Well, today was my last day of rural medicine and if I didn't have to be someplace else, I could easily show up for work on Monday without a second thought. You see, I've gotten rather comfortable dodging the potholes and frost heaves on the road paralleling the Kennebec River on the way into town, and encountering patients in the grocery and hearing them say, "Goodnight, Doc," even though they know I'm a student, has warmed my heart. Being treated as though I was expected to stick around has been wonderful and it's made leaving far more difficult than I could have imagined six weeks ago. I'm going to miss those Mondays.
Working in a private practice in a small town has been the fulfillment of a fantasy I've entertained since the 1990s when I first saw the film, Doc Hollywood. Although I've mentioned this on numerous occasions, I'm bringing it up now because the idea of having experiences similar to those depicted on screen was an important one at a time when the dream of going to medical school was very far away. So far, in fact, that I hadn't begun giving it serious consideration. You could say, I was still in the "wouldn't it be nice" stage, back then.
Fifteen or so years later, I'm a student who's only used his stethoscope on other students or model patients, pretending I have more than a vague notion of what I'm doing. I thanked God for all the times I'd taken blood pressure readings as an inpatient psychiatric clinician because at least I could do that with a modicum of confidence. I'd taken illness histories while performing psychiatric intakes, so I had that down, too, but there was much that was "new" in every sense of the word. I owe a word of thanks to every patient who smiled and let me fumble my way through our initial interview, trying my dead level best to do no harm in the process.
And especially to those who said it didn't hurt each time I stuck them with a needle administering a TB test or allergy shot, whether it did or not. They were braver than I would have been, had it been me.
I'm grateful because each morning and each afternoon brought me closer to walking into the examination room feeling it was my business to sit down and ask, "What brings you here today?" And, upon hearing what each person had to say, knowing how to lead us on a fact-finding mission together, discovering what name we ought to give their problem and what we might do about it. At first I was wrong as often as I was right, but neither my patients nor my preceptor were eager to find fault and things gradually got easier and I got better. Another reason why I'm going to miss Mondays.
Most of all, I'm going to miss talking over the day's census in those precious minutes before all hell breaks loose, working through lunch and sharing an orange if there's time, greeting patients in the waiting room and chatting about the snow or road conditions like we've known each other all our lives. I'm even going to miss the blasted wall-mounted blood pressure unit that always sent me running for my portable cuff because I never could get the knack of dealing with its idiosyncrasies. The past six Mondays have been good ones, and despite being someplace new, seeing new patients and learning new things, I'm still going to miss Mondays in that tiny little town on the Kennebec River and most of all, the people who live there.
(Photo copyright 2011 by the author)
I feel a bit like Jessie Livingstone of Pink Hats and a Mack Truck, when she likened Dr. Bob Z to George Harrison on the cover of Abbey Road (chapter 10). You know how it goes when you meet a person who strongly resembles someone famous and it's hard to get the connection out of your head. Well, it's that way with my current preceptor. He not only looks and sounds like actor/dancer Fred Astaire, the two have similar mannerisms. Not that I'm anywhere near old enough to speak about Fred from personal experience, but if you check out some of his films on Turner Classic Movies, you'll see what I mean.
I'm nearly through this rotation, sadly but also gladly, and pediatrics is looming on the horizon in the Berkshire Mountains of Western Massachusetts. Sadly because I've thoroughly enjoyed every moment in north central Maine as I've said in numerous posts, and gladly because it means I'm moving on to something new. I've gotten to work with a few younger patients on my current rotation, mostly school age and teenagers, and they've been a lot of fun. I'm looking forward to seeing more like them as well as babies and itsy-bitsy kids.
I'm especially grateful to my preceptor for his willingness to "throw me in the briar patch" of patient care. Having to call upon things I've tried out on campus and do so now, in real-life situations, has been a challenge that's forced me to address my weaknesses. You can dodge some of that in the lab, relying on your student status and the fact that your patient is a paid actor, the presumption being, you'll get it eventually. But when your patient is truly short of breath, looks like death warmed over, and tells you they feel sick as a dog, you've really got to stand and deliver. I love that. It means I have a chance to do something that can genuinely make a difference.
Now, how much can a medical student actually do? That depends. Naturally, I can't pull out the old prescription pad, scribble something down, and hand over faith and hope on a 3 x 5 piece of paper. Still in all, I can do a careful history and physical exam, try to cover as many bases as I can, and then decide on the best course of action in collaboration with my attending's greater experience. It's more practice and practice creates confidence. I can't begin to tell you how good it feels, walking into the examination room and seeing someone for the first time, knowing the tools in my kit are ones I can meaningfully use.
There was a time, not all that long ago, when my black canvas doctor's bag with all its esoterica within, seemed like an appealing stranger. Now, I carry it with me every day, and feel a little naked without it. One morning its contents were as cold as the wind blowing off the Kennebec River and the next, as warm as my dog's greeting when I come home at the end of the week. I don't know when the change occurred, but it has and I'm glad I was there to experience it for myself. I guess you could say it's what happens when you have a chance to take lessons from "Fred Astaire."
(Creative Commons image of Fred Astaire and Ginger Rogers on the cover of Life Magazine, 1938, by Zooomabooma via Flickr)
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)
Can you believe it? Here I am, somewhere on the upside of maturity, however old that is, and I've never even seen the inside of a gambling casino. Not unless you count Oceans 11, Rain Man, Leaving Las Vegas, and Viva Las Vegas (on television, that is), and I'm not sure that counts for much. Now, this may not sound like anything to be concerned about, except I've got friends who're younger than me by at least three or four centuries and they've all boldly gone where I've never gone before.
Metaphorically, I've hung around Vegas on numerous occasions, since having been both a minister and a psychotherapist, I'm privy to confessional secrets. You know, what happens in Vegas, stays in Vegas? In other words, whatever you do while you're here, your secret is safe with us. Sounds confessional to me, more or less. Anyway, that and the movies are as close as I've gotten to the real thing until this past Wednesday.
No, I didn't hop a quick flight west after my last patient and gamble the night away, only to show up at my preceptor's office on Thursday, bleary eyed and broke. What I did was drive up to Bangor to see some friends from medical school who are on rotations at Eastern Maine Medical Center and stopped by Hollywood Slots, a real live gambling casino on the edge of downtown. It seemed like a perfect opportunity to take a look at what for some, has been the River of No Return.
The first thing I discovered was, it's difficult to just look because the place is an experience in sensory overload. Walking through the glass entry doors, the sound of slot machines clicking over their tumblers dominates all else. Naturally, there was music, a nondescript form of contemporary rock and roll, but no one was dancing like they show in the movies. The gamblers, almost all of them retired persons, were far too busy doing what they came there to do and, besides, the Muzak wasn't likely their cup of tea, anyway.
The next thing I noticed was the lights. Lights from the machines, from fixtures in the ceiling, bright enough to avoid tripping, but not so bright as to take your attention away from the all important one-armed bandits which, it turns out, don't have arms anymore. I suppose that's more of a throwback to the original Oceans 11 with Frank Sinatra and the Rat Pack, still worth renting for a date night at home. The "bandits" they use now are like computer games and operate with the touch of a button.
It rather reminded me of Percy Jackson and the Lightening Thief, though there weren't any pretty girls in skimpy skirts and low-cut blouses offering me magic mushrooms -- talk about bad luck. There were waitresses serving drinks all right, but their uniforms were unremarkable. Either the casino owners assumed male gamblers would be too busy to notice or too old to do anything about it if they did. Curiously, there were no windows in the gambling area, nothing to mark the natural passing of time. A person could get lost in the slots for days and until their money ran out or they fell asleep, they'd never realize what had happened.
As I walked around row upon row of slot machines, I noticed that's all there was. No cigar smoke-filled room with high stakes poker players, no classy roulette table with a tuxedoed James Bond and gorgeous babes hanging on both arms. Maybe I'd misunderstood, but that was my conception of a gambling casino. Slot machines for the low-risk, low return gambler, and gaming tables for the high rollers. I was disappointed. Not that I expected James might call me over and ask if I'd hold his place, using his chips, while he slipped off to the loo -- any winnings were mine to keep -- but stranger things have happened.
At one point, I stopped walking and stood still, listening. At first all the sounds blended together like coffee, chocolate, milk, and sugar in a gigantic Mocha. But then, one by one, first chocolate, then milk, and sugar were flung out of the swirl and I could hear them individually, against the undertone of the machines -- about an A above Middle C on the musical scale. The stereo was three dimensional and the only word I know to describe it is hypnotic. The sound throws the mind's gearshift into neutral, turns off the switch, and drops the key into its pocket, not yours. One instant you're reaching for the key and the next, you're wondering why you wanted to in the first place. And that's how it happens. That's how you forget where you are.
It almost happened to me. My tour had brought me back round near the entry and like someone who's had too much to drink, I fairly staggered out the doors and up the stairs to my car, hoping I had the presence of mind to locate the exit. I headed for Tim Hortons, two doors down, for a bracing dose of sugar and caffeine to clear my head. The pastries tasted better than magic mushrooms and the coffee was all of 92 octane. With scarcely an instant of regret over the thousands of refined sugar calories I was consuming, I slugged down the Joe and drove off into the sunset, though not, unfortunately, like Percy Jackson and his friends, in a "borrowed" Maserati. I guess you can't have everything.
(Creative Commons image by L. A. Nolan via Flickr)
"If Barack Obama had yo' hair colah, the two uh you could be twins."
"Ted, I've got three inches and twenty pounds on him, not to mention the other, rather obvious differences between us. You think my hair color matters that much?" Bob asked, grinning.
"No, I mean you both have or soon will have beautiful wives and two daughters, and that's a fine comparison to make, wouldn't you agree?" asked Ted, dropping his ethnicity for emphasis.
"I would, indeed, though as much as I admire him, I wouldn't trade jobs for love nor money. Difficult as mine is now and then, I'd rather be in hell with a fractured spine than have his. Though I suspect he'd say the same."
"Maybe, maybe not. Sometimes I think he'd like to be a healer, but some of his 'patients' are recalcitrant-prone."
"Mine only have tantrums."
"So do his," Ted said, with a wink and a nod, "especially the ones in Congress."
"You know what a tantrum is, don't you?"
"After four kids, not including yours, and nine grandkids, I'd say I have a fair idea."
"It's what he must feel like having when he wishes he could lay a few of them across his knee and apply the hand of cooperation to the seat of partisanship. And that's why I wouldn't want his job. You can make kids stand in the corner, but senators and congressmen?"
"Besides that," said Jessie, handing each of them mugs of steaming peppermint hot chocolate from a tray Halley was holding, "the only 'White House' I want to live in is the one we're buying. Any political aspirations will have to wait until all our children are grown and I'm tired of having you underfoot." She leaned over and kissed him sweetly. "Don't count on that happening anytime in your lifetime -- or mine, understand?"
"Oh, yes, ma'am, I do," Bob said, solemnly. He turned toward Ted, "I'm practicing saying that, both 'yes, ma'am,' and 'I do.'" Ted roared with laughter.
They were relaxing in the Green Granite Inn's lounge at Cranmore Mountain Resort in North Conway after a day of skiing punctuated by Bob's first snowboarding lesson. He and Jessie had taken turns with Halley and Ted, babysitting and occasionally pulling the girls round the lift area in a miniature sleigh Jessie and Halley purchased on a recent shopping outing. It was the same day Jessie also found a navy blue wool sweater woven with a reindeer across the back for one of Bob's presents. "He loves reindeer," she confided to Halley.
The Holiday was a week away and the Inn had been transformed with wreaths on every door, pine bows, poinsettias, a traditional solitary New England candle in each window and a huge Balsam Fir, wrapped entirely in star-blue lights brushing the ceiling, near an equally huge stone fireplace. After all that had gone on in the past few weeks, the couples decided a day and a night away was certainly what any doctor with a healthy dose of common sense would order. Jen and Chuck, fast becoming an item after meeting two weeks earlier at Bull Feeney's, offered to take care of Sam.
"So, did you decide on the giraffe, Bob?" asked Halley.
"Shh, make sure the twins are still asleep, first."
"They aren't going to understand you, not yet at least," she responded, drawing the blankets back from each of the unconscious pair in their carriers, "Yes, they are, now did you?"
"Come Christmas morning, Sam is definitely going to have a surprise waiting next to the tree, and the girls? Well, I know it will be a few years before they can really appreciate it, but one look and I couldn't resist." He was referring to a five foot tall stuffed giraffe he and Jessie had seen at Tree Top Toys in the Old Port. Far too big for anything but occupying space at the moment, it grabbed his attention when they walked in and he couldn't leave without it.
"They say having children is a chance to re-experience our own childhood, do you believe that, Bob?" asked Ted.
"I don't think it's our own so much as it is seeing the world as an adult through the eyes of our children, but in either case, it's something I've missed, I know that much. And, I'll tell you this, I'm deeply grateful life doesn't hold grudges when we don't get everything right the first time."
Jessie reached up and stroked his hair. "I got an email from my dad this week and he said something I think you'll appreciate. He said relationships like ours do far more than simply give us second chances. They give us the ones we've never had. You could say -- and I'm definitely saying it -- this is our first, at long last, and I'm going to make sure neither of us misses a single minute of it."
"Like Arrowsmith? You don't want to miss a thing?"
"Just like Arrowsmith."
(Photos copyright 2011 by the author)
For a generation of men raised wearing oxford cloth shirts, what I'm about to say may come as a surprise, but I was in high school before I developed my life-long affection for the button-down, all-cotton variety. Why so long? It's not because they hadn't been invented yet. That took place in the nineteenth century when English polo players discovered the basket weave pattern provided better ventilation during a match. The buttons were added when someone complained about collars flapping in the breeze.
Growing up, as I did, the son of a cowboy-saddlemaker, my father's shirts and mine were made of broadcloth and had snaps on the front and cuff plackets. Patterns were more popular than solids in Western-style shirts, and the truth is, you really can do a lot more with broadcloth when it comes to designing shirts in patterns. Don't believe me? Take a look at your Land's End catalog for men sometime. Brooks Brothers, Joseph A. Bank, you name it. Stripes do fine with oxford cloth, especially pinpoint, but the Scottish plaids, paintbrush styles, and paisleys (if anyone wears those anymore), are generally made of broadcloth. It just takes the dye better.
So, that brings us to high school. Somewhere along the line, my mother came home with three oxford cloth shirts, two of which were all-cotton, the other a blend. We had our shirts laundered at the time because you could have that done for a song, unlike today when it costs a symphony to get them out of hock. It was quite a while before I figured out why the all-cotton ones took starch so well and the blend, no matter how much starch was added, hung on me, limp as a banana peal. Polyester may help reduce wrinkling, but it can't absorb starch, and it's due to the fact that polyester is petroleum-based and starch has to be mixed with water.
I'm thinking about all of this today because I have freshly starched shirts drip-drying on hangers in the shower. It's part of my weekend routine. Come home from my rural medicine rotation with a bag of laundry, starch the shirts, dry and iron them. It's a habit I got into several years ago. I used to think having shirts professionally laundered was the way to go until learning about the process itself changed my mind. Because shirts are draped over a form-fitted model and steam is shot through the fabric, professional laundering tends to break down the fibers and as a result, shirts wear out faster. Since the steam is hot, they also tend to shrink a little each time. I don't know about you, but being on a medical student's income, there are limits to my shirt budget. Besides that, once I find a shirt I like, I'd prefer it to last a while.
I suppose one could argue laundering, starching, and ironing takes time and time is money. That's true, but the time I spend doing all of this is not time I'd spend making money, so in the long run, I'm saving it. Also, you have to consider how, once you've learned to iron and iron well, you get faster by sheer practice. If you iron while watching television, you can do two things at once and it cuts down on boredom.
Now, before the male members of the audience start thinking this is "woman's work," I'd like to suggest a couple of things. First, never, ever use the term "woman's work" around the opposite sex unless you want to limit yourself to first dates, because that's all you're going to get. Just because mom used to press your clothes, don't entertain the fantasy that girlfriends do likewise. Second, one of the secret benefits I've discovered about doing my own ironing is, women find it attractive. I'm not kidding. If you're a man, you already know there are things cooking in the minds of women that you won't understand if you live to be a million, so stop trying. This is one of them.
Still, I'll hazard a guess. I think women find it attractive because it suggests to them a man is secure enough in his identity and masculinity, that he can do domestic chores without thinking twice. They take it to mean he takes pride in himself, his appearance, and knows how to be responsible. A man who can do these things can also take care of them. Not that they can't take care of themselves, because they can, but you get the idea. It means a man is dependable, mature, and especially, confident. He's got the stuff money can't buy, no matter how high is his credit limit.
Oh, and if you'd like a good recipe for homemade starch, drop me a line.
(Creative Commons image, "The Morning Routine," by Mike Schmid via Flikr)
I'm home again after another amazing week in rural Maine. I gave my first tetanus shot yesterday and identified, if not actually diagnosed, my first case of outpatient pneumonia. The latter was a biggie for me since we didn't have a chest x-ray to rely on; instead, it was a matter of taking a careful history and listening to our patient's breathing, then asking what was the most likely explanation for their presentation. As I've mentioned previously, I can't get over how much more akin to internal medicine this rotation is turning out to be.
In part, this is due to the fact that my preceptor's patient population is, by and large, an older one, so the colds, flu, measles, and chickenpox that show up in family medicine don't walk through his door too often. It also stems from his comfort level, dealing with difficult and challenging cases. He won't admit it -- something I admire about him -- but he's a careful and astute diagnostician. He takes his time with patients and encourages me to do likewise and make certain I offer well-reasoned and thorough explanations for what we're doing and why.
More than accurate explanations, he wants to make sure we provide ones that are comprehensible. This appeals to me strongly because it's the same principle my friend Dr. Lynn Smith and I followed when writing our book. We wanted to communicate effectively, not impress readers with the extent of our vocabulary, something that often characterizes academic writing. "It's not what you say or do," my preceptor reminds me over and again, "it's what people think you said," that matters. For this reason, you want to make certain what they think is the closest approximation of what you actually said, as possible.
So, for example, when urging a patient to take a complete course of antibiotics and not stop once they begin feeling better, he'll say, "It's like wolves who attack the weak and sickly in a herd of deer and then go after the strong." An antibiotic kills off the weaker members of a bacterial population in the initial few days of taking it, but you've got to finish the prescription in order to get the ones that remain after you've started to improve. Makes a lot of sense, doesn't it?
I'm three weeks down in what's usually a four week rotation but I've been offered the chance to extend it by another two, and that's what I'm doing. I'm learning too much and having too much fun in the process to turn down the opportunity. Of one thing I'm certain, when I graduate, whatever kind of physician I'll become, it will be strongly colored by the weeks I've spent with this guy and his gal Friday in north central Maine. Am I ever the lucky one.
(Creative Commons image of the Kennebec River Valley by jimmywayne via Flickr)
