Oh Yeah...

For potential medical students or those already in a program:

Just remembered some advice I was recently given and want to pass on before I forget. It came from a surgeon I respect very highly - one of the sharpest and kindest guys you could ever meet. He said, of the things he uses today, he wished he had studied "bugs and drugs" better. That would be microbiology and pharmacology. Sounds like these are things we will need to know in detail when we are in practice, but may not have a ton of exposure to. It makes sense that we will need to be better able to comprehend the things that are coming at us and how to employ the tools to deal with them, but he says it's easy to get lost in the minutiae. Just a heads up.

Christmas Thanks

Our lives consist of the relationships we have with one another.

Relationships by definition, I suppose, are described by the way we share things, the way we give to one another and accept things from one another. That’s how we connect. I am convinced that our lives will be measured in the sacrifices we have made for one another. To that end I am certainly thankful for where I am right now. I’ve been given much more than most.

One of my best gifts is a wonderful wife with a huge heart. She pours herself out for her children and friends, for the kids she teaches, and for me. There is a challenge with big hearts, however. They are like the large vase in the middle of the table that is easily bumped by the careless, or easily stolen by the greedy. I think most of us tend to shrink our hearts down, so they are more manageable and less fragile. We try to fit them into our chests in order to keep them well-protected. Deep inside our rib cages. Closely guarded. So, I am thankful for Hillary’s example. Lots of folks have bumped her carelessly (myself included) or intentionally taken advantage of her due to their perceived need. But, she continues to love and to be a reminder that love must be what we are made of. I hate to think of where I would be without her presence.

Unfortunately, I haven’t had much time to share with her, lately. Or with Katy. But I’m reminded of the wonderful experiences we have had together. Trips we’ve taken across the country and to beautiful places. Shared moments are the stuff of life. Even the time I had with her sons. Much of it was hard. Some of it I wish I could do over. But, some of that time was pretty darn good, and I hope I made a difference for them. Indeed, we all illustrate our lives with the brushes we choose to paint with. I hope mine can be love rather than hate, compassion rather than coldness, and joy rather than misery. I hope I add color while I’m here.

Caring for others at the most basic levels has been a humbling wonder, and I am constantly learning how to turn myself upside down and give away the things that are most precious to me. I’m reminded of parents and friends, brothers and in-laws. I entrust them to their choices and to the creator that guides them. Before you misjudge me, however, know that I am no saint. I have to confess I’m not built this way. It’s hard for me to always be a nice guy (which is why some of you have noticed I am not…). Maybe that concept resonates with some of you folks, too. Truth is, I really have to work at it. I need reminders from the good people around me. I’m surely grateful for them. There I am being thankful again.

Of course, I’m thankful for the opportunity to go to this medical school. I fall somewhere around the 99.95th percentile when it comes to age. Way out to the right on the curve. Out of over 18,000 folks I started with, you could probably count students my age or older on both hands. I’m very blessed, very fortunate. I truly hope this will be another way for me to really learn to give away both the parts of me that I already have and those I am able to create anew. Hopefully, I can leverage that capacity to create a greater effect.

It’s been quite a year. Wishing you all the best you can be and all the joy you can know.

Home for Christmas

We are on Christmas break now. Two weeks of bliss for most of us. I must confess that I am tired. The last test was challenging, maybe even more than the previous. I went into it feeling less sure about what I knew. – You must understand that in medical school we cover a great deal of difficult material in a short period of time. We are essentially reviewing everything we should have already learned, and then they add icing on top of that cake. If you haven’t even been exposed to the material, it can be an uphill climb. I would guess we cover three or four times the amount of material you are covering in your undergrad courses in the same amount of time. For example, how long did you spend on the Krebs Cycle? A week? We spend an hour. And you have to know everything about it. Of course, we don’t… Most of us only answer about ¾ of the test questions correctly. Just understand that these are very bright people and very challenging tests. The bar is always being raised.

If medical training is on your horizon, I strongly suggest you learn all you can about the human body in the greatest detail you can muster. You won’t be able to learn the detail you will gather in the four years here, but you will need the base to operate from. And, I do emphasize the term “learn”. You must have mental access to this knowledge. Your recall must be crystal clear. You must do this with intent. You must realize that your patients will be counting on you to have made this effort. Very few people are actually willing to do this. It takes a person with a wonderful combination of desire, perseverance, ability and compassion. I hope that’s you.

From the gallery, I think all of this hard work and bar raising is a good thing. I truly can’t imagine any better way to become a doctor. We all need motivation, and this can be a very useful way for us to soldier on. So, bring all of the best equipment you can pack as you head toward this, though try not to be weighed down with the things you don’t need. Many times we have been advised this is a marathon. Pay your entry fee gladly (thankfully), grab your Gatorade every mile or so, stay light, be strong, and keep your eyes focused on the next marker. In the end, you will be amazed at how far you have come and what you know. Then you get to apply it. You will be blessed beyond your wildest dreams. Do well.

On Grieving Patients

Went to my Living with Life-Threatening Illness class today. The room settled down, and a gentleman stood up. As he began to speak, I focused my attention and listened carefully as this veteran oncologist (a medical doctor) told the story of how his son had died suddenly several years ago. I listened as he told us of three years of grieving and painfully sorting emotions until his life felt livable again. His pain is not gone, and his emotions will likely never be entirely sorted, but he was present, and his story was, at that moment, ours as well.

Knowing that our interaction with patients would probably only occur over a few days or months rather than years, I asked him a question. “As future physicians, what we should be doing in those moments or days in the hospital when patients and their families receive news of fatal prognoses or watch loved ones draw their final breaths? What do we do when the wounds are raw and open?” And, this is what he said.

Just be there.

Don’t try to fix the problem. They don’t want us to try to fix the problem. Don’t tell them how things will be okay. They’re not okay. We need to take off the doctor hat for a moment because what they want is for us to open our hearts and come close. They need to know we care. We may not need to say anything. Less is probably better. Just soak up their grief and share it.

That’s right, future doctors. After 12-15 years of challenging training, the best you can do is sit there and cry. Maybe hug them. They have a lot of hard work to do, and this will help them begin to do it.

I really hope you’re listening.

Note: Permission was granted by the doctor to post his story.

Brutal, Baby...

We’ve just finished the third of three difficult tests a week apart. This is supposed to be the hardest segment of the hardest year of med school. So, we seem to be done with this hard part. Hopefully, I passed. This last test was very challenging to say the least. Right now, I am studying. What else would I be doing? I am attempting to finish material for next week, read ahead. - Is this what the rest of school will be like? Probably not. I think this is just them placing us on a three-legged stool and kicking one leg out from under us, so we have to grab hold and become engaged in the process of 'active sitting'. The objective is to keep us in the game. They want us to have taut muscles, pumping hearts, thoughts and focus on the stool. They want us to tend to the important details of learning rather than being sidetracked by other people and events in our lives. We can always get up and leave, but we know that we must sit in order to learn and reach our final goal. We must stay the course.

On Purpose

One of our instructors in the Living With Life-Threatening Illness class indicated that people have hope as they die because they feel they have a purpose in life. So, I looked up the meaning of purpose in my dictionary. The definition revolves our desire to intend to do something, or it refers to a reasonable, rational end to an act, a creative effort, or use. Also, when we have a purpose, we are determined - resolute even - in achieving a practical result, effect, or advantage. It speaks to imagination, design, and forward thinking. It also speaks to a need of the ability to think. And, as far as we know, of all the things in this universe, only humans can do that.

So, I applied this definition to our purpose on earth. It had to have reasonable, rational intent. And, since we didn’t place ourselves here, as best we can tell, it had to originate from somewhere outside of us and our present understanding. And, indeed, any purpose we may have would have to be tied to our ability to think and understand. Understanding would have to be part of what we call purpose. It would also follow that learning, in order to gather understanding, would be part of being able to have the intent to do. Our purpose, then, is also tied to our learning.

We are certainly learning from the time we are born – to eat, stay warm, get along – to survive in general. We protect ourselves, our things, our children and people we care about, our systems of behavior and codes of conduct. These things help us live better, longer. We survive. But, so what?

I wondered if we are learning the wrong things. Nothing of this life remains, does it? What could possibly “remain”? And, if it remains, where and in what condition does it do that? Good question.

The things we take to survive (food, clothing, shelter, reproduction) cannot be tied to our purpose because they do not exist beyond our life here. Earthly survival cannot be tied to our purpose on earth unless it is tied to a survival beyond this existence. Of course, we may have no purpose. But since I have hope (purpose), I write this paragraph. Hmmm, how circular… or how obvious.

Our ultimate purpose, as revealed in death, cannot be to take. It can only be to give and to learn from the experience of giving. Indeed, we have a tremendous capacity to have and then give away over the course of our lives. Problem is: we don’t. We focus on present survival for the most part. Hmmm.

So, if we give away our things and ourselves, what would we learn? If we give up this life, what are we giving it to and why? Purpose predisposes us to consider a design and intelligence outside of our understanding – something beyond and outside of this life. Seems logical. And, in order to have a larger purpose, we have to believe in something we can’t see or understand from our current perspective. We have to use our minds as we are convinced of something beyond our birth and death. We have to rationally consider the finite and the potential of infinite.

Our purpose will certainly be determined in the things we are convinced of. The most hopeful thing I can possibly rationalize is that something exists outside of this life. Something I cannot see or understand but that is no accident. Since purpose includes intent and thereby thought, my purpose must include something that thoughtfully created us. And, that creator (to personify) clearly thinks and acts well beyond my ability to understand or comprehend in any more than very basic ways from this point of view, and this creator chose (intent) to create us in our present condition. We all must be logically intertwined in a larger purpose that we are hoping to truly understand. Indeed, our dying would be part of our collective purposes and, given that death is beyond our control, we know that we have far less control over our lives than we imagine.

Now, you may say you have no purpose. You could hold tightly to every earthly thing to have nothing when you die (because nothing truly matters). Or you could take the chance of having a purpose and having everything (whatever that may be) when you die. If you are right, we both have nothing. If I am right, our creator will explain to us more clearly why expressions of giving were so important. And, our creator will explain to us why taking was so useless.

Seems I can only win here. At least in the long run. I wonder how long I’ll live after I’m dead. Hmmm.

Creating the Invisible

Reflection for the body donor service:

One of the jobs I’ve had in life was to teach. During my education, I learned that there are many ways to learn, and I even learned how I learn best. I know that I assimilate understanding if I can pick up an idea, twirl it around, and see it from different perspectives. I gather knowledge best when I can touch the object I am discerning and feel its borders, comprehend its density and texture, and place it into a frame of reference for future application.

The special gift offered by the gentle persons who taught us anatomy will spread out like ripples in a pond of giving. They made a choice to open our eyes and minds in a way that no one else could. We will hand their choice back to the world in the form of clarity, perspective, truer judgment, and a common desire to give ourselves away.

When we leave this earth, I hope we will leave it having given away as much as we possibly could have. I hope that what persists in our physical absence will be the same kind of reminder that these people have provided us: a reminder of what lives on. I hope we have the courage to create what does not go away.

One Day Closer to Death

Started a new class this week called Living With Life-Threatening Illness. In this class we visit with and learn from patient-teachers who are in the end-stages of life and then share our experiences weekly in groups.

On this first day we met to learn more about the course, to meet one another and to discuss our motivations and reasons for being there. At the halfway point, we broke into smaller groups and sat in a circle, so we could all see one another. The group leaders asked us to describe in more detail any events in our lives that had caused us to be interested in end-of-life care and in wanting to be part of the class. The instructors told their stories and several others also told theirs. As I began to speak, my brain disengaged and my heart began to speak as memories flooded my conscious awareness. Thoughts bounced from one to another, completely out of chronological sequence. They all seemed to be emotionally tinged as the pump had been primed by the moving stories of others in the group.

I must have perceived that gathering and room to be a safe place since we were advised that shared information must remain confidential. I trusted them because they trusted me. I gave them glimpses of deaths I had been near and how they had impacted me. I told them about how I want to help people die with some comfort and dignity, with joy and clarity. I told them I want to discuss death and make it a part of life that we accept and embrace with less fear and more understanding. My voice broke as tears flowed. I can’t completely say why I felt so much emotion. I suppose I’ve seen so many people die with so little fanfare or so little care. I would like to help people know they are loved before they leave this place. I suppose that’s not an easy thing for some people to hear or believe. Too bad you can’t just come out and say that as a doctor. We have another job to do. That one takes precedence. Professional distance and objectivity have their value. There are some things that most patients simply aren’t looking for in doctors. Family, friends, clergy, counselors and advocates fill those roles.

But we can help to get this right. We can learn what works and what doesn’t. We can learn how to listen to patients' needs as they encounter an end to their path here. They can choose how those days will be spent. Maybe they will believe in an afterlife. I believe in a purpose and existence far beyond this one. I know what I know. I have experienced what I have experienced. My faith runs deep.

Will be interesting to see what I learn here – about how people approach death and how we can improve that experience, about skills that I can obtain in order to facilitate their final moments, about what lies inside of me that has been shoved into long-forgotten corners.

To Tell the Truth

Thesis: Being truthful with our patients is a necessary part of being a physician.

As physicians, we have a “duty to inform” our patients of their conditions, outlook and possible cure. This may be an implicit requirement or an explicit legal requirement depending on the laws in the state in which we practice. As physicians we are legally expected to tell the truth as we understand it and allow patients adequate information in order to make intelligent choices about their care. More importantly and beyond any legal mandate, telling patients the truth simply demonstrates respect for them and in doing so we create a covenant of trust with them that is central to the practice of medicine. Should individual patients prefer to receive less information about their health scenario or choose to assign their autonomy to others, we can always modify the amount of information we convey to them but never the quality.

When our patients are not told the truth, they are, by definition, uninformed and may not seek care. They may very well fail to receive necessary attention because they are unaware of a problem and will have no incentive to correct it. As well, they might make decisions in their lives that would be very different had they a clearer understanding of their overall health picture. Also, many patients are comforted in having a name assigned to their condition, and not knowing all pertinent information in their case may add anxiety and tension to their decision-making due to a sense of uncertainty. Indeed, persons who are not made aware of health problems are not afforded the opportunity for personal growth as they make choices about how they will receive their medical information and allow it to impact their families. And, without stretching our definition, withholding information from patients could be construed as a deception which would undermine their trust in us and in the medical profession, in general.

So, telling the truth is simply a high ethical standard we maintain as physicians - but we and our patients realize other valuable benefits as well. As stated above, our goal as physicians is to engender the covenant of trust we establish with our patients as central to the practice of medicine. It is plainly the most respectful and legally proper, and financially responsible mode of behavior. Additionally, however, we know from our PCM course material that telling the truth has been shown to cause patients to follow their care plans more closely, decrease patient pain when they have a fuller understanding of their health status, and improve health outcomes as patients are more fully informed. Telling patients the truth also has been shown to increase patient satisfaction in that they feel trusted and a partner in their own health care and makes patients less likely to change physicians when we allow them to participate in decisions about their care. As the final trump, telling the truth has even been shown to decrease malpractice claims.

Truth-telling should plainly be a habit any future physician practices without hesitation. It may require some effort as we consider specific legal requirements and individual cases, but we should always be attempting to tell the truth well as we are able and at every patient encounter. If we are not able to do that, it’s time to pursue another line of work.

The Art of Acceptance

Question: How will I incorporate and be understanding of persons with different cultural perspectives who come into my practice?

After a PCM presentation highlighting a Chinese naturopath and an M.D. having a mostly Hispanic patient population, I asked myself the question above. Our reading indicated that 70-90% of patients manage their sicknesses outside of the realm of formal healthcare and that our individual cultures play a powerful role in how we care for ourselves. Specifically, our material describes folk remedies that exist in all cultures and which vary tremendously from one culture to the next. So, how can I learn and apply knowledge of complex, culture-based care?

I think the answer consists of two parts: Gaining practical, on-the-ground experience and through independent study. Before I can do either, however, I must realize who my patient population typically will be or could potentially be as I begin to interact with them. I will likely have easy access to this information if I join an existing group practice or hospital. Or, if I begin a solo effort, other local providers or the community composition in the location I select will provide the initial profile.

As a first effort, I will need to read all I can discover concerning the cultures I expect to encounter. Each patient will present with different concepts of family, ideas of social justice, hierarchies among relatives, decision-making authority, folk remedies, and how they will approach their healthcare based on the cultural solutions they are familiar with and of which they are convinced have value. I will need to understand what each patient truly believes will make a difference for them and whether it will truly improve their health. Of course, much of the reading will be found in medical journals – and much of it will not. It may be uncovered in cultural periodicals, stories of persons who live in or originate from those worlds, and articles that describe their practices and beliefs as written by persons who are members of the fold. I will simply have to devote a good deal of my personal time to learning about my patients and until I have a firm grasp of who they are and what they believe will impact their health.

As a second means of learning, I will need to gather information directly from the patients themselves. Since this learning will occur one patient at a time during individual encounters, it will transpire at a much slower rate, but, as I am attentive to each person, I will steadily acquire this understanding. It will require a humble attitude that allows me to hear, and I will have to be open to new ideas and accepting of habits I don’t understand. I will need to inquire consistently as to their ideas and cultural remedies, and seek nonjudgmental compromise as we work together in their plan of care. Indeed, as indicated by Dr. An, the naturopath, some persons believe that the body only heals itself, and we merely need to attempt to get out of the body’s way or remove any impediments to the body being able to heal. And, as long as their methods are not deemed harmful, it may be best to negotiate a treatment plan whereby patients pursue their chosen remedy in addition to any I may deem beneficial or necessary. Possibly, their positive belief and outlook may make a remedy worth pursuing.

As I progress through medical school I will likely gain valuable insight into many cultures and practices. There will always be more to learn. I will continue to seek out new information and clarify my understanding of every culture I encounter. And, as a generous side benefit, my patients will educate me about new cultures in depth, and I don’t even have to purchase a plane ticket. Nice bonus.

Hearing to Heal

Question: How can I communicate with patients so they feel heard, cared for, and cared about?

I consider this question in response to the woman who addressed our PCM class and who told the story of losing her material goods and livelihood due to a husband’s financial dealings and a precipitating stroke. On that particular afternoon, we were hearing how people deal with acute illness and life crisis issues as this woman described the painful interactions she had with busy doctors who left her feeling distant and unheard.

As I listened, I wondered something to myself. What would happen if patients could write their own notes in their charts about how they feel, what their symptoms are, what they think might be wrong with them, and what we (doctors) should do about it? I began to wonder how much of that note a doctor would actually “hear” and take to heart if it were written in that sacred space and whether they would truly believe their patient’s opinions mattered. The truth is we mostly only allow patients to interact with us on our terms and in our official spaces which doesn’t seem to be a way to place them at ease or engender their trust. To do that I believe we must be partners with them in their care and understand them as they present themselves. While we are trained to approach medical problems from an evidence-based perspective, we can never truly have an “understanding-based” perspective until we include in it the expertise that each patient possesses of their own condition and history.

When I finally enter a practice of my own, I will spend much of my time listening to, encouraging, and negotiating with patients as I come to terms with their worlds and seek cures for their ills. Patients can help me do all of these things. One of the ways the woman described above communicates with her doctor is to write notes in advance of her visits, so she can present a complete list of her concerns when she arrives. Her doctor suggested she do this. Of course they aren’t placed in the chart, but, since she has difficulty remembering her symptoms and collecting her thoughts while she is in the room with him, it effectively allows her to feel that she provides all relevant information to her doctor, and she feels like it is an important part of her being heard - of her story being told. The lesson for me is to be aware of what a patient is capable of and aware of how they will communicate with me. I need to find ways, if they are lacking, of being able to communicate well with patients. It can only give me better information to make a more appropriate diagnosis and allow me to have a sense of where patients are at in order to understand them as “whole” persons.

Here are some additional relevant gleanings that I learned from my favorite family practice physician, Dr. Jeff Stoessl at Salem Clinic in Salem, Oregon:
· Sit down
· Don’t stare at the computer when in the room with a patient
· Don’t look at papers, books, or charts except as a quick reference
· Be 110% focused on the patient - nothing else matters right then
· Look patients in the eye when you both talk and listen
· Politely let them know what you are doing – communicate what is occurring at the time
· Allow patients time and space to think

It sounds obvious, but it comes down to a moment-by moment choice. We must choose to care and listen to every patient. We must choose to act in order to make a difference. We must choose not to be paternalistic or arrogant or the keeper of knowledge. We must convey to patients that we have an interest in their lives and that we care for them as whole human beings. Every encounter is a chance to get better at these things. I can’t wait to try them out.

Another Story of Kindness

When I first realized how sick I was with the flu, I went to the ED for help at 4 a.m., and they kicked me out of school for a week. Good for everyone, I know. But, it meant I couldn't make the test that afternoon, so I emailed my instructor the details of what happened and asked what to do. He said, " This is what you normally need to do, but, don't worry, I've taken care of it for you. You just need to get better. Let us know how things go. Wishing you well!"

And, you know, I did feel better. That was a relief. I had no idea how I could make up a lab exam having 50 structures to identify and that were tagged on the same cadavers that students used every day. A weight had been lifted.

I sent back a status update the next day and advised that my fevers were increasing. He sent back a note jauntily claiming that my quarantine status was a terrific idea and encouraged me that the timing for the illness was perfect in that this was the easiest block for getting caught up. He told me to take care. – I hadn’t realized the block was the easiest. But it really was. The illness was becoming less perilous by the day.

I sent back a note the next day thanking him for the encouragement and letting him know I hoped to be ready to go when they let me back into class. – He replied to let me know that he would allow other options that would permit me to take the test at a relaxed pace and/or at a later date as the illness allowed. He said I could decide when I felt better and to let him know if I was interested in that option. Above all: Try to feel better!

And, so I did feel better. I had options. I was trusted. He believed I was sick and wasn’t a con artist. He believed I was doing my very best, and he wanted the very best from me. He was going to help me do that with every tool at his disposal. Wow. Out of 160 students in that class, he took the time to make sure this one had what he needed. Impressive.

So, the following Monday rolled around. That was the first day anyone was willing to let me come near them. Can’t say I blame them. I was still sick with something. I went in to take the written make-up test. It was handed to me at arm’s length, and the staff was quite gracious as they set up the room for me and started the slides. I finished the test with a minute or two to spare, pages swimming in front of my eyes. At least it was over.

I went into the office, and who was there but our instructor. I had never seen him in there before. He greeted me with a big smile and seemed genuinely glad to see me there. He wished me luck and took the test from me for grading (electronic scan).

I was checking email later that night and up popped an email from the instructor. Apparently, he had graded the test within an hour or so and was congratulating me on an excellent score. I was incredulous. Normally, it took two days for us to get our scores. Then... I get congratulations! – I had no worries about how I did and a boost to keep me going.

And, that’s not all. The next day, he dropped by our lab table to tell my labmates how glad he was to see me back in class on Monday. He gave a robust fist pump and a big grin. He was rooting for me.

Right about then, something clicked. My brain kept telling me to re-evaluate what was happening. I realized something special was occurring. This was no ordinary person and no ordinary act of kindness. This was a person who actively sought out the cause of someone’s pain and worked diligently to cultivate a cure. He was persistent and careful as he tested his remedies. He would not give up until he was certain I had been restored to health.

I realized this was a guy who cared deeply about every single person in our class and who was completed invested in our success. We mattered to him. We really mattered. He truly cared that we learn and that we take away every lesson possible from the experience.

Indeed, he took the time and made a significant effort to create a place that allowed me to heal. He helped me get better. He’s not an M.D. But he’s a healer. He’s the one guy on staff who performed flawlessly during my illness. Without hesitation, I tell you it’s an honor to sit at his feet and learn the healing art of medicine.

Thanks, Dr. Ciment. We’re damn lucky to have you as an instructor.

Something Different

Here's a poem I wrote the other day.

Healer

I hurt so much
And fear so deeply
That I am all undone

When she arrives in pain
At the very least
Do not harm her further

When she brings the shattered pieces of her life
In her hands
Do not jostle her
Or squeeze her hands so tightly
That you cut them
As the jagged pieces
Dig into her flesh

Choose differently

Ask her to place the pieces
On the table between you
And seek to discover
The source of her pain
And the healing that need be done and
Create
The place where healing can occur

Allow the science to work its magic
As you pour yourself over the broken pieces
Causing peace and love
To flow over the shards
Of her cup
And allow them to mend
So she might fill her cup
Once again

Classy Class

While I was out of class and in such a pitiful state, I was able to observe some behaviors that I normally wouldn’t have. Thought they were worthy of recording here.

I confess I was beginning to think our class was just a group of above average folks who seemed well-suited enough for medicine. Nothing about them that truly stood out and really caught my attention until now. But, my glasses were a bit smudged, it seems... Turns out that there are some folks in our class who have an amazing capacity for compassion. They effortlessly embody joyful sacrifice.

As soon as they heard I was sick, they began to extend assistance and wishes of a speedy recovery. All entirely unsolicited. Katie offered to take her own time to go over class notes that I missed and try to explain material to me - which she did. Freddie offered to record class lectures that I would be forced to miss – which he then posted online for me to listen to at my leisure. Sarah offered to get me up to speed on abdomen exam procedures and Thu offered homemade chicken soup. Over and over, folks inquired about my health and expressed their relief at seeing me back. They told me how glad they were that I was feeling better.

I’m sure there are many others who would have acted in a similar fashion, but who simply didn’t feel they knew me well enough to approach me. Possibly they were persons whose paths I didn’t cross. Possibly they did extend some kindness or good words, but I was unaware as I ambled about in a fog.

The selection committees who allowed these folks to assemble here seem remarkably capable to me. I can’t help but think that these students are undeniably the raw material for a group of future doctors. Not just doctors. Great doctors. My faith in them has been restored if it ever faltered. They are much more than bright. They have something much more valuable than intelligence.

They have heart.

One of my personal sayings is: “We will all do what we each will do”. Go ahead and Google it if you want. I made it up myself… To the point, I think these folks will do the absolute best they can. And together they will do something utterly amazing. Makes me a little giddy just guessing what it might be.

To the good people of the OHSU School of Medicine Class of 2013: Thank you.

Splendidly done.

Don’t Get Sick

Been a couple of weeks since I’ve been here.

Went in to the clinic the Monday after the last entry. Turns out I have pneumonia. They gave me a second antibiotic. Finished both last Sunday. Worked okay, but I’ve still been coughing up crap every 10 or 20 minutes as of today, can’t breathe, have night sweats and feel exhausted after eight and a half hours of sleep. I nap a couple three hours in the afternoons I have off. They say I have to wait it out. Could be another week.

I’m getting better though. Have more energy. Have my wits about me for the most part. Been three long weeks. Glad to be getting better. Hope to get into the gym again next week.

How It All Turned Out

Not well, actually. Seems I picked up a secondary bacterial infection after recovering from the flu. Something nasty that crawled into my lungs and took hold with a vengeance. Am taking the big Augmentin to try to kill it with some speed. Have just been beat to pieces over the last eight days. Will be very glad to be feeling better. It will be at least a week until I have recovered from these back to back illnesses. Will be quite tired for awhile and will have to just do the best I can until I return to 100%.

After two days of the antibiotic I think I am finally seeing a bit of light at the end of the tunnel. The problem is that material is given to us to learn at a very rapid rate and in volumes, so, when unable to study and absorb the new material, one can easily fall behind. Am feeling as though the bacterial infection is on the run and am able to look at material and have it make sense. Quite a relief. Wasn't able to schedule my make-up exam until after I was allowed to come back to class. Was quarantined from patient contact, class attendance and any contact with staff until the end of the one-week waiting period.

It has been an interesting experience in patience, humility and maintaining a big picture perspective. I am reminded once again that pain is a humbler. When I see people in pain I need to find ways to assess their condition accurately and ease their pain, so their lives can come back into focus. Intense pain steals every awareness we have access to. Our reality only contains the color of the pain. Every idea is distorted and every hope is dashed. Don’t forget, Paul.

Lots to catch up. Need to get to it.

Life Happens

Picked up the flu last Friday. Worst I can recall. Fevers close to 103 would jump up within hours after going to bed and stopping the ibuprofen. Today is the third day. We had a big test for block 2. I wasn't there. I'm glad I didn't have to take it while I was this sick. Wasn't able to study all weekend either. Will take a make-up exam in a couple of days. All I want to do is sleep. Whatever kind of flu this is, it really beats you up. Sweet dreams.

Living stories

Question: How might I employ the BATHE technique in my future practice?

This week in our Principles of Clinical Medicine (PCM) class we discussed the BATHE technique. BATHE is a mnemonic that stands for background, affect, trouble, handling, and empathy. The technique is an interviewing tool designed to elicit more and better information from patients. As students, it helps us understand how psychosocial issues can have great bearing as we diagnosis and treat the people in our care. As I listened to our instructors and began to consider its value, I realized it was something I wanted to keep in my toolbox for future practice.

About an hour after I left the PCM class that afternoon, my wife and I climbed into the car in order to attend a speaking engagement in downtown Portland. The speaker was Dr. Atul Gawande, a nationally-known surgeon and author interested in improving healthcare in our country. He spoke about his experiences and a number of topics, but one of the stories he related was of a hospital and a particular doctor who specialized in the treatment of patients with cystic fibrosis. Dr. Gawande had travelled to their institution to try to understand why they were having better outcomes than other CF units while spending far less money. This particular hospital, as led by this doctor, had average survival rates that exceeded national averages by almost 42%. Their patients typically lived to be 47 years old as opposed to 34.

Dr. Gawande proceeded to tell the story of how he was observing the doctor with a patient, a 17-year-old girl, whose numbers had taken a turn for the worse. The girl was not disclosing some relevant information as to when and how she had been taking her medications, so the doctor needed to employ a more novel means of questioning in order to elicit her full story. Using a blackboard and Dr. Gawande as his foil to direct the focus off of the girl, he calculated the odds ratios for folks who take their meds and for those who don’t. He told Dr. Gawande that, given irrefutable statistics, it is quite clear that outcomes are poor for patients who do not take their meds and that it is quite obvious when meds are not being taken when poor outcomes are occurring. He cleverly persisted at inquiring in third person as to the relatively sudden change in the girl’s status as she listened from the sidelines.

The girl then joined the conversation again and finally revealed why she wasn’t taking her medicine. Her reasons were two-fold: a new boyfriend with his own apartment and some new school rules for taking medications only at the nurse’s office. He continued to question the girl and found out what was happening in her life and how she was dealing with it. He discovered more clearly the impediments to her progress. He offered workable solutions and found support from friends and family to help her stay on track. Indeed, the doctor considered her failure a personal failure of his own, and he helped her realize that she needed to see it as a failure, so she could admit where she had gone astray and choose a better path for herself.

About halfway through the story, I realized this doctor was using the BATHE technique to a large degree, and I became convinced I needed to take his attitude and methods to heart. Of course, the point of Dr. Gawande’s story was simply that the reason this doctor had such remarkable results was that he cared deeply about his patients and was willing to spare a small amount of time to gather a complete picture of how their health was being effected by the events in their lives. We need context, and we need the truth if we’re going to truly make a difference for our patients. Of course, I want optimal outcomes for my patients, and I’ll need to use every tool at my disposal. By emulating this doctor’s methods, I can begin to effectively employ the BATHE technique as I enter a practice of my own.

The Value of Tests

The first test went well. I confess I actually did a bit better than I thought I would. It was certainly challenging, and I was dawdling through the first part of the written portion, but got it in gear enough to be able to review most of the questions before the buzzer went off.

The test made me feel like I was officially in med school. For some reason I still keep pinching myself. It truly does feel dreamlike in that I can’t believe I get to do this and that I decided to do this at such a relatively late period in life. - Do I have any regrets? Not even a teeny, tiny one. I’ll be through this in a few short years and performing the best job on the planet. How could I ever think this was too hard or too late? I’ll still put in at least 20 years as a doc and probably 30 as long as I maintain my health and energy. Chances are pretty good that I will. Parents are still alive, both 80+, and I’m still training for triathlons. Feel good.

This test made me think I need to a better job of studying. I need to find a groove more quickly and become more effective via a better focus. I’m disciplined enough to take the time to study, but I find myself distracted easily. Emotional ideas often work their way into my psyche.  I need to compartmentalize better and set issues aside. I have one primary objective here: to learn as much as I can as I pursue the best specialty for me. Any day that I don’t use my time effectively to do that is a poor use of those moments. Yes, balance is important, but the education takes priority. I just need to remain human and maintain current obligations as I prepare for a new life. This kind of transition requires an exceptional effort.

Any advice about tests…? Hmmm. I suppose the most important thing is simply to look forward to them. They let you know where you stand. They can spur you on to further accomplishment. The bar is raised. Sometimes you learn more material right then and there. They make you focus harder to gather and retain material. They sharpen your skills.

I truly found myself studying with joy this week. The material is fascinating. My classmates are engaging and curious. They try hard. They inspire me. Old dogs do learn new tricks. They’ve just got to get off the porch and sniff around in the woods. Use it or lose it applies.

The Big Picture... and then there's us

My interest in healthcare at a macro level continues to grow. As the debate rages on, I confess I continue to lose faith in the possibility of a brighter future for us. I forsee higher rates, reduced services, and more pockets being lined due to the larger customer base and as new taxes are levied. I see doctors being used even more as the gatekeepers to services. Most docs don’t enjoy that much. I see only the same sad business-as-usual greed under the guise of altruism. Every party wants all they can get, and those that have plenty seem destined to get more while indifferent, distracted, working Americans will continue to pay a larger portion of their incomes to subsidize their goals. Frogs in a great big pot.

Why am I so cynical about this subject when in the last post it was considered a no-no? I suppose I can only look to the past and judge by the manner in which our country has evolved from its original high-minded objectives. I can see how taxes have been spent and how executives continue to earn monstrous salaries and obscene retirement packages. I can see how doctors are fragmented in their belief systems and lack a cohesive set of plans. Rather than being at the forefront of the discussion, many have either taken a back-seat, wait-and-see attitude or are so focused on their practices, they have little time to commit to such things. I can hear how so little information is communicated in such a muddled fashion in order to sway our opinions, to bristle our fur, and to move our attention away from the play at second base. Guess I’m just tired of the huge shell game. I imagine I will write more about this later. I hope to attend an AMA gathering in November. Maybe I will learn more there.

Our first big test is in a couple of days. Many of us are anxious and hope to do well. For the most part we think we will breathe easier after we have a sense of what the test will be like for this section of the coursework. We think it will be easier when we have a feel for the road ahead.  – I will keep studying and do my best. Hillary is coming up this weekend. Looking forward to her companionship and smile and encouragement. Will try to offer my best in return. The work is engaging and challenging but very doable. I still think the trick is to enjoy each moment. It’s cool stuff, and I get to sit around learning about it. Darn.

Mealy mouths: Do Not Enter

This week I was in a class consisting of medical, physician assistant, and respiratory therapist students. We were reviewing the week’s material and responding to instructor prompts as to the locations and names of various anatomy landmarks. One of the students in front corrected the instructor about a mistake concerning the innervation of a particular muscle (teres minor, I think), and I heard a gentleman behind me say, “She just wants to show everyone how smart she is.”

I immediately thought to myself, “Well… she did get into med school. She must have something on the ball…” But, as I began to ruminate on it, I became a bit more indignant. Truth is she may very well be full of herself and be looking to make points, but we really have no room for cynicism in our group. Over the course of my years I have seen many obnoxious and arrogant men and women save more than a few lives and improve the quality of the lives of many of us – simply due to their expansive knowledge. Truth is, too, that is hard to sit in that room and not have a tremendous potential to effect people for the better. It will likely happen no matter how shallow or petty we may be. Indeed, in light of our universal imperfection, I think it much wiser for us to set aside our smaller sense of self and rise to the occasion of lifting up our comrades in arms.

I have always been able to find some good in most every person, though, I must confess, I have written a few off as unredeemable. I place them in the hands of a higher authority. I simply do not have the compassion to find good in them. But, we do need to remember the vetting process we went through to sit in that audience, and give credit where it is due. If one of our colleagues is willing to put in the time to learn the material in pursuit of their goal to be a better physician, then by all means let us set them on our shoulders and carry them forward. They could discover the idea that cures cancer, and their hard-earned knowledge could make them a powerful ally some day. Together we may join them in building a better world.

So, if you want to go to med school, leave the bad attitude in the rearview. You won't have room for anything other than a positive outlook. Prepare to work hard and join others who came here to do the same thing. Every day is an incredible opportunity here. I think if you stay aware of those opportunities and avail yourself of them, you’ll definitely make it to Oz. It’s a little harder than tapping your heels, but you’ll get there. Just stick to the road and keep skipping.

Dem Bones, Dem Bones

Our first part-time week is at an end, and, I must confess, it’s been a bit of a blur. Most of us are still trying to find our rhythm and create a workable study schedule. Seems like life is just one long series of implemented plans. But that’s a good thing. We actually accomplish important goals using that method. It’s amazing how quickly our moments can be wasted when we aren’t paying attention…

We are well into our cadaver dissections and have already learned a dump truck full of terms - and we’ve only been in class for two days... I have held a man’s spine in my hands and gotten back to my Latin (old Latin) roots. I can’t help but wonder how we will all find a path from this humble beginning. Our fingers have just begun to fumble around for the keys to the future. There will be so many bones that will create the skeleton of our education, and we will soon be engaged with patients in order to flesh out the reality of caring for actual human beings. Will be great to watch everyone blossom.

Most of us have had some sort of interaction with patients, so I know we all won’t be complete idiots as we start our preceptorships with the doctors who so generously donate their time and patience (and patients) to the cause of educating the next generation. I’m fortunate to be spending some time in my chosen specialty at the outset. Most folks in the class are quite undecided, but, as an older person, I have a pretty good idea where I want to be and what “best fit” actually looks like for me. It’s been recommended by several savvy folks that we decide earlier than later if at all possible. My recommendation is to take the personality tests, visit with and shadow anyone interesting, rule out any obvious “no’s”, and get on a specialty track right away. Ain’t no time like the present.

I’ll spend most of this weekend preparing for next week and thinking about how to get it all done. There are still a few loose ends to be tied up as the term begins: a few introductions with Big Sibs and physician preceptors, writing my first check for school fees, and doing a 4-hour training session on the hospital computer system. Will also get a chance to spend some time with my wife and step-daughter this weekend. Will be a welcome respite.

Organization and diligence are key here. Persistence will be our watchword. One step after another.

In the beginning...

... my brain was without form and void... disbelief, I guess you could say. Numb fer sure, dude.

When I received the email that I was admitted to the medical school I was hoping for, I was in complete shock. Truth is, it lasted for several days. I couldn't believe they actually let me in. In fact, I confess that I didn't even start this blog until I had finished orientation in the off chance that there had been a terrible mistake, and at some moment a kind-but-lower-level-official would pull me aside into a quiet corner to explain I would not be joining the class.

But, no news was clearly good news in this regard. And, with more pomp and circumstance than I could have imagined, all 120 of us were ushered into the inveterate halls of medicine yesterday. Indeed, we were all "cloaked" with our white coats in an official ceremony commemorating the beginning of our careers. The marker has been created, and the work is ours to swim in as we now float in strong currents toward a new life.

As I remember the ceremony, I hear the speakers reminding us again of the tremendous privilege of our new undertaking and of the deep trust reposed in us as future medical practitioners. As I sat there, I couldn't help but take it to heart. You see, I truly believe in this stuff. I feel unbelievably honored to be allowed here. It's a humbling thing to be so trusted by so many. Misty eyes were the order of the day, I think. I hope every day for the courage and strength to be worthy of that amazing trust. May our hands be true and our intentions pure. It was a big day. Even for an old guy.