age, gender, or social standing, but to gain whatever is necessary to pass board exams.

That said, we're all in a position of having to unlearn one way of dealing with the material and learning what I feel safe calling an entirely new one. In the process of delving into such organ systems as cardiology and neurology, students typically attempt to commit massive lists of diseases, signs, and symptoms to memory. The "time-honored tradition" of downloading information only to reproduce it for an exam -- called binge and purge learning -- becomes your default position until you've found a framework that fosters integration and the discernment of patterns.

For someone who has made his way through history and theology looking for connections, being shown how and then urged to apply that same inclination to medicine, is a radical departure from anything I might have expected. It's value, I think, lies not only in the way it promotes learning, but in the ways it builds upon strengths one already possesses. In other words, it's empowering, and that is something we all need no matter who, or how "young," (smile) we are.

(Public Domain image of Patterns in Ice via Wikipedia)

Mexican Food and a Saturday Night

So, there we were, the three of us, driving through downtown Champaign on a rainy Saturday night, looking for Mexican food. I was at the wheel, my room and classmate from school in the back, and a smart, sweet, down-to-earth young woman from Northeast Ohio was riding shotgun and deftly handling navigation. The Red Hot Chili Peppers were red hot on the radio but the outside temps rendered navy sweatshirts the evening's dress blues.

Now, I admit I wasn't sure what to expect. Mexican food can be good, great, or merely an approximation of edible, depending on what part of the country you're in. Back east, I'm afraid to say, it's called Mexican but that's about as close as it gets to the real thing. Illinois is closer to the Source, but one never knows. Anyhow, new in town and weary of our own cooking, any risk seemed tolerable as we pulled into the parking lot of what was probably once the home of fast burgers and fries. We were ushered without delay to a booth where our waiter, a gentleman of Hispanic descent, quickly placed a basket of fresh, hot chips and two bowls of homemade salsa on the table. One bite told me we'd made no mistake.

Crowded with students and parent-types, Dos Reales is clearly a local favorite and for good reason. I don't recall hearing Mariachi music in the background, but the walls are painted in desert tan overlaid with murals reminiscent of life in the Southwest, making me feel right at home. I ordered my usual chicken enchiladas while my partners, a poblano pepper dish and vegetarian something or other. I didn't quite catch the latter's name because the gal with us ordered in Spanish, a little tidbit I realized would be helpful when I asked the waiter for more time to reflect on the menus and he looked at me with a face like a question mark.

In between quizzing each other on board review questions -- this was meant to be a "working" dinner -- we made fast work of the salsa and then forgot all about the Comlex and USMLE when our meals arrived. The last time I recall having freshly made refried beans was in Southeast Colorado when I served as a substitute pastor for a small Hispanic church in La Junta. But that's what I discovered on my plate last night. I wouldn't be surprised if the tortillas were made on the premises. It was simply sumptuous. At one point, my female friend commented she wished she'd ordered more -- until she finished her meal, that is, and then said, "I couldn't eat another bite." We knew exactly what she meant.

Ordinarily, I'm all for a bedtime snack, despite the fact that my instructor has admonished us that any food consumed after 8.00 PM gets metabolized straight to cholesterol -- an fyi to anyone who wants to lose weight and, like me, can't always resist a late evening close encounter with the refrigerator. Last night, the thought never even occurred to me. If I was rich and self-indulgent (which I'm not -- rich, I mean) it would be tempting to fly out here just to have dinner now and then.

If you're ever on a trip and you can reroute near Champaign, I'd encourage you to do so. Dos Reales is located on North Prospect Ave. and my guess is, all you have to do is follow the crowd and bring an appetite. The staff is attentive, unobtrusive, and the food, like my program, is one of the mid-West's best kept secrets.


(Creative Commons image of The Red Hot Chili Peppers via Wikipedia)

A Fellowship of Failure

It's fair-skies and 48 this morning and the view from my patio penthouse includes the sun trying to reach me through the cottonwoods. Maybe by mid-October they'll feel more generous, but right now they're holding onto their leaves as though the last days of summer depended entirely on them. If they know Wednesday evening saw the Autumnal Equinox, they're not telling.

I was thinking, the other day, about the one thing nearly all of us have in common (aside from being medical students) -- failure. Some, to be sure, come simply as a supplement to their education -- not a bad idea at all, frankly. They’ve yet take their stand in the middle of some dusty street at high noon while spectators scurry for safety and then anxiously peer from windows or peek around corners, waiting for the bad guy (board exams) to go for his gun. But, they're in the minority; most of us have had that experience already, at least once, and the outcome hasn't been pretty.

I suppose this is why we’re inclined to be accepting of one another, why no one sighs impatiently when another student doesn’t correctly answer a professor's question, why hands don't shoot up like a flock of geese startled by sudden movement, eager to show they know what you don’t. Perhaps this is why asking the instructor to repeat a point isn't accompanied by snickers and rolling eyes and why busy hands copy down what their owners also missed the first time around.

I've often wondered, quite truly, what it would be like if a class was almost entirely composed of people like me. Not like me in the sense that everyone has creaky knees (I've known athletes with them in their 20s, by the way, so there) or can't wait for the 9:30 coffee break. Nor people like me who pound the treadmill in the late afternoon hoping to generate sufficient energy to keep the Rack Monster aka Mr. Sandman at bay long enough to spend the evening studying. 

 

I mean people who've had to wrestle with medical school – people like Jacob, who dared wrestle with an angel, holding onto him with all his might and through gritted teeth declaring, "I will absolutely not let you go until you bless me." People who, like Jacob, got the blessing all right, but had to pay for it when the angel dislocated his hip, so that he walked with a limp the rest of his life.

People like that.

Well, now I know. To tell you the truth, it's been refreshing. For one thing, it's delightful seeing the faces of my MD colleagues light up when I've done a little osteopathic manipulation on their cramping wrists after a day of writing like their lives depended on it. They've heard about our little secret, they know us DO types can do things with our hands they never learn, but seeing it up close and personally, they act like any one of us would when a magician pulls a rabbit from a hat and this time you know the magic is real.

More than that, it's good being among persons who’ve seen failure face to face and are determined to not let it define them. Part of this stems from the atmosphere created by our professor who knows from his own experience what it's like to have a dream behave like your nemesis. Medical school was hard for him, too. So was life, growing up on the South Side of Chicago. In his family, new clothes meant a trip to the Goodwill, not Macy's. He told us his story yesterday, holding back none of the unpleasantness, describing how he discovered the Faith that changed his life.

He reminds me of something I wrote in my very first blog post, i.e. he's one beggar sharing with others where he's found bread and then showing them how they can find it for themselves. In so doing, he inspires confidence when things seemed very much in doubt. As you walk in the main entrance, six metal letters are arranged on the counter in front of you, spelling out the word "Believe." Every day, someone on the staff drives home the message that our achievements depend as much on faith in ourselves and each other, as they do hard work. In this fellowship of failure, I suppose you could call it, we're becoming not only better future doctors, but better people. Little did we know.

(Photo copyright 2010 by the author)

Hard Places

Good Morning, Happy Sunday, Greetings from the Trenches.

The sky from my patio perch is cloudy gray mixed with distance blue; I'm not complaining, though, because it's pleasantly cool. By Tuesday, it will be in the 90s again, as autumn continues to play a waiting game here.

I had an interesting conversation over breakfast this morning with one of my roommates, who happens to be a veteran as well as medical student. Despite my having not served, it wasn't hard to establish a meaningful connection. For one thing, I know the life and for another, at least right now, we're in the same foxhole. And even after we've advanced past the current obstacle, we'll always be comrades in arms.

This is something I can't ever quite get over. It surfaced the other night as well, while chatting with a young woman who is a student in a neighboring state. One minute we were strangers and two days later, we're pals. I'm talking, of course, about the instant intimacy that so easily develops between medical students and physicians. To a certain extent, it's as though our radar is attuned to picking up on another of our own kind.

Part of this may be simply due to the fact that we're all immersed in a community of intuitive types, but I've run into it in other contexts as well. Medical ones, that is. Where it hasn't always been so readily apparent, oddly enough, has been among ministerial colleagues. I've often wondered about that and I really haven't come up with a satisfying explanation. I've noticed that whenever I've met up with a minister who's been battered by a pastoral experience or had some sort of personal crisis like a divorce, the camaraderie is there, right off.

Just thinking out loud for a minute, I wonder if hardship is what makes the difference. Seminary is tough, make no mistake, but it's not tough in the sense that it confronts inadequate defenses, teaching you to build up new ones in their place. The ministerial focus is on formation, challenging one's thinking processes and predispositions, but it seems less painful in retrospect. As a result, it's not until life gets to that point, i.e. painful, that collegiality becomes so important.

As you've probably guessed, I'm not one of those who thinks pain is, by definition, a bad thing. Where it takes us can be destructive or constructive, depending on our disposition and willingness to change in response to its presence. The more willing we are to adapt, the more benefit we obtain. It's only when we become stubborn, resistant, and determined to head-butt our way through circumstances that are less amenable to power-oriented approaches that we come away with a headache.

Furthermore, it seems we most often find kindred spirits when we're in situations that tax our abilities to cope. Speaking for myself, those relationships are the ones I value most, those formed in hard places with persons I've never met, who nevertheless know what it's like to be me. And among whom I know what it's like, being them.


(Creative Commons image by Te55 via Flickr)

REO Speedwagon Way

I'm guessing the 80s rock group, REO Speedwagon, must have gotten their start here in central Illinois because there's a street named after them in downtown Champaign. I ran into it by accident on my way "home" from running a few errands, one of which took me to the northern edge of the University of Illinois. I was driving through the Greek community (sorority/fraternity row), when a turn onto my street led me across REO Speedwagon Way aka Main Street.

I'm mentioning this because it just seems so unlike what I expected. This is corn country where multiple FM stations broadcast church services on Sunday and you can walk around the local mall without feeling like you've tried out for an Iron Man competition. Saturday is clearly market day and the traffic reminds me why I've come to appreciate life in Maine so much. Not because people drive crazily -- far from it -- but simply because there are so many going the same direction as me. It was as though they all decided, "There's Beggar, let's follow him," while I felt like saying, "No, no, I'm new here, follow someone else!"

The past couple of days we've been reviewing the key elements of biochemistry, learning how to abstract a whole series of medical tidbits from a single concept. For example, let's take proteinuria, which means protein has been found in the urine. Now, urine is not where you'd ordinarily expect to find protein, any more than downtown Champaign is a place I'd have expected to find REO Speedwagon Way.

If a patient is losing protein, they would likely present with weakness, shortness of breath, elevated heart rate, and have problems tolerating exercise. So, then you start asking yourself where the protein might be coming from. It could be muscle tissue, maybe the kidneys, and that leads you down the path toward diagnostic possibilities. It's the kind of process a person would use in a clinical setting. Applying similar principles to taking an examination reduces the amount of brain cells you have to devote to rote memorization. And since I seem to have a relatively limited number anyway, memorizing tends to use them up fast.

Once again, I find myself surprised over what I'm discovering here. It's kind of like, who knew there was so much tucked away in middle America and all a person had to do was look.


(Creative Commons image of an REO Speedwagon by jcbwalsh via Flickr)

The View from the Treetops

The best laid schemes of mice and men gang aft agley ~ Robert Burns

Boy, did he ever get that right. I was planning on stealing a few minutes every day for writing, even if it was only a paragraph or two. Turns out, this program is just like medical school. Now, what madness possessed me to think it would be otherwise? I know, it's a review course. Uh-huh -- that and a buck something will buy you a cup of coffee at MacDonald's.

Let me tell you, as I said to one of my roommates, a fourth year student from Chicago preparing for step two of the USMLE, "I feel like I've been rode hard and put up wet." He knew exactly what I meant. And that's one of the things I've always loved about being part of the community of doctors and medical students. You can't be so tired, so overwhelmed, or so overworked that someone can't empathize and generally does. It's wonderful.

Anyway, this program is very much like medical school. You see, I've had the sneaking suspicion the material we cover in our first two years, that accumulates as rapidly as blizzard-quality snow piling high against the side of my barn, needs to be boiled down to the essentials for board preparation. It simply has to be. Some things are important and others are so insignificant even the writers of board questions don't care whether we know them or not.

The process of boiling down is what our professors here have undertaken on our behalf (thank God), teaching us how to look at our education and see what is critical, namely, the big picture. Now, the truth is, I really should have written, the BIG picture, because it's more accurate that way. There is an amazing amount of material to handle in the course of eight hours of lecture and Socratic dialogue each day.

I'm having a great time, rest assured, but it's still a lot of work and some days, like yesterday, I'll drag myself up the stairs to my third-floor apartment wishing the management office had seen fit to put me on the ground floor, instead. I like my treetop patio, and this morning, at 49 degrees, the solitude (excluding the traffic on the main road) is refreshingly delightful. But the intensity of learning and then knowing I've got 40 pages of notes to go over, reminds me that even when breaking things down to their essentials, the view from the treetops can be formidable in its own right.

(Photo by the author, copyright 2010)