Certainty

Another one of those cases where being wrong rocks.
Yesterday afternoon, I overheard the doctor who had showed me the man with the Nec Fasc talking.

Apparently he was still alive (as of yesterday)and had actually regained his sight (he was blind prior to yesterday).

This may be the uplift before he dies, but it was not predicted, so maybe it means he will live. Maybe he didn't have true Nec Fasc and so the antibiotics we gave him actually worked.

All in all, a much more uplifting Thanksgiving story than yesterday's.

I guess nothing is ever certain, even when we are sure it is.

Necrotizing Fasciitis

I saw a man with necrotizing fasciitis today.* This is a medical student's dream; the grand hoo haw of infectious diseases. Nec Fasc is not something that you come across every day. It's the joy of being a med student that every practicing doctor wants to show you this crazy thing they just found. They haven't seen anything like it in all their years of practicing, and there you are, lucky enough to be a student and the receptical of all things educational. Our job is to be enthralled, inquisitive, and to validate their excitement. We reassure them that this is fascinating, we confirm that this is important, and perhaps our learning injects some hope into what might otherwise be merely a tragic incident; a sad waste. But that might be vanity speaking.

So back to this man I saw today. I got chills tonight, a momentary tear in my eye when I thought about what I had actually seen. It was not just necrotizing fasciitis. It was not just an infection superimposed on an already feeble, ill man. It was this man's death that I saw. The way that his life will end laid out on his body like tarot cards predicting the future. By the time he was diagnosed, 8 hours after admission, the flesh-eating bacteria had attacked too much of his already crippled body. Down one leg, up his back, weaving it's way down his other leg. Like a wave in slow motion, yet so fast, too fast for his body, for our medicine. There was nothing to be done except treat him for pain, treat him with antibiotics for palliative care, and help him die. And that's what grabbed me tonight. I saw this man for, at the most, 5 minutes, but he made an impact on me and not just because I had never seen necrotizing fasciitis before. He's the first person I have had contact with in the hospital who I know is going to die in the next several hours. And what's more, I know what he will die from. In my brief time in the guts of the clinical world, I have met many patients who I know are not long for this world. I know that we are merely postponing their death, but I do not know which one of their 10 problems will finally claim them. So even though we know they will die soon, we are ignorant about what they will die from, and the patient and the doctor(s) are gifted the freedom of continuing on in the charade, blissfully naive to the ending. Seeing this patient was like watching Hamlet after having already seen it. There is nothing to do but simply wait for the ending that you know by heart. You want to run up and console Ophelia before she drowns herself. You want to pull the poisoned glass from Gertrude's lips before she drinks. You want to reconcile Hamlet and Laertes before they stab each other. But you can't, because the show must go on (or so they say), and the ending always comes, and it always comes in the same way.

And so I know that tonight, at 10:45, the infection has now completely consumed both of his legs. It has moved onto his upper body. I am almost certain that he has finally developed sepsis and possibly fallen into unconsciousness. It is quite likely that, at this hour, roughly 24 hours after coming to the emergency room, he has succumbed to the ultimate, irreversible outcome of such tissue destruction.



*Necortizing fasciitis is one of those things that really scares me - both from a doctoring stand point and from a patient stand point. In other words, it's something I'm worried I'm going to miss in a patient and something I'm petrified that I am going to acquire. It's also something that fascinates me. I get the same chills up my spine, the same obsession/revulsion feeling about it as I do about deadly snakes and sororities.

Alaska

This week, I saw a man in his 70's. He was wearing a thick flannel shirt, suspenders, and a trucker's hat. First question out of his mouth was "Who did you vote for? I voted for McCain." He's a retired bear hunting guide and taxidermist, but he still likes to guide for 30 day scientific expeditions through the Yukon, in the winter (yes folks, I did say he is 70). He also swears that fried chicken gizzards are just about the most delicious thing he's ever had.

Amazing.

I Love Tuesdays

One week later and I am still in shock. Like everyone else who blogs, I feel the need to put something down to mark such an historic, nation changing, nation shaping event and I figure that within 1 week, it still counts as current. I sent a text message to pretty much everyone in my phone (except for my die hard conservative friends). Below are all of the texts I received about the election over a 30 hr period, including the responses to my text. I heard back from people I hadn’t talked to in years, highlighting for me how enormous the collective sense of relief, freedom, and change was. My text was sent at 19:15, it is italicized

(And a side note: Tuesday is apparently going to be the most superior day of the week this year. .last week was the end of stupid-people-in-charge era, and today it’s dumping in Alaska. . .did I mention I’m back in AK these days.? . happy like a clam).

5:48: I’m at the polls right now-very exciting.

18:04 Looking good

19:15 Congrats! Woo! This is the best day in eight years.

19:17: Yay!

20:21: Owwwwwwww!

20:26: !!!!!!!!!!!!!!!!!!:)!!!!!!!!!!!!!!!

20:29: Amazing night! We can be prove americans again!

20:34: Maybe 30 years. Halle-flippin-lujah!

20:34: Absolutely!

20:38: Indeed it is.

20:39: I finally love america :) When can we get together?

20:40: Drinking and cheering

20:40: Historical moment my friends! Obama!

20:41: Fuck yay

20:42: Yes yes. ** says he has been depressed for 8 years. Just ichatted with – Log what a speech

20:45: Fuck yeah!! 221 years in the making.

20:45: Cap hill we’re all cbheering and crying and just f*ing ecstatic

20:45: Yes congrats to us all. It’s a great new day in this country.

20:47: No kidding!!!! It’s fucking AWESOME! Awesome speech too

20:48: Fucking amazing

20:49: Yay! Coming to the comet tomorrow?

20:49: Wooohoo! I have chills! That speech was incredible!

20:50: Indeed

20:50: Totally! So excited!

20:52: Hell yeah

20:53: People at literally dancing in the streets here in NYC.

20:56: oh hells yes. We’re in DC right now… total mayhem… like effin carnival… it’s beautiful… love.

20:57: Indeed! Bravo! Hurray! Watershed moment ;-D

20:57: woo hoo is right. What a great feeling! I still have goosebumps from his speech too!

21:01: Epic! So proud. Miss you!

21:03: Fosho… How u been?

21:09: Yeah!!! Um, who is this?

21:11: Not sure who this is but I agree!

21:14: Oh nice to hear from you. And thank goodness we won! I cried.

21:14: Yeah! I feel so good the election is over and obama won

21:15: Yay!!!!!!!!!!!!!!

21:17: Ppl lighting fireworks in Berkeley streets

21:20: so youre alive

21:22: Let’s see what happens on prop 8 before we get too excited, but yes, I am happy so far!

21:24: Gregoire!!!!!!! Obama!!!! Happiest moment of my life :-D
F Yeah America!

21:39: We did it! Democracy worked. We are a better nation today. I’m so damn excited

22:28: Why? What happened?

Wednesday, November 8, 2008

3:40: Yipeeeee!

6:01: Amen to that!

11:33: Who the hell is this

11:34: Hey my phone got messed up, who’s number is this?

11:37: Aw Jessie I miss you and I still cannot contain my happiness today. I wish we could celebrate together!

Teaser

I am nearing the end of this whirlwind tour through academic medicine. I have had the impulse to blog, flashes of thoughts I wanted to put into written form, but my desire to reflect is weak compared to my imperative need for sleep. And so this page has remained silent for almost 6 weeks. Which is funny, because I feel brim full of epiphanies had and stories witnessed. So as I wind down my time here and transition back into the slower world of winter in Alaska, I am hoping that my memory will hold and I will have time to sort through the jumble of emotions and thoughts brought on by my last 6 weeks.

For now, this:

Frequently I look at those of us who are training to be doctors, and those of us who are residents, and those of us who are attendings and I think, dear god, we are just children play acting. There are young children, like myself, who mimic and there are older children, like the attendings, who decide which games we will play, but we are all nothing more than children in a big, scary, chaotic world. We have information gleaned from good and bad studies that we use to make decisions, we have the experience of the way similar situations have gone in the past, we have a stethoscope, we have MRIs, and we have blood tests, but these are weak defenses against the uncertainty that fills the spaces created by the heterogeneity of patients. There is, over our shoulders, a constant question of uncertainty. Sometimes it looms large, sometimes it squeaks small. The latter are days of success, I think. This uncertainty is not what I find disconcerting. It is expected, it is why medicine is referred to as an art rather than a science. It is why so many of us are drawn to the field.

What I find disconcerting are the ways that we try and manage the uncertainty. There is the ridiculous paperwork that tries to minimize unnecessary uncertainty. Perhaps our best response to it is the collaboration that is the foundation of doctoring. And our worst, the one that would keep me up at night if anything could keep me up at night these days, is our collective approach to each patient as a game, a puzzle to be solved, a mystery to explore, a lesson to be learned.

I think of the pre-code we were called to several days ago on a post-call morning. In front of us was an unconscious, large middle aged man. His pillow was red from the blood drooling from his mouth. He grunted to pain, when we pulled his eyelids open, we could watch his eyes rove back and forth in a rhythmic pattern. One side to the other, one side to the other. His vitals were stable, his blood gases normal, nothing to indicate what was going on. And the three, maybe four of us in white coats stood at the foot of the bed nonchalantly discussing his case.

R3: What do you think is going on?
Other R3: I have no idea. . . maybe a seizure?
R3: Yeah, that's a good guess. Probably is what it is. I mean, it doesn't look exactly like a seizure, but, what else could it be?
Other R3: Yeah, I mean, his vitals are stable, ABG was good n' normal, normal sugars. . a seizure could look like this, I think.
R3: So should we give him some ativan?
Other R3: Maybe. Did you call Neuro (to the intern)
Intern: Yes. Couldn't get ahold of them.
R3: Hmm. . I guess we could just give him the ativan, it's not going to hurt him, right?
Other R3: I don't think so. Seems like it's something to do.
Silence
Nurse: So do you want me to go get the ativan?
R3: Yes, I guess. . I mean. . I think so. Yeah, sure.

And so on. . eventually no ativan was given, and we all backed away from the patient as his primary care team arrived. He was still seizing, or doing whatever he was doing. I was struck by how we stood at his bedside, fascinated by what he was doing, without any urgency to fix it. I felt like we were children – our white coats fit too large, our stethoscopes looked awkward. Our feet shuffled. .how can we make this more fun again?

Sound advice. . .

. . that I overheard the other day went something like this:

"Just remember, you never know when you are going to have your last first kiss."

Priests and Layfolk

I can’t believe I am actually saying this, but it may be that the thing that I find unsettling about family medicine is the emphasis placed on patient centered care and preventative medicine. It’s not that I don’t believe in those things, I absolutely do. The only way we as a population can become healthier is by preventing ourselves from doing those things that make us unhealthy. And of course, the patient should always be at the center of health care.

The problem with preventative medicine in its current incarnation is that we have made basic common sense seem like something you need an MD to understand. Preventative medicine is not rocket science: don’t smoke, don’t drink too much, eat fresh stuff, exercise, don’t get too fat, don’t get too stressed. It is possible that by naming these topics medical we have actually done a disservice to our patients. Once something is medical, it is seen as inaccessible to anyone other than a health professional. Practitioners have become the priests required to access common sense; we are the intermediaries between laypeople and their own health.

Along those lines, with patient centered care, the patient is always right and every concern they have is equally valid and important. Of course a patient’s worries should be addressed, but I’m not sure it’s to their benefit to come in for every 2-second pain or unusual sensation they experience. This is linked to the sequestration of common sense to the medical elite. People don’t trust themselves anymore. They have no connection to their bodies and so they doubt every feeling they have. Normal body processes are now seen as death knells. The medical field reinforces this ignorance of self by giving a visit to every preoccupation. And we validate every anxiety by solving it with medical advice. Instead of saying. “well, sometimes that just happens,” we prescribe opiates or anti-anxiety medicine. And our latest trend response to non-issues issues? Yup, you guessed it. . preventative medicine, which means that people only do preventative medicine when they are told to as a curative measure (and is that really preventative anymore??). (And on a side note, of course there are forms of preventative care that should never be abandoned - cervical cancer screening, for example).

I'm not 100% sure if I agree what I wrote above. Since I believe in holistic medicine and I believe in treating the entire person rather than the illness, there is something to be said for being able to prescribe things like "eat better," and "exercise," and "meditation." And I never want the medical pendulum to swing back in the direction where doctors are patriarchal figures - telling their patients what is best without any input from the patients. That said, I do think that we these 2 concepts aren't sitting quite right. There is work to be done there, because I'm not sure that, at this point, we are doing the best by our patients.

28

I’ve been neglectful lately. Somewhat willfully, since I have been gifted late mornings and a job that I leave behind when I go home. But somehow I have not had the drive to write. And I have suffered for it, I think. Like exercise or yoga, reflection is one of those activities that makes us feel so good that they are the first thing to go when we get anxious or restless.

So I am nearing the end of my 2nd rotation. Family Medicine. Experiences continue to occur, although I feel less engaged by them this 6 weeks around. I’m not sure if it’s the place I’m learning or the field itself, but I certainly don’t feel the light me up sort of passion I felt during my OB/GYN rotation. That may not be a bad thing. In fact, if my goal is to wind up living a balanced life where medicine is a job rather than a lifestyle, family medicine is the simplest answer. For sure it is lackluster, but I like to think that it would inspire me to seek passion elsewhere. That said I have some concern that dullness is catching – leaving me with an overall subdued existence. The dying adolescent in me shudders at the thought of such complacency (the horror, oh the horror). Of course I also am worried that an uninspired medical career would swing the pendulum in some warped direction where I forget to fill my time with things like outdoors, music, food, art, politics, thought, people, etc, etc. Instead, in search of more intensity, I would resort to old habits of poking at my relationships till I create some purposeless drama and find myself in a familiar mess I had sworn off years ago. Luckily no decisions have to be made yet. This year is just for observation and information gathering.

In truth, the last 4 weeks have brought out strong examples of both responses. Instead of writing and reading and playing and exercising, I have slept and complained, and (oh the shame of admitting this) watched T.V. And when I wasn’t doing that, I was regressing to my late teens and foolishly getting caught up in ridiculous drama. I behaved poorly towards others and towards myself and almost cost myself a friendship or two (the outcome may still be uncertain). Suddenly old tapes were playing and I lost the clarifying breath of perspective; I became a person I like to think I no longer am, but obviously still have the capability of becoming. I suppose we are never rid of our lessons learned.

But on the eve of the start of my 28th year, I figure I get to clear a slate. Birthdays, like New Years, are good times to kick start the drive to grow and improve. Resolutions (that will always be broken, and set again) abound. As Emily would say, it’s probably a good time to build that bridge (yet again) and get over it (thanks lady).

Well, sentimentality is getting the best of me, but it’s almost my birthday, so I can give in to it tonight. I just want to say thank you to all the folks in my life (those who read this and those who don’t). I am damn lucky to know such incredible people. When I look around, I see crazy beauty and passionate commitment and so much laughter. It’s a good reminder to breathe and live it up, all purty like.

I love y’all.

Well Said

Exactly that. . . well said
You can sign it too (scroll down to the very bottom).

Part 4: Economic Down-Turn

This is Part 4 of a 4 Part Entry. . you might want to scroll down to Part 1 - Sometimes Dreams Do Come True.
**
Other highlights included an incredibly athletic, very tall black stripper who was so flexible (like pretzel flexible) that I’m pretty sure she had some cartilage disorder. At one point she was doing the splits and then put her arms under her legs and lifted her entire body off of the floor and proceeded to do multiple push-ups. It was like Olympic gymnast quality. I was floored. I went up to the dance floor and gave her money, but I made someone go with me.

A highly informative chance encounter with a different stripper in the bathroom revealed that stripping has lost some of its stigma and has seen an increase in the number of women coming to strip bars. According to her women in strip clubs are a mixed bag because, while they do buy dances, they usually only buy one and they often make the 40 y/o virgin males (“who still live with their moms. . .can you believe that?”) uncomfortable and shy. Just like Sexy Lexi, she loves her job, although she is disappointed by the recent decrease in her earnings which she suspects is due to the economic down-turn and high price of gas.

Very rarely, illusions do (more or less) turn out to be the reality. I am still completely overwhelmed by the amazingness of last night. Really, all that was missing was a pole.

Part 3: The Wisdom of our Elders

This is Part 3 of a 4 Part Entry. . you might want to scroll down to Part 1 - Sometimes Dreams Do Come True.
**
When the waitress came over to take our drinks, Sexy Lexi told her my plan. The overweight, older waitress became very concerned that I was serious and said, “Honey, do not drop out of medical school to become a stripper. I mean, you could do it, and maybe do it to pay for school, but don’t drop out of school. It may look glamorous, but it gets old fast. You only have a few years in you, and then, well. . I used to be a stripper, and now look at me – waiting tables here.” I felt like I was in a movie.

I reassured her I wouldn’t do it, and counted myself lucky. It’s not often one receives words of wisdom from a former stripper.

Part 2: A Stripper Called Me Crazy, And Other Tales of The Night

This is Part 2 of a 4 Part Entry. . you might want to scroll down to Part 1 - Sometimes Dreams Do Come True.
**
Sexy Lexi was the 26 year-old woman who my kind and generous colleague hired to give me a lap dance. She started by telling me I was hanging out with a very hot group of guys, “Um, thanks?,” I said. I wasn’t really sure what to make of that.

(On a side note, what does one do during a lap dance if one is getting a lap dance? Obviously no touching, but where are you supposed to look? What facial expression are you supposed to have? I felt horribly awkward and when I feel awkward, I just start grinning from ear to ear. I’m not sure goofy grin is the facial expression of choice for lap dance reception.)

My friend chose wisely in Sexy Lexi. When she was done, she said “So you guys are really all medical students? I have so many questions for you.”

Could this have been any more perfect? I was so excited “And I have so many questions for you!”

Turns out, she has her BA in international politics and used to work as a para-legal until she found that she makes bank (and I mean bank) stripping. She and a friend are essentially traveling strippers. They come to a USA town that has good gigs, strip for a while, and then take all of their earned cash and go travel to other countries (Guatemala, Costa Rica, Japan next). Eventually she wants to go back to school to get her masters and become a Mandarin Chinese interpreter. Really, not a bad set-up.

I asked her if she likes stripping. “I love this work, it is so much fun.” And she told me that the lap dances are for the customer, but on stage, she dances for herself. Wow. I was totally sold.

She hung out with our group for a while. She told us that she wanted to make out with all of us and we should return on the 27th, her last night of work, when she didn’t care if she got fired (later at the all-night diner, my friend said earnestly: “No, I don’t think I’m going to go back on the 27th – hah!). The anthropologist in me continued to pick her brain. I told her about my fascination with strippers and that I was thinking about dropping out of medical school to become a stripper. (a joke folks, a joke). “You are really crazy,” she said and then looked at my friends, “She is really crazy.”

Part 1: Sometimes Dreams Do Come True

I went to a strip club last night. The Great Alaskan Bush Company is apparently notorious for being the “classiest strip club outside of Vegas” (according to my friend, it is the tourist strip club in Anchorage - who knew there were strip clubs for tourists and strip clubs for locals). A regular hang out spot, I was told, even the women come there to hang out. And, once I became desensitized to all of the tits, ass, and pussy, it was sort of like a normal night’s activity. It was more like watching a show, or going to the circus than it was like hanging out at a bar since everyone’s attention was focused in one general direction (the naked women) rather than scattered over the variety of intentions found in a bar. It was, as my friend put it, a sort of amusement park. I didn’t find it particularly arousing or erotic (I actually felt the opposite of those), but I was never bored, so I guess I can understand the entertainment value of the whole thing.

The truth is, I’ve wanted to go to a strip club for a long time. There is an allure there similar to my fascination with debutantes, sororities, Texas high school football, and the mafia. It’s rooted in curiosity about a culture that exists side by side with, but is very different from my own. And, if I’m being honest, I have several glorified fantasies of those lives not lived. I mean, really, what girl hasn’t wondered at some point about what it’d be like to be a stripper. So yeah, I’ve wanted to go for a long time, but I was always reticent for fear of shattering the illusions I have about the glamorous lives of happy strippers. I didn’t want to see the depressing reality of sleazy bars, disgusting old men, and miserable, bitter women. I figured that I would just chose wisely so that the strip club I would eventually go to would be clean and classy and not too much of a let down. Who knew I would find all that and more on my first real night out in Alaska? (I love that this is one of the first things I’ve done other than medicine in AK)

Mistakes Were Made (Mistakes Will Be Made)

Yesterday was one of those days that reminds you that humility is not always a graceful, humbling, educational experience. Sometimes it comes in the form of plain old red face embarrassment.

So I finally got to do my first pelvic exam. It was going ok (not great, not horrifically) until (you knew there was an until) the bimanual exam. Now, mind you I got an “Exceeds Expectations” on this part of my OSCE during medical school, so I was thinking, “yah, I got this one down.” Apparently doing a bimanual exam on a plastic model with no legs and no pubic hair is a bit different than doing a bimanual exam on a real live human being.

Without being too graphic, what happened involved some uncertain fingers, a misguided approach (but, thankfully no entry), and a rapid readjustment prompted by the patient’s, “Um. . .are you supposed to use the back door?” My attending looked at me horrified and asked “Did you just do a recto-vaginal exam???” I shook my head (somewhat frantically) and said “No,” in an incredulous voice (as if to say, “what do you think I am, an idiot?” Of course I am an idiot. That’s my job, and that’s all I am going to be for the next few years). This was the beautiful conclusion to a very long day of me being unable to answer basic questions like “what is pregnancy induced hypertension.” I perceived the aftermath to be a totally disappointed attending who thinks I am hopeless.

I left the clinic humiliated, beating up on myself. I had excuses: I’ve been sick, on cold meds, end of the day, first pelvic exam in almost a year, nervous, etc., etc., etc. But, that didn’t make me feel better. I was not a happy girl. And then I realized that I had damn well better laugh at myself for a botched pelvic exam, because if I don’t start lightening up on myself, I’m going to have a complete breakdown when I accidentally cut an artery in surgery or hit a nerve during a procedure. I say when because mistakes will be made (for good reasons and for no reasons) – it’s a matter of time, not a matter of if .

Lesson One: Check

First lesson. I know that I have ranted and raved about how taking a political stand is one of our most important doctorly duties, but sometimes my words taste mighty sweet, so I am eating them. Nurse D is sort of in charge of our experience in L&D (that’s labor and delivery in fancy schmancy medicine talk). She’s an important person to be on the in’s and in’s with. She’s someone you want to be on your side. You don’t want to piss her off. And, as I learned yesterday, you don’t want to let her see the Obama pin on your bag, because that quickly pisses her off and puts you on the out’s and out’s, on her enemy’s team. Here was the sequence of events: Scene 1: Laughing about small talk, everyone smiling. Scene 2: awkward elevator induced silence during which Nurse D eyed the offending pin on my bag and then scowled at me (there were eyewitnesses to this event, so it wasn’t my paranoia). Scene 3: Nurse D is mean and unfriendly towards me, but nice and friendly with everyone else. Scene 4: I covertly (and sheepishly), take the pin off of my bag and stuff it into my bag, along with my high horse (see earlier posts). Apparently AK is a red state. Who knew? Chalk that error up to education: Lesson one learned.

So this bring up 2 things. First, if I accept that my job right now is to learn everything I can from everyone willing (and unwilling) to teach, projecting my strong opinions about things is probably not the best way to be successful at my job. I remember in grade school they used to tell us to put our hands down and write down our idea so we could pay attention to our classmate speaking instead of spending all our energy concentrating on the brilliant statements we wanted to make. I’m not saying I need to give up my core beliefs and not so core political alliances, but I do believe that, at least in these early days, the more neutral of an image I present to my teachers, the more they will be willing to fill in my (seemingly) blank pages with their thoughts and knowledge. Then I get to go home and use those stored morals and values to sort through their beliefs and ideas. And I guess that brings me to number 2. Being neutral (within reason – you have to have a spine and think for yourself) for our elders is beneficial (again, in the early days); being neutral for our patients is almost essential. This is why we dress nicely, but not too nicely (business casual, or maybe a bit more). This is why, at least early on, we do not wear flashy jewelry, or dye our hair green, or show too much cleavage. It’s almost as if we want to be inconspicuous, because the less our patients notice us as individuals, the more reflective we become, and the more they divulge to us (and usually themselves) and the more we are able to help them (and they themselves). Later on, as we learn other tricks and become more steady on our doctor feet, this undercover, almost sneaky method of information gathering will become less important, but right now, it’s one of the only tools we have.

Hardness

This is hard. So much harder than I thought it would be. I truly believed that I was going to enjoy studying for the boards. I had visions of studying for 8 hours a day, and then going home to cook dinner, run, play frisbee, watch movies, read a book, play guitar, languish in long philosophical conversations with friends over wine or beer. This was going to be the beginning of reclaiming just a little tiny bit of my life back. I was going to be able to start being that person I used to be, or that person I really, really want to be. So innocent, so naive.

Turns out this is hard. It’s not that the 8 hours has turned into 10 and 12 hours. It’s not that I’m (not surprisingly) so much less productive and efficient than I imagined myself being. It’s not even that I am finding relearning this stuff less interesting than I had hoped. It’s the hopelessness. It’s the reality that I will spend my next 3 weeks studying all of the time only to start working 100 hours a week. Sure, it is doing something I want to do (or that I willingly signed up to do), but it’s actually that much further from being able to shape my life into something that feels more manageable, more bearable, more me.

Roughly two weeks ago I had a conversation with a colleague. Not a friend, but a classmate I know from before I even started at UW. Back then, he was making the same decision between schools as I was and we conversed a bit through email about the decision. Without knowing each other’s names, we exchanged pertinent personal background data and gave each other tips/insight into our “difficult” decision. I had a symbolic crush on him – he seemed so thoughtful, so smart, so interesting, so passionate. . .to me he was exemplary of the world I was about to enter – endless possibility, life changing, completely engaging, and the future source of my most meaningful friendships and, hopefully, lifelong partner. He remains symbolic to me because he, like so much of this experience, has been vastly different than what I expected. Almost the personification of this school, I find him subtly deceptive and frequently the bearer of cold truth. I don’t dislike him, but I am wary around him. We were at baseball game and as we walked out, we started some uncomfortable small talk about the end of the year and how great it felt and how we can’t wait until we get to start “what we really came here for.” I mentioned how nice it was to have some free time. He laughed almost ominously, “It’s nice,” he said “that we get a transition. That we get to slowly move from our old lives to this new one. That we have 2 years to adjust to being busy all the time, to never having enough time to ourselves, two years to become doctors. I don’t think I could do it overnight.”

There is a good deal of talk in medical school about becoming a doctor. We talk about the privileges and the responsibilities. We talk about the changes and the sacrifices. We talk about what it means to our family, what it means to our communities, and what it means to the greater world around us. And we talk about what it means to us. My colleague, the bearer of realities I’d rather ignore, seems to have equated becoming a doctor with sacrifice of self. I’m not sure he would describe it that way, but I think he will thrive on denying himself to serve his profession. I think he is excited about that (and in some ways, what an easy way to live .. if you know that your work is the most important thing, decisions are essentially made for you).

At this point I am far from sure about what becoming a doctor means to me. Truth is, I think I’ve been (and continue to be) in a bit of a denial about how much this process will change me. A good piece of me still believes that when I am done with these eight years, I will just return to the life that I lived before. I will have this skill when I am done, and with it I will simply slip back into the life I’ve put on hold. Intellectually I know that this is unlikely and emotionally I am beginning to realize that no matter how I resist, I will finish this 8-year process a completely different person. Obviously 8 years doing anything changes someone. I think what I have been fighting (tooth and nail) is the rather obvious idea that this process is going to change me in ways different than if I’d done something else for the next 8 years. What I think I am uncomfortable with is that there is a prescribed change that I have to go through so that I can become this doctor person. It seems like I will no longer be able to hand pick the changes I want to move through and ignore those that I dislike.

It’s a funny feeling to no longer be in control of the direction of my growth. It takes a huge amount of trust in my elders (something I am terrible at) and an even larger amount of faith that this will all turn out alright in the end. For me that faith has always been patchy at best: I did not enter this process knowing, without a doubt that I want to be (was meant to be) a doctor. I hemmed and hawed over 6 years; I weighed options, made lists of pros and cons, and, in the end, going to med school had a slight edge over the other options. I understood it as a process, one more adventure. And I suppose I still see it as that, on some level. I think the gravity of what I don’t know coupled with the unabashed expectation that this become a lifestyle has given this journey some weight. I must travel more slowly, more deliberately, more thoughtfully. Lately I do so looking backwards at what I have left behind or left and right at what I am missing. At some point I should probably do a turn around in my head and refocus my attention. I’m sure it would change the sensation I have of being swept up by things I have no control over. I’m just not quite sure how to get there, especially when I feel so empty of the doctor faith that is supposed to drag me through this.

Retreat

It's been a while, I know. . .and lots has happened and not very much has happened. I'm spending the week out on Orcas Island studying - a retreat away from the distraction that was the city. I have no internet or phone service at the house, and that is conducive to wholesome things like studying, playing guitar, and writing. The writing seems to be a bit more. . .well, reflective, contemplative, heavy, and maybe a little long, but I guess that's where I'm at these days. And I think the way that this whole blog thing works is that I post what I want to post and you read what you want to read. Or something like that.

3 types of smiles

My friend Nate finds the most ridiculous stuff on the internet during class. You can always tell how bored he is by how much stuff he texts out to everyone. Anyways. . today he sent out 3 things that made me smile, each in a different way.

The wry smile

The awww smile

And the hah smile

Oh. . and this was just a full laugh out loud for me. . I guess I'm a little mean.
(let it load first, and then watch it for full effect)

Fun with. .

Stephen makes all of the ridiculous shit that has been going on in the democratic circus feel a little less horrific.

Go here and watch Hillary's video first, then Barack's.

And then watch this to make you wish that there still were 3 people in the democratic race, even if it might have meant another white male in office. . . .

That Thing

Talk about Synchronicity. . .I wrote the following yesterday with the plan to post it today. . and now with osf and Toby's comments (especially Toby's) - well, yeah.

**
I’ve been thinking about compassion. Perhaps inspired by the Dali Lama’s visit, perhaps from hearing about empathy in my ICM class, perhaps from the gentleness my mom is exhibiting in the face of her father’s decline, her sister’s insecurities, and her mother’s panic. Perhaps it’s because I’ve been struggling lately – my blues are encroaching in tighter and tighter circles. I’m fighting it, but I am so busy these days that I don’t even notice what’s going on until I’m cloaked in monotony. These oh so gray days are flat, disheartening, and discouraging. It’s not depression - that is too personal – it’s more of an anhedonia borne from the underbelly of the medical profession. It’s the despair that comes from crying uncle on trying to hold onto the life that once ways; it’s the defeat you feel when you accept that your life can no longer be relationship-centered, at least for a while.

Lately compassion has been in short supply in my life. I’m worn down by my friends, I’m annoyed by a patient’s complicated presentation, I mutter about my housemates for the chaos that is our fridge. I can’t remember the last time I felt positive about a class and just about every sentence I form starts with the words, “You know what would be great,” or “Why can’t they just. . .” My parents never say the right things on the phone and even Annie, the dog, rubs me the wrong way. Basically, I’m sitting deep and dark in the thick of it.

I’m convinced that compassion is the cure. But compassion is a funny thing and while I know that I need to breathe more, compassion more towards those around me, I think that the real deficit is inward compassion. Just like that age-old adage, you can’t truly love others until you love yourself (or something like that), I’m not sure it is possible to express compassion towards others until you feel compassion for yourself. Can you even know what forgiveness feels like if you don’t forgive yourself all the shit you do wrong? And if you have never felt forgiveness, can you genuinely give it to others?

This may be coming across as all wooo-wooo-y , so let me try and clear it up a little. See, I am beginning to see that compassion is an art that walks the fine line between being patronizing and being invested. I don’t really know what it truly looks like, or feels like, because I am either too engaged or too removed. When I am too involved, my feelings become my focus and I can’t get any perspective. When I am too distant, I view those suffering with curiosity or, even worse, pity. Thus far, when I say “I have compassion,” it is linked with a sense of having figured out the other person’s problem, being beyond his or her problem, being unaffected by his or her problem – and there is some superiority in there that doesn’t belong. And there is the strange paradox that I experience which is that the more compassion I feel towards someone, the less connected I feel to them. Even my closest loved ones – when the compassion washes over, the detachment creeps in, and shortly thereafter the dissatisfaction and the loneliness. Obviously, I have some serious work to do.

This brings us back to wise words about compassion. “Be compassion,” is likely less about giving compassion to others and more about breeding compassion from within. And to do that, I think forgiveness of self is required. This means I have to forgive myself when I have to cancel an obligation. I have to have more compassion when I fail at doing daily living things (like getting my oil changed, making my bed, cooking). I have to let myself fuck up on tests, cry because I fucked up, and rationalize both of those events. When I get annoyed at my peers – forgive. When I am not exercising as much as I would like – compassion. When I skip class – permission. Even though everyone else around me seems to be handling it all so much better – compassion, compassion, compassion. That’s not to say that I should throw my hands up in a relativist fit and say, well, none of it matters anymore. Of course not – I still strive to improve all of those things, I still evaluate my (endless) shortcomings, I still fight and cry and struggle. But I work on decreasing the guilt, quieting the critic, and just slowing down the panic. Perhaps once I have that down, then I can spend some time figuring out the whole golden rule thing.

In Sync

The Dali Lama just left town. He spoke at several large events and, no, I did not get to see him, sadly. But I still received a bit of his wisdom indirectly – I actually think this city is moving a little more lightly since he was here. I have never met the Dali Lama, I have never seen him speak, and I have no personal experience with his wisdom or the clarity that people find in Tibetan Buddhism. But I have witnessed the effect he has on others, and it is powerful. I remember when I was in high school going to a symposium held by some top-level physicists who had met with the Dali Lama in an exchange of ideas, unsolvable problems, and solutions. They were glowing with their transformation and, through them, I was too – US history and geometry have slipped away, but I still hold on tight to what I learned there. And yesterday I was on the bus when two older women got on. They were carrying programs from one of the Dali Lama events that had just happened and the young man sitting next to me asked them how it was. Another lady joined in and a conversation between strangers ensued. Not many were talking, but everyone in ear-shot was listening. Compassion, they said, that was his message.

I don’t much believe in fate these days, but I do believe in warped moments of synchronicity. And I think that being on the bus at the same time as those shinning women was one of those moments. When they came on, I was having a rather negative conversation with one of my classmates. I don’t have a lot in common with her, so complaining about school is the only way we have found to fill the awkward bus time we share. There was a sharp, almost visible contrast between our dark, angry tone and their brighter airs and it was humbling. Suddenly I heard the words coming out of my classmates mouth and I was reminded of how awful complaining really sounds. This was a reminder to shut up and appreciate.

Returns

Long, long time ago, I started this blog. And I think I said something like, "1 post every 2 weeks, or so." Well, it's been longer than that. I've been a bit busy these days, and my mind has been more than a little dry. Or at least dry of things that belong here. I'm going to try and pick it up again, but I'm not even sure what is happening in the rest of world. If I'm supposed to write about what I know, it might be time for me to focus on medical school, medicine, and such.

In the mean time. .

Here's what I did for Spring Break:


And here's something that happened today - it's important.
We should be protesting the Olympics in China, and I'll try and get into that later.

Good Signs

Hats off to Ross.

Refreshing

Imagine a society that not only values happiness as much as success, but understands it as a means to productivity.
A community that sees pursuing passion in even the most obscure direction as critical to the community's survival.
Picture a place that gives folks freedom, and trusts them to make responsible decisions.

Then shake yourself and stop fantasizing.
Or don't and go work here:

This is whimsical, with some good points thrown in there at the end.
I am less than happy with the way the media is treating Hillary. After several conversations with folks (my sister-in-law included), I have realized that she IS getting bashed, and a good 2/3 of it has to do with her gender. It makes her appear that much more attractive, really. And if I were a conspiracy theorist, I would note that maybe that's the grand plan after all: attack her so much that she gains popularity again, gets put up as the democratic candidate, and then the republicans take the election because people will actively vote against her. Now that would be some reverse psychology, Mr. Rove

The Choice

Very interesting article on what it is we are actually choosing between when we compare Obama and Clinton.


That link may not be around forever and I'm not very savvy in the ways of making things stay around on the internet, so let me know if you want to read it after it's gone (I have a copy of it I can forward to you).

Corrected

I've been meaning to write this entry for a while. Usually I think of something I want to write about and I put it off in the name of focusing on my tasks at hand. And then time slips by fast and furious and the thought becomes forgotten, or more tragically, obsolete. This entry is important. It's so overdue it is now awkward, cliche, overdone, but it's still important, so I'm going to push aside relevance and say it. Short and sweet like.

I stand corrected. I was wrong. And I'm happy about it (shocking to hear/read me say that, I know).

A few weeks back I wrote an entry titled Physicianhood and talked about the lack of political engagement from folks in this country. Well, I stand corrected. The last 2 months (and really this last month) have seen an incredible surge of passion and concern from people everywhere in this country. My fellow medical students got excited about the caucus. They attended, they volunteered, they buzzed. The anticipation made it feel like Christmas morning. It's hard to know what it is. Maybe people are fed up, maybe people are scared, maybe people suddenly understand that politics really do effect their day to day lives, maybe people are inspired. Perhaps it's the fact that the image of the politician is getting reshaped. It's no longer just an older white male, entrenched and overdone. A politician can be female, it can be black, it can be young, it can be inexperienced, it can make mistakes, it can change it's mind. And a politician has the potential to be anyone. The cynic in me says it's a trend - it's the hip thing to do right now. Politicking has new faces, new controversy - those things create popularity. Those things get stale. But my optimist tells me to believe that this is the beginning of a new phase in our country's history. It's a baby step towards recognition of what it truly means to be a member of this world. And it's a motion, a small gesture towards changing our unsustainable ways.

Of course, more needs to happen. None of the candidates are putting forth proposals for real change. They are magicians, we are willfully enthralled. But maybe our country needs illusions of change before we can embrace the real thing. A model before construction, a dress rehearsal before the show.

Still, for now, I'm content, gleeful even, to be proven wrong.

I'd love to write more, but medical beckons with the crooked, scolding finger of an old lady.

Downsides

There are some things I love about medical school. These days, I talk about all of the things I dislike about medical school. There is so much to complain about: the busy work, the long hours, the anxiety, the feeling of perpetual incompetence. In truth, most of those negatives are just talking points, things we (medical students) use to keep the conversation going, things we use to mar the fantasies that others have about medical school. When one gets past the long hours and tedious studying, we are lucky to be learning such amazing things and privileged to get to enter into that sacred healer-patient relationship.

What is hard, what lacks any sort of consolation prize, are the relationships that are drastically altered. I knew before I started that there was sacrifice involved in this process. And I knew that I would change, my life would change. But I did not expect such an erosion of my friendships. Some of my conversations have become hollow and rushed, remnants of what once were full-bodied, lively relationships. Now exchanges are empty and the awkwardness is amplified by the echoes of experiences once shared. There was no natural end to the friendship, no easy fade-away. Instead, the separation was sudden, drastic. We were both pulled apart and thrown into our respective realities - neither party has had time to adjust to the changes, and we are left with a disconnect between the reality of our situation and the lingering memories of a friendship that once was. And this is pervasive - with my closest friends, my oldest friends, and my family. (Although an interesting side note is that some of my relationships (most familial) have improved since starting medical school, likely due to an increase in the level of respect afforded me - I can now be taken seriously, and, since communication was sparse B.M. (before medicine), the time constraint had no negative impact).

To clarify, I am not writing off my B.M friends, I know that my friendships will last this - the bonds are strong and those people I love are even stronger. Time and distance impact, but they do not destroy. But it is hard to watch this transformation without trying to control it. This will elicit groans, I am sure, but it is reminiscent of a doctor who has to accept that a patient will suffer before he or she will improve.

So this is one of those unexpected, slap-in-the face side effects of medical school. This is part of that change in identity that they talk about on the first day of medical school. It is hard to maintain connections with people you love while fostering new friendships in such an intense, demanding environment. And I know that these are choices I make, and I guess that’s what makes this so hard. Certainly the structure of medical school is not conducive to relationships, but I’m not a huge fan of using that as an excuse for choices I make. I used to think I was stronger than that. I guess that's why they teach us that song in preschool.

"Make new friends, but keep the old ones
One is silver and the other's gold."

An Opinion

Bye Bye John

Why did he drop out?
Well, there's a lot of speculation running around out there, but I found this this afternoon and thought it was a somewhat interesting analysis of the situation. Not sure I agree with all of it, but some interesting ideas.

More later, I'm off to physical therapy for my elbow.

http://onegoodmove.org/1gm/1gmarchive/2008/01/
why_john_edward.html

Physicianhood

I was at a dinner party the other night and I got into a political conversation with a friend of a friend. It was heated (warm, but not hot) and fast, fairly superficial, and we didn't completely agree with each other. It was certainly intense, but it wasn't an angry, loud or aggressive political conversation. Still, in a matter of 3, maybe 5 minutes we cleared all but 1 person out of the room (I think something like 8 people left). I know I can be overwhelming in conversation, and this guy was too, but these are my classmates, fellow medical students. These are the students touted as the cream of the cream of the crop; these are the people who are some of the most highly educated members of our society, these are the people who are supposed to change the world. And, yet, these are also the people who are made physically uncomfortable by 10 minutes of a superficially political conversation.

I left that night feeling depressed and frustrated. When did our community get so afraid to express opinions? When did our community get so passive? Of course this is not an affliction suffered by only the medical community; political apathy is one of the most insidious epidemics of our society. Among most communities in the United States, speaking of politics with any conviction is a conversational taboo worse than religious beliefs, earning power, and sex. I spoke with a friend and colleague the other night about this and she noted that labeling yourself political is almost viewed as negative – a black mark against you. It is not surprising that people have become so alienated from politics – corruption, failure, and insulation from the consequences of governmental decisions make anyone frustrated and disillusioned. But why is our accepted, indeed, encouraged, collective response detachment and distance from the political process? Why don’t injustices and suffering galvanize us to question, probe, and fight for change? Without doubt the former is easier. Some argue more that apathy is more consistent with human nature, but this theory is weak against the reality that in general, people in other countries are politically engaged. In most communities around the world, to be apolitical is abnormal; that is the socially awkward stance.

So then why, why does the most powerful, richest country in the world have the most apolitical people? Or maybe those two statements answer each other. We are apolitical because we have little to worry about (being buoyed by the illusion of power, safety, and wealth). And we are the most powerful, richest country in the world because we are the most apolitical people. And then we must ponder how? What part of our system, what shaping forces in our country’s history brought us to this point?
**
I have had several conversations recently centered on politics, medicine, and the safety net. There is no lack among future physicians of good intentions. There are only a small number of my classmates who are NOT interested in working with underserved populations in some capacity when they are practicing physicians. And we all spend much of our time volunteering in local food banks, tutoring centers, free clinics, and at homeless shelters. And most of us, myself included, do it out of a genuine desire to help, a sense of responsibility to give back. Whether altruistic or not, these are generally understood as noble motivations.

So we all want to help, which is wonderful. The gap of awareness that is disconcerting is the emphasis on charity work as an alternative to (or separate from) work towards change (which, for linguistic ease, I will call politics). There are many who believe that charity work without political work is one of the primary things that sustains and perpetuates our current societal

system. Indeed, it is possible that charity in isolation actually harms the underserved since it insulates people from the outrageous injustices being forced upon them: charity work prevents things from getting totally unbearable and it makes those inclined to help feel as though they are doing their part – thus perhaps Marx was wrong – it is charity work that is the most dangerous opiate.

I am not arguing that politics is more important than ground level work. Paul Farmer has shown again and again the importance of providing underserved individuals with basic necessities. My point is that charity and politics are intimate bedfellows – isolated, they can cause great harm to the people they are trying to help.

I first started expressing interest in medical school at a time when I was frustrated by politics. I was burnt out on activism and exhausted by dogma and political absolutism. I was having a difficult time seeing truth in anything and I felt wrong putting so much energy towards controversial, ambiguous issues. I didn’t feel right pushing my agendas on others. Politics felt dirty, unfair, and unproductive. Wasn’t it all about community anyways? Wasn’t it all about changing yourself, your relationships, and your own personal environment? I wanted to live in a Gandhian way –be the change you want to see in the world. So I started seriously looking towards medicine. At the time, I saw it as a neutral way to help people and give back to my community.

I am older now, and my understandings of politics and life have changed, as understandings and beliefs tend to do. A few years have taught me that things are oh so much more muddled than I thought they were. I now understand politics to be inseparable from life. I read Gandhi’s statement not just as a suggestion to live the way that you preach, but also as recognition of the consequences our actions and our inactions have on the world around us. It is an acknowledgement of our inherent political self – just by being we make a statement, whether we want to or not. This is unendingly powerful, and frighteningly dangerous.

So I have learned that I cannot be neutral. There is no such thing as a neutral participant in society. There is apathy, there is silence, and there is inaction, all with consequences often as forceful as the consequences wrought by passion, speaking up, and action. Not advocating for change is a statement in and of itself. So perhaps that is the gap in understanding among us medical students. We have power. . .because of our personhood, because of our citizenship, and, now, because of our impending physicianhood. Just because we don't actively use our power towards something doesn't mean that the power dissipates. It stays, and with silence and inaction, we invite others to use this power to fit their agenda.

The Merit of the Majority

We need a leader who does not hold all perspectives and opinions as equal. While I believe in open discussion and acknowledgement and understanding of all sides of an argument, I also believe that not all ideas carry equal merit. The problem with this election cycle is that we have democratic candidates intent on unifying the diverse views in the country. Obama notes that “There (are) a set of things that I can do that no other candidate can do. I can bring the country together around a working majority for change in a way that Sen. Clinton, for example, cannot." But Hillary Clinton is no better. She is so tainted by politicking that she cannot commit to a position on anything, for fear of alienating some base. While she does not profess to be a candidate who unites, her actions show that she is reluctant to exclude anyone except the most fiscally and socially conservative, voters from her platform.

The problem with such a strategy is that this country’s problems should not, cannot, and will not be solved by more conservative methods. It’s not to say that the more conservative answers to our problems didn’t work at some point in our country’s history. They did and they were very effective; that is why they have remained so popular for so long. But times have changed, the world continues to progress, and the conservative response has become outdated and ineffective. The Merriam Webster dictionary defines progress as a “forward or onward movement.” It is not a recycling of used ideas, it is not a return to traditional plans and morals, and it is not a continued reliance on tried and true methods. Progress requires innovation, invention, and creativity. Innovators, inventors, and creators usually do it. And those people, the truly successful, truly brilliant who push our world to change are rarely obsessed with pleasing others. Indeed, those presidents who drastically altered the direction of our country were not making decisions based on popular opinion. They were taking risks and pursuing a vision, at most costs. (Of course, this can also be applied to our currently unpopular President, George W. Bush, undeniably he has wrought significant change, but change does not equal progress).

Compromise Versus Mediation

Without a doubt, a successful president must excel at compromising. But it seems that compromise has become an established virtue rather than the dynamic tool that it should be. Since a compromise is a merging of multiple ideas, one must have a foundation of concrete ideas from which to compromise from. This foundation is made of strong opinions, beliefs, passions, and the conviction that some solutions are better than others. From here, one can meet others in the middle and produce a unique outcome that, although it does not satisfy all aspects of it’s diverse origins, promises to address at least some of them. Compromise is a great thing, but one cannot be a good compromiser without taking a stand and risking alienating those with a different view. It seems that we have erroneously equated compromise with mediation.. A good mediator facilitates a compromise between multiple views. A good compromiser comes from one opinion and makes concessions to form a new solution. Both have value, both are important, and we need a president who is capable and willing to do both..