Cranberry Sauce by the Fire

It's windy this morning, usually not a good thing. A little breeze is fine and velocities from 10-20 mph, even up to 30 now and then are okay, but lately there have been days when the speedometer has flirted with 50 and that's when my internal warning sirens go off. Unlike Colorado or Illinois, Maine is heavily forested as readers from New England well know, and it's the trees that generate my concern.

In Boulder, the wind comes swirling off the mountains, swooping down a long corridor paralleling the Flat Irons (photo), and slamming into town like a freight train out of control. We have trees, of course, but they're not nearly as dense as they are in my back yard or along the lane to the east. When power lines go down in Colorado, it's more often due to heavy, wet, early winter or late-spring snows.

The unpredictability or perhaps better, the predictability of losing power at some point is why I'm writing this post now, while I can. I'd love to get back to Pink Hats and a Mack Truck because, frankly, I'm just as eager as I hope you are to see how things turn out with Dr. Bob and the twins. Some writers work from an outline and have a story fleshed out in advance of its development. I take my clue from Stephen White who freely admits he has no idea how a novel is going to unfold until he gets to the end. I like that; it allows the unconscious to work and express itself spontaneously.

My plan, as of last night, was to have morning coffee with Dr. Bob and see what he's been up to -- until the vigorous sound of waves washing up on the beach drug me from a sound sleep and I noticed trees swaying precariously through the window. Two weeks ago, while I was basking in 60 degree weather on my Champaign patio, anxiously buried in cardiology or some other medical -ology or -ary, a white pine on my property split two stories up from the ground and sent wood flying into the power lines, blocking the road and inconveniently blacking out my neighbors across the creek. I hope that doesn't happen again but you never really know.

The upshot of all this is the cranberries and home-made rolls I want prepare for tomorrow's dinner with my best friend's family need to take precedence over pleasure, so I'd better get cracking. If we're lucky, the lights will stay on and the oven hot. If not, Thanksgiving dinner might turn out to be a can of soup warmed up in the fireplace. As disappointing as that sounds, it reminds me of wonderful evenings around the campfire with Boy Scouts and their fathers. At least the soup will be accompanied by fresh cranberry sauce and who can complain about that?


(Creative Commons image via Wikipedia)

Returning to Normal

We have a York, Maine and a Scarborough -- sans Faire -- but not a London, at least as far as I know. New Hampshire has New London, but that's "live free or die" territory (the state motto) and over there, they make up their own minds. This afternoon, however, the soup outside my front door is thick enough to confuse the compass and stimulate an appetite for a cuppa Twining's Lapsang Souchong. Ever had any? It smells like freshly fired gunpowder and tastes like woodsmoke. Perfect for a grey day.

I spend the morning rewriting yesterday's post after rereading it left me wondering what I meant to say. Then the canine and I stepped out for a walk in the rising mist, noticing the rest of the neighborhood had the good sense to stay inside by the fire. The chipmunks, by the way, have taken up residence behind my fireplace again this year -- I still haven't figured out how to charge rent. And if I left them a statement, I have a feeling their response would be similar to that of General Anthony McAuliffe, commander of the 101st Airborne Division at Bastogne to the German demand for surrender, "Nuts."

Fall has come and pretty much gone in these northern climes and any hopes I had of seeing some color along the southern rim of the Adirondacks on the way home faded fast -- what remains is pine tree green interspersed with masses of naked deciduous branches. Having spent mid-September through early November in the Mid-West, I feel like I've missed something back here. It's as though I stepped out of and back into time, expecting everything to be the same on my return and it's all changed instead.

My cat seems to have had the hardest time with my being gone. The dog, of course, was overjoyed when I got home, but Mr. Mouser was distant and it took a few days for him to warm up to his usual self. I guess that's the difference between cats and dogs: even cats who are "dogs on the inside" have an image to maintain. At any rate, the little farm on this side of the Saco River is slowly returning to normal and winter is just around the corner.

(Public Domain image via Wikipedia)

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)