Anatomy on the Beach

Resident

2011-11-29T13:16:00.003-05:00

It's been an interesting few months. I am now officially a resident, halfway through my first year. It seems like it's gone by so fast!

Highlights:

-Working for my uncle all spring.

-Singing in a benefit concert this spring in Toronto.

-Packing up my stuff, buying new stuff, collecting other stuff that had been stored in various friend's basements and garages, packing it into a uhaul, hitching my car to the truck and driving across the border to start this adventure.

-Moving into a lovely apartment that wasn't finished renovations.

-Assembling a lot of Ikea furniture.

-Getting a lovely greyhound rescue that I realized very quickly I didn't have the time or money to take care of.

-Meeting my residency class and getting to know some fantastic people.

-Catching my first babies.

-Putting my first IV into an infant.

-Getting to the hospital at 4:30 in the morning.

-Eating some great food in some world-class restaurants.

-Enjoying a long distance relationship.

-Buying finger shoes and running my first real road race (5k).

-Losing ten of the twenty pounds I gained in my ER rotation as a med student.

-Wearing a kilt at my twin sister's wedding.

Biography

2011-01-19T08:34:00.003-05:00

So I've been invited to sing in a benefit concert in Toronto in March. It seems weird to be writing a singing biography, after all the time I've spent working on my medical CV and essays. Here's what I came up with. It's not terribly creative, but it works.

Tenor, Beach Bum, has performed across Canada, and in the US, the Caribbean, and England; in a variety of genres including opera, oratorio, and musical theatre. His credits include: Ralph (HMS Pinafore), Rolf (Sound of Music), and Harry (What about luv?). He has appeared as tenor soloist in works by Mozart (Requiem, Solemn Vespers), Handel (Messiah), Haydn (Lord Nelson Mass), and Stainer (Crucifixion). He has performed with ensembles including the Saskatoon Symphony, Opera NUOVA, the International Symphony Orchestra, the St. Paul’s Cathedral Choir and Orchestra, the Parry Sound Choral Collective, and Musical Theatre Productions, London, Ontario.

In addition to performing, he has worked as organist for churches across Canada and England, taught music and drama, and directed and stage managed for theatre companies in Alberta and Ontario.

He is currently studying voice with Jean Ronald LaFond, based in New York and Berlin. He holds undergraduate degrees in music and biology, and recently completed his MD degree. He will be starting a Family Medicine residency this summer.

Personal Statement

2010-12-16T07:39:00.000-05:00

Several months ago, I posted the first few drafts of my attempt at writing a personal statement for residency. I received some excellent suggestions, and offers for help. Thank you to everyone who contributed and gave advice. I thought I'd post the PS I used for my US applications. It was positively commented on by everyone I interviewed with. One PD even commented on the Tennyson quote. Thanks again.

I want to be a Family Doc.

Holding the scalpel poised, I make my incision. This is a “lumps and bumps” clinic; routine stuff for a family doctor. But as I carefully remove a suspicious lesion, I am struck by a curious sense of completion; that my life, my skills, and my medical training led me to this moment. An early passion for medicine, a family of family doctors, a genuine interest in people, varied experiences, a love of learning, a wide range of interests, and clinical experience in the United Kingdom, Canada, and the United States; all these have prepared me to be an excellent family physician.

I want to do that.

A little boy sitting on a hard bench under tired ceiling fans fretfully stirring the heavy African air, I sat waiting for my latest malaria smear results. Watching my fellow patients in that dirty place, I still remember wondering what brought them to the hospital; fascinated by the elderly man with weeping ulcers on his legs and by the local snake farmer who came running in after a bite from one of his snakes. But as exciting and exotic as the snake man was, my most indelible memory of that day is of the Doctor running across the dusty courtyard reading the directions on a packet of antivenom.

I have a clear memory from that day of wanting to do what that doctor was doing. And while I have developed and explored other interests, my passion for medicine has been my constant companion.

This is my place.

Leaning on the nurse’s station in a rural Canadian Emergency Department, I am the doctor’s nephew, shadowing to explore the world of medicine. Watching my aunt guide my sister, already a medical student, in placing a suture correctly, I turn green at my first sight of minor surgery. Sitting in the hallway with my head between my legs, a silly grin spreading over my face, I can’t wait for more.

I have four rural Family Doctors in my family, and their example and encouragement has meant that my knowledge of and passion for Family Medicine is strong. I have a real sense of commitment to providing continuous care for families and becoming part of a community.

I will drink life to the lees.

My life, study, and work experience has prepared me well to be an excellent family physician. Growing up in West Africa has made me acutely aware of other perspectives and cultures, and has made me uniquely positioned to practice cross-cultural medicine. My undergraduate degrees in music and general biology trained me to think across disciplines and see the bigger picture, both from a psycho-social and artistic perspective and in terms of inter-connectedness inherent in the physical world. My extensive experience as a music and drama teacher has allowed me to hone my communication and motivational skills, both of which will be extremely valuable to me as a practicing physician. My journey as a professional operatic tenor has taught me the value of hard work, and the sense of satisfaction that comes from being a part of a team working at a world-class level. My work as a church organist and choir-master has taught me the simple joy of becoming part of a community of people, and working with them to help them live their best lives.

I am a generalist, and a global thinker. I am excited about new experiences, love learning new information and skills, and do my best to live as intensely as possible. Family Practice appeals to me because of the breadth and wide scope of practice. I enjoy seeing the big picture, and am excited about coordinating medical care for patients as part of a team of health care professionals. I am interested the possibilities that rural Family Medicine offers in working in both rural inpatient and outpatient settings, emergency departments, and obstetrics.

I want to be a Family Doc.

Working stiff

2010-12-15T18:48:00.004-05:00

So after accepting an offer for residency in the US (Family Medicine, starting June 2011), the trip I had planned to NYC to interview was a moot point. But since I had my plane tickets already, and they were non-refundable, I went anyway. I had a wonderful week wandering around NYC, seeing shows and eating in great restaurants!

Now, I'm back in Southwestern Ontario, and started work today in my uncle's office (I was supposed to start on Monday, but was snowed in for two days). I am involved in a project to help update his EMR and transfer data from his paper charts. And seeing as he has somewhere between 2000 and 3000 patients, it's a big job. But it's a job I am qualified to do, and by pouring over several thousand charts in the course of the next few months, I expect to learn a lot. And because I expect a LOT of snow this winter, I have purchased snow tires for my little car. It's not that much of a waste, because where I'm moving for residency gets a LOT of snow too.

In other news, I am getting serious about getting back into shape. I have an incentive; I would like to wear my kilt at the New Years dinner/dance, and need to lose a few inches in order to do so. So I have three weeks to lose a couple of inches off my waist. Which will be doable, but just. So I will be sore and tired (and downing protein shakes and eating poached chicken and broccoli) for the next few weeks. Those of you on FB can expect daily whinging.

I am still somewhat surprised whenever I see correspondence labeled Dr. BB. I wonder how long it takes to get used to that.

And in other news, I passed my next Canadian licensing exam, and am in the process of applying for USMLE Step 3. I have four more exams to take before I am completely license-able in the US and Canada: USMLE 3, US FP Boards, MCCQE2, Royal College FM exams. It's kind of weird to think that, including the MCAT, I have already taken 6 big medical exams. More than halfway done!

It's official...

2010-11-24T22:21:00.003-05:00

It's been a while since I last posted (and my blog was private for a few months). But my medical school diploma arrived in the mail this week. It's official...

...I am a doctor.

And in other news, I have accepted a pre-match residency position. So I know where I'll be next year.

These last few months have been somewhat surreal. It's weird when someone I meet asks me what I do. I am a doctor, but because I don't start residency until next July, I'm not much good of one. Yet.

Anyway. I have a bit more time in the next few months, so I hope to start writing more. And I'll have to decide whether to keep writing here, or to start up a new doctory blog, like many of the medical student blogs I've followed over the last few years have done.

It's official, I'm finished. This part.

BB

Engage with Grace

2010-11-24T22:09:00.004-05:00

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us in the United States are celebrating Thanksgiving and are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We have included them at the end of this post. They are not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.
This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could have (and should have) been better. We have stared down political opposition. We have supported each other’s efforts. And we have helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.
For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us in the United States are celebrating Thanksgiving and are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We have included them at the end of this post. They are not easy questions, but they are important -- and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.
This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could have (and should have) been better. We have stared down political opposition. We have supported each other’s efforts. And we have helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go”– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.

We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.
Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. Please feel free to join our blog rally by copying this post and putting it on your own blog for this holiday weekend.

Birthday weekend!

2010-07-18T20:13:00.002-05:00

So we have an evolving tradition; my sister's and my birthday lies very close to an aunt and uncle's wedding anniversary, and my cousin-in-law's birthday. So for the past several years, there has been a family get-together at Stratford, Ontario for a weekend of holiday theatre-watching at the festival there.

This year was the first year in four that I've been able to attend. It was great to be able to get away, even for a couple of days, watch some plays, and hang out with family. And shop, never forget the shopping. I didn't purchase much, just a few kitchen knick-knacks, and a new wallet. And a lovely shirt and jacket for work.

It's actually been a good summer for theatre. Last month, I drove to Iowa, to watch a friend perform at the Des Moines Metro Opera summer festival production of Nozze di Figaro. And this weekend, while we saw three productions, the highlight had to have been seeing Christopher Plummer as Prospero in The Tempest. In a celebrity sighting moement, Mr. Plummer was staying at the same B&B we were, so while we didn't meet him, we did see him wandering around all weekend (and he graciously signed copies of his autobiography for those in the family who'd purchased it).

It was astounding to see someone hold the stage the way he did, and to see him inhabit the character and breathe life into Shakespeare's old-fashioned language. And while the rest of the cast was good, it was somewhat amusing to see how much better Mr. Plummer was; he made them all look a little dim when on the stage beside him. A wonderful lesson on stagecraft, and a wonderful evening. And then just as instructive to see him wandering around the next morning in his sweatpants and cool sunglasses looking decidedly ordinary out for his morning constitutional.

And now, I'm back to the grind. I can't believe this rotation is half-over, and in two weeks, I'll be heading back to the US for my last three months of rotations.

It's going to go very quickly!

In any event. Hopefully, I'll be able to go to more theatre. But that may have to wait until I'm done, and have some time off.

New Post

2010-07-07T14:36:00.002-05:00

It's a hot July in Southwestern Ontario, and I had forgotten how muggy and nasty it could be. But who's complaining? Come January, we will be wishing for warm weather.

I have just started a 4 week rural family practice rotation here in SW Ontario, the one Canadian elective I was able to arrange. And that was only because the doctor I am working with was willing to go to bat for me. Thanks Dr.!

I am still in the proving and explaining myself stage. But hopefully, as the clinic I'm working with gets used to me, they will realize that I am not a moron, and things will get better. It is a good group of people to work for, though, and I'm enjoying the experience.

It's really odd to be back in the city I lived in for 3 years before I got into medical school. Things are at one hand familiar, and yet not. And I am now a very different person than the one that left here three and a half years ago. And much of my social network has either moved away, or I have lost touch with.

And once the month is over, it's back to Detroit for 3 more months, and then I'm done. It's a little scary to think that I'll be finished so soon. And then I'll have 8 months off and residency applications/interviews (hopefully).

So the big push is on. And as I start the process of applying to the US and Canadian Matches, this blog may degenerate into a rant on the Canadian medical establishment and how they treat IMG's. I'll try to keep my frustration in check.

So I'm off for now. Be well!

Bitter

2010-05-24T19:05:00.002-05:00

I have just been turned down for a visiting elective in Canada. I am fast discovering why other Canadians I have spoken to are so disheartened by their attempts to return to Canada they are not planning to return to Canada to practice.

Seriously, I don't have leprosy. I wash behind my ears and use deodorant. And I have consistently honoured my clinical rotations in hospitals in England and the US (i.e. not under a tree in Outer Mongolia).

I'm a little bitter right now. And weary. I didn't expect a red carpet when I went this route (I knew I was going to have to jump through some significant hoops to return to Canada to practice). But I didn't expect to feel the kind of contemptuous indifference I have experienced from the Canadian medical establishment.

It makes me more than a little bit sad.

Ugh

2010-05-03T20:36:00.002-05:00

It's been a while since I updated my ~~two~~ readers. I was done in the UK at the end of Feb, and returned to Canada for March, where I studied, did paperwork, shadowed my sister in the hospital and office, went skiing, took the cat to the vet, cooked, and drank Jamesons on St. Patrick's day while remembering margaritas last year in Dublin.

I have since moved to Detroit, where I have just started my second fourth year rotation (inpatient FM, after a month of Nephrology).

It's been good here in Detroit, although I must admit it was somewhat wearying moving again, and while I am getting used to this new place, I was grumpy about the necessity of finding where the good grocery stores are, etc. Thankfully, I was able to spend the first few weeks staying with a friend who helped get me acclimatized. I do need to find a good barber.

I have now (mostly) gotten my bearings, and am enjoying myself, although I still can't wait to be done. Speaking of being done, if all goes as planned, I should be done sometime this fall.

Which means that this summer will be full of residency applications. Look for more procrastinatory/ranty posts.

I am now in full-blown procrastination mode, with exams coming up in the next few weeks. Ugh.

Be well.

Personal Statement - Second Draft

2010-04-01T20:19:00.003-05:00

Thanks everyone for your input. Still editing.

Personal Statement - first draft

2010-04-01T12:49:00.003-05:00

Thanks everyone for your comments. I've posted a second draft, which I think works a bit better.

Piano, 8 hands

2010-03-29T13:03:00.001-05:00

Falling in love with a fish...

2010-03-24T08:54:00.001-05:00

This looks like a great movie!

2010-03-11T18:56:00.001-05:00

A Trailer for Every Academy Award Winning Movie Ever -- powered by Cracked.com

Sorry, I couldn't get the embedding to work...

Home

2010-02-16T09:41:00.002-05:00

Here then at home, by no more storms distrest,
Folding laborious hands we sit, wings furled;
Here in close perfume lies the rose-leaf curled,
Here the sun stands and knows not east nor west,
Here no tide runs; we have come, last and best,
From the wide zone in dizzing circles hurled
To that still centre where the spinning world
Sleeps on its axis, to the heart of rest.

Lay on thy whips, O Love, that me upright,
Poised on the perilous point, in no lax bed
May sleep, as tension at the verberant core
Of music sleeps; for, if thou spare to smite,
Staggering, we stoop, stooping, fall dumb and dead,
And, dying so, sleep our sweet sleep no more.

Dorothy L Sayers, Gaudy Night

A lovely sonnet from one of my favourite novels. The idea of home as a place of rest in the middle of the spinning world holds a lot of resonance for me; who has never really found home.

I started this post while still in Europe, and while I found it bittersweet wrapping up and getting ready to leave, I have to admit that I am really glad to be home.

England was a fun adventure. I enjoyed my studies, enjoyed travelling, and enjoyed living so close to London. It was exciting, busy, and I was always a little amazed and bemused that I was actually doing what I was doing. There was a sense of unreality about my being there that I couldn't quite shake. And it certainly was surreal to be able to hop on a plane and fly to Germany for the weekend (or wherever) and then be back at work the following week.

But I have to admit, that now that I've been back in Canada for a week, and back in the little town I intend to settle in, I am home. As much fun as England was, I could never really see myself living there. I don't know whether it was the landscape, the culture, or a little of both.

But as I drove north from Toronto, and the agrarian landscape of South Western Ontario spread out around me, and the snow lay thick on the fields and trees, I could feel a part of me start to revive; those little roots I have allowed myself to put down over the last few years whenever I have come here on vacation starting to spread a little deeper and find a bit more nourishment in this place.

I am home. And although I will have to leave again soon, and it will be several years before I can settle here permanently, I have found a place I can call home.

Personal statement

2010-02-15T13:50:00.003-05:00

On paper, a middling medical prospect.
In the hungry years before, "low motivation for medicine"
kept trickling down from the bench, and stern arbiters
wondered at atypical activities
and sneered at passions haltingly expressed.

I do not fit the mold. And did not want to.

The tenor dreams of medicine. The actor yearns
for another role. The poet throws his script aside.

And all the paperwork minutae, all the flaming loops of arguement
do not encompass an answer to the question.

"Why do you want to become a doctor?"

Because.

Sometimes I feel like a child, perilously close to tantrum.

Because.

So completely inadequate for that harried and cynical admissions apparatchik.

Because.

But so completely right it needs no other explanation.

Because.

I try anyway, "I want to help people?"

Because?

All I know, with unshakeable certainty, is that
my inexpert floundering, my dull, prosaic babbling
is an attempt to communicate burning desire.

Because.

And beyond desire, there lives an undeniable certainty,
a knowledge beyond logic that this is my place.

I cannot tell you why. I cannot explain.

Because

In honour of the Olympics

2010-02-12T05:27:00.001-05:00

Vancouver is a lovely city! I did my undergrad, an hour outside of Vancouver, and still love the North Shore Mountains, and the sea...

Food Glorious Food!

2010-02-12T02:09:00.000-05:00

We love you Jamie!

Quote for the day...

2010-02-10T01:55:00.002-05:00

There's no pot of gold at the end of the rainbow, there's only the rainbow.

From an online forum for classical singers I post on.

JK Rowlings on the Benefits of Failure

2010-02-02T08:14:00.000-05:00

J.K. Rowling Speaks at Harvard Commencement from Harvard Magazine on Vimeo.

Another interesting idea...

2010-01-31T05:50:00.001-05:00

I really enjoy running, but tend to get various pains in my shins and my knees. I think I'm going to try this out and see what happens...

Geo - Medicine

2010-01-26T11:58:00.000-05:00

an interesting idea...

self portrait series

2010-01-25T04:16:00.003-05:00

I've been home sick for several days, and have had just enough energy to try some self portraits out. The mask I bought at a little artist's coop in Cordoba.

All works copyright 2010, Kent Tisher. All Rights Reserved. These images are NOT in the public domain!

My new favourite blog

2010-01-24T07:08:00.001-05:00

The Sartorialist

The archives are really worth looking through!

A bit of singing...a vanity project.

2010-01-23T15:54:00.004-05:00

I've made a little movie of photos I've taken this year in Europe, with some of the recording I did last week. The singing is not perfect, but there are a few decent moments.

The Amateur Transplants

2010-01-21T15:10:00.001-05:00

Totally NSFW! With a lot of strong language! But some great ~~medical~~ gallows humour.

In which he does two weeks in A&E and discovers that recording opera arias after a day seeing patients isn't that great an idea...

2010-01-18T16:32:00.002-05:00

Thank you to those readers who emailed and let me know they were thinking of me after my last rather gloomy post. I'm doing much better thank you. I had a good two weeks in A&E (ER for those of you of a North American persuasion; Accident and Emergency). It was good feeling as if I actually knew something. My IV cannulation got much better, I hit several ABGs without incident, and I am starting to be able to take a history, do an exam, and come up with a differential and a plan with minimal input. I also saw some pretty cool things. I can also say unequivocally that performing CPR while slightly hung over is not a good idea. For those of you who have never done actual chest compressions on a person, it is HARD physical work; and work that I recommend one be in top physical form before attempting. And several of the docs and ENPs I was working with said nice things about me and my skills as a medical student. A little ~~ego stroking~~ praise can go a long way when you're feeling down. Especially if you're a tenor.

And apart from the cowboy stuff, I did get to see some sobering medicine; the young patient who died unexpectedly from an unforseen complication of a totally treatable disease, the cancer patient who came in dying sooner than anticipated from something rather peripheral to their struggle with cancer, the senior citizen who was fine yesterday, but today was aphasic and whose CT shows a tumour in the brain. There's nothing like a little life and death to put some winter blues and homesickness in perspective. And frankly, as sad as these things were, I am actually gladdened that in a few small ways, I was able to acknowledge their humanity, and ease their suffering.

And last week, I did a bit of recording. I got together with a pianist friend with a portable recorder, and sang some Handel and Donezetti (among other things). And while I don't recommend singing difficult repertoire after a day seeing patients at the hospital without doing much warming up, I was generally pleased with how the recording turned out. There were some really nice moments, despite the fatigue, and I have some real ideas of what to work on next in the shower. And I hope to head to Berlin in Feb. for a weekend masterclass with my voice teacher, which should be a welcome break from things medical.

I have now started my last rotation here in the UK, Paediatrics. And in 6 weeks, I will officially be finished my third year of medical school. Ummm...where did that time go? I'm not quite sure. It's a bit scary. But I'm looking forward to being home and one year closer to not knowing what I'm doing with my life.

Be well!

A New Year's Update...I think

2010-01-10T10:38:00.004-05:00

I has been a long time since I wrote an update. And, like Disraeli, I am not generally one to embark on explanations or apologies...it's not because I haven't had anything to write about. There have been several incidents that I needed to write about to get out of my system, but which I didn't have the energy or courage, or both. It occurs to me that I might be a bit depressed, or suffering a bit of late culture shock, or maybe I'm just tired...

So on with my generic update. I had a good time in my Obstetrics rotation. Wrote two exams at the beginning of Dec (Surgery and Ob/Gyn), which I passed. Sang two Christmas concerts, one of which I had a couple of nice solo bits. Took two weeks off for Christmas and New Years (hence the pictures from Spain). And despite all of the interesting things I've been doing, and the stuff I've been learning, I'm tired and ready for a break. In fact, I'm feeling a bit burned out. Which is a little alarming, because I still have a long way to go. And while I keep telling myself I need a vacation, I've just come back from a lovely two week one with my parents.

I am a bit lonely. While I have developed a bit of a social network over here, I'm still missing family and friends from home. And I'm getting very tired of the dismal living situation here. What is it about the UK and dire student accommodations? This place would be 100% nicer to live in for a coat of paint. Several years ago, I was in the UK as a member of a Cathedral Choir on tour, and we stayed in student accommodations at a University-that-will-remain-nameless, and I thought I'd never seen such awful living conditions. But there apparently this is not entirely uncommon...

This is from our shower room.

And I'm getting awfully tired of messy flatmates who leave the kitchen an awful mess, steal food, and seem oblivious to the common courtesies inherent in shared living arrangements. Were these kids all raised by wolves? Ok, so I had to walk to school uphill in blizzards both ways, but it still rankles. Although to be fair, they did get me some drugs when I was puking my guts out this week (Norovirus is going around).

Oh well, this too shall pass. I'm only here another few weeks, and then it's back home to study for more big exams.

Other than the desire to be back home and my dealing with some stupid personal crap, I'm not sure why I'm feeling so blah. I feel like I've lost much of my confidence, and every time I walk into the hospital, I feel like I know less than I did the day before. And while this is quite possibly true, it isn't terribly comforting.

I shall keep plugging away. And I'll be home at the beginning of March, so if you're around, let me know. Be well!

More photos from Spain...

2010-01-04T16:05:00.002-05:00

Christmas in Spain

2010-01-03T06:23:00.004-05:00

I had a good time with my parents in Spain this Christmas. Here are a few photos...

The joys of live performance.

2009-12-12T04:14:00.001-05:00

This is why I love live performance, anything can happen. This has never happened to me, though.

Engage with Grace

2009-11-26T11:43:00.003-05:00

Last year, I posted a series of questions designed to help readers think about what sort of medical care they wanted during the last moments of their lives. The med blogging community is reprising last year's effort, and I thought I'd participate again. I have reproduced below a blog post from Engage with Grace. While it's not necessarily the most enjoyable subject, it's a worthwhile one to contemplate.

-BB

We're continuing a tradition at THCB started last year. Asking you to take a moment this weekend to discuss your desires for how to live the end of your life as meaningfully as possible--If you want to reproduce this post on your blog (or anywhere) you can download a ready-made html version hereMatthew Holt

Last Thanksgiving weekend, many of us bloggers participated in the first documented blog rally to promote Engage With Grace, a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations, our closest friends and family.

Our original mission, to get more and more people talking about their end of life wishes, hasn't changed. But it's been quite a year, so we thought this holiday, we'd try something different.

A bit of levity.

At the heart of Engage With Grace are five questions designed to get the conversation started. We've included them at the end of this post. They're not easy questions, but they are important.

To help ease us into these tough questions, and in the spirit of the season, we thought we'd start with five parallel questions that ARE pretty easy to answer:

Silly? Maybe. But it underscores how having a template like this, just five questions in plain, simple language, can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we've included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there's been a lot of discussion around end of life. And we've been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife's preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that's fulfilling in all the right ways.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )

Criminal Behaviour

2009-11-15T08:17:00.001-05:00

A brief update...

2009-11-14T16:18:00.003-05:00

I've just started my Obstetrics/Gynae rotation. I must admit, I am VERY glad to be finished with surgery (although Obs/Gyn has a fair bit of theatre time as well). I had a wonderful two weeks off with my sister in France, and got back ready to start up again.

And it's been a wonderful week! The Obs/Gyn team here are really pleasant to work with, from the midwives, to the junior docs, to the consultants! I have spent time in clinic with docs, midives, and hung out in the labour ward. I've seen two c-sections, and one normal delivery (which is pretty good for my first week; it's hard as a male medical student to get consent to observe a delivery).

The first section I saw was an emergency, and was one of the most harrowing surgeries I have ever seen. And this wasn't because of it being my first one, everyone involved (from the consultant to the midwives, to the peadiatrics team) talked about how this was possibly the worst they'd ever been a part of. But in the end, the baby was born and after a bit of work, started breathing. It was pretty intense, and I'm not sure I've really come to terms with what just happened.

The next section I saw was also an emergency, but not nearly as panicked as the first. And when the baby was born, in excellent condition, as the young father came over to greet his child I must admit I had tears in my eyes. I am really liking this delivering babies thing! And the vaginal delivery was pretty cool!

Today was a slightly lazy day. I was at the hospital until after 1am last night, so I slept in this morning. I'm afraid my internal clock is getting a little bit turned around. Oh well.

Tomorrow, I'll have to really hit the studying. I have a surgery exam coming up in a few weeks, and it's hard studying for something I really have very little interest in, while in the middle of something I am really enjoying! Oh well, it has to be done.

So it'll be a busy couple of weeks. Add to that the two choir concerts I have agreed to sing in Dec, and I'll probably be really needing my vacation.

This is awesome!

2009-10-24T06:56:00.000-05:00

And now for something completely different

2009-10-21T14:17:00.001-05:00

The Button Accordian like you've never heard it before.

I've always wanted to try the button accordian. Here's something of what it's capable, in the hands of a really, really good player. He's technically brilliant, and I'm really interested in seeing what he plays like in a few years with a little growth and maturity as an artist!

The Tchaikovsky Violin Concerto 3rd Movement.

hat tip: The Collaborative Piano Blog

Autonomy, Mastery, Purpose

2009-10-19T09:39:00.002-05:00

There is an interesting essay on the New York Times website by well-known columnist PAULINE W. CHEN, M.D. on "How Mindfulness can make better Doctors." One of my favourite med-student bloggers wrote a rather snarky response to the article which appears to suggest (to paraphrase a line in one of my favourite movies), "If she thinks she can do better, she's quite welcome to come try for herself." And of course, the comment section of the original essay is full of doctor-bashers whose premise seems to be that since doctors make SO much money, they are morally obligated to put up with shitty working conditions.

(It dismays me to see that so often, when doctors start to speak about the often inhuman conditions they work in, the message they are sent is one of pure dollars and cents; their contribution is stripped of any humanizing qualities and distilled into the stark capitalistic purity of numbers on a page. I recently read a helpful book that suggests that part of the reason we are so demoralized in the West is that our lives and work have been stripped of every sense meaning and purpose but financial.)

And while, as an actor who was trained to acknowledge my emotions without being mastered by them and as someone who has practiced yoga for over five years, I agree that mindfulness is an important quality to cultivate for anyone performing a demanding and stressful job, it does not take away from the fact that working conditions for many physicians are intolerable. Mindfulness, meditation, and therapy may well help physicians deal with their workplace stressors, but does nothing to deal with the underlying problem; many of those stressors are avoidable. And this is where I think the Dr. Chen article missed the boat.

(Many would tell physicians to stop whining! After all, we're all making half a million dollars and all live in mansions and drive fancy cars. And we don't have it half as bad as lawyers and teachers, etc. To them I say, lawyers and teachers may well have shitty working conditions (my parents are both teachers, I KNOW they do), but I write about the doctors, because I will soon be one. This is the world I am coming to know. And frankly, the fact that some professions are willing to put up with shitty jobs and shitty working conditions for ~~inexplicable~~ a variety of reasons, doesn't mean that someone is wrong when others explore ways to make their own job less intolerable. Physicians are starting to talk about working conditions, and that discussion is the first step in real change in the way doctors do their jobs and are treated. IMO, this is a good thing!)

Several weeks ago, I posted an interesting TED talk on what motivates us. And while Dan Pink isn't necessarily the most qualified of social scientists, and while his argument is somewhat jingoistic and simplistic, his description of intrinsic motivation is compelling:

Autonomy
Mastery
Purpose.

In our discussion of physicians and how they do their jobs, we often ignore these important aspects of what helps us get up in the morning to go to work. Sometimes, I think we assume that because we are in a "helping profession," we automatically have these intrinsic motivators covered. Perhaps, for that brief moment when we were writing our admissions essays, we did. But from the very first days of medical school, other motivators, mostly extrinsic, come into play: grades, social expectations, financial pressures. I wrote about this when I first started this blog; how easy it is to get sucked into the daily slog and stop seeing the big picture.

The irony of this is that I learned this lesson in my artistic life. No sooner had I stopped the pursuit of a career as a singer did I start to sing really, really well. As soon as I starting singing entirely for myself, I was able to discard the distractions of worrying what others thought and sing for the pure pleasure of it. This intrinsic motivation had an enormous positive impact on the quality of what I was doing as an artist.

I recently spent the weekend with a group of medical students in Ireland, who are participating in an almost entirely PBL* course. They spoke of their frustrations at "having to teach themselves to be doctors." I remember saying that had I been in their situation, I would have wanted to poke needles into my eyes. But for all the disadvantages I see in PBL, I can see that in the right hands, it could be a powerful tool for allowing students to nurture their own intrinsic motivation for learning. And frankly, isn't that what we ultimately all have to do, teach ourselves to be doctors? Learning comes from within, and while a negative external stressor can be helpful in the short term. Its that information that one learns for the sheer joy of it that often really sticks.

It's an interesting balance. We do what we do to help people, but ultimately, what we do has to be about us for it to really motivate and inspire us. I treat all my patients equally because I believe in the infinite worth of all, and because to not do so would run counter to the person I believe myself to be. And frankly, those physicians who treat patients because they want their patients to like them or even to get better aren't going to last terribly long. We have so little control over our patient's outcomes or what they think of us.

Autonomy, Mastery, and Purpose. I think that in many respects these motivations are often neglected and eroded in the modern practice of medicine.

There is so much ink spilled in discussing why new medical grads aren't going into primary care specialties, and financial incentives (or the lack thereof) are proposed as the most likely reason. I would like to suggest that while being able to pay off my massive student loans is important to me, a specialty where I am able to practice with as much professional autonomy as possible is even more important. I would suggest that part of this picture is that many, possibly even most, of the more highly sought-after specialties are ones that do carry with them more autonomy.

Mastery goes without saying, as physicians, we are all called to an high level of achievement; after all, people's lives and well-being are at stake. But this concept has twisted over the years among physicians. There is an extraordinary amount of hubris in the medical community, and the leaders of our profession seem to suggest that long-term, sustained, superhuman effort and achievement is not only the norm among physicians, but the measure by which all physicians must be measured. As a performer, I am very familiar with the phenomenon of post-performance letdown. We would sing a run of shows, and when it was over, we would crash for a couple of days, rebuilding reserves and recovering from the intense activity of the preceding nights. Airline pilots sleep after a flight. Sustained, high-level performance takes a toll; there is always a physical and emotional price to pay for excellence. As a community, our unwillingness to acknowledge that fact makes a lot of really smart people start to look really kind of dim. I find it simply arrogant to assume that just because I am going to be a doctor, that this makes me somehow a more capable, better person, and less subject to the demands of my body than the individual piloting my plane across the Atlantic. It doesn't work that way. We are all normal humans, physicians included, and while we are all capable of extraordinary things, we are none of us capable of extraordinary things all the time!

Why do you want to be a physician? The classic medical school interview question. And most of us try to come up with something that doesn't quite say, "I want to help people" but which means the same thing. We all generally have some sort of purpose in choosing medicine. But in many cases, that purpose gets lost in the struggle. I have come to the conclusion that in medicine, what we do for people and the help we offer them is often far less important than who we are to them. That saving my patients is often not possible, and that I can't do much for the vast majority of them. But I can walk alongside them for even a few minutes of their journey. I can acknowledge their humanity, and be with them in their pain. And if I use my knowledge and expertise to make their journey a little easier, then that's a bit of a bonus.

To change the way we do our jobs as physicians, to reclaim our professional (and personal) autonomy, to reconnect with a sane concept of mastery as normal human beings, and to find a renewed sense of purpose in our everyday lives; this is something worth striving for as a profession. To accomplish it will require that we change the way we see ourselves. Perhaps there is something to be said for mindfulness after all.

*Problem Based Learning - a way of teaching medicine that involves small group and self-directed learning for most of the curriculum.

death and dignity

2009-10-18T06:36:00.005-05:00

In an interesting and poignant post, keepbreathing writes about observing a death without dignity and pathos.

Elderly women drinking coffee with a dead man and then leaving his side only when forced to by an unfortunate loss of bowel control. I hope there’s more to getting old than this.

There is a lot written, especially by medbloggers, about the futility of much of end-of-life care, and how disturbing it is to torture some poor old person just to keep their heart beating a few more tired beats. I have written about the guilt I felt when performing CPR on an individual and breaking ribs in a vain attempt to restart their "life." In much of this discussion, when we talk about dying with dignity, we seem to cherish this image of some sort of Hollywood scene where the dying individual is surrounded by loved ones who are all sniffling tastefully (with nary a makeup smudge), and they slip away with a beatific smile on their face, having said their last, heartfelt goodbyes and cleared up a few minor misunderstandings to ease the regrets of the living.

In my past life, I have played and sang for a lot of funerals. (I would far rather play for a funeral than a wedding...but I digress.) I have always been quietly amused at how everyone who dies is a perfect human being. The deceased is ALWAYS the best husband, father, mother, daughter that ever there was; who never spoke a harsh word to nobody, and who spent all their spare time volunteering in soup kitchens. No one gets up at a funeral and says, "So and so was a right bastard, who beat his children and yelled at his wife." Or even, "He was a complicated man who meant well, even though he got it wrong a lot of the time."

"Do not speak ill of the dead." There is a mythology in death that we seem to want to embrace, even when it flies in the face of reality. Is this born out of our fear of how we will be remembered?

Death, like life, is messy. It frequently involves pain, fear, blood, piss, and shit. And sometimes, it is funny as hell. I remember one memorable night several years ago when a couple of friends and I sat in our local dairy queen and laughed together for hours as they told their "dead dad stories." Both their fathers had died after long, drawn-out illnesses, and they both had some really funny stories to tell from the time they spent in the hospital being with their dying dads.

As we write and speak about the way we treat the dying, I think there is a danger of simply exchanging one horror for another; the horror of medical torture for the horror of dishonesty. Because not everyone wants the Hollywood version of death. For some, it's not appropriate. For some, it's not true to who they are. And for some, it's just not funny enough!

And while I will continue to use the phrase "death with diginity," for me it will mean more than just a slightly fake decorum that allows us to pretend that death isn't that big a deal after all. For me, "death with dignity" will be about celebrating the dignity of a person's humanity, and celebrating the journey they have been on, with all the road bumps and swerving, and swearing and detours, and break downs and speeding tickets that journey implies.

So to the little old ladies who sat with their deceased with their coffee and their laughter until one shat her pants, I say, "Way to go!" They were celebrating his life and death with their messy presence and their humour; in their own honest way they were allowing death with dignity.

Rotating in the UK

2009-10-18T04:12:00.003-05:00

In response to my last post, AE wrote a compliment and asked a question. I started to answer it in the comments section, but it kept getting longer and longer, so in lieu of a real post, I thought I'd answer it here.

AE,

Thanks for the kind words! I'm not pleased with how my blogging has gone in the last few months, but c'est la vie.

You ask why the UK and not the US. I chose to do my third year in the UK for several reasons:

-I get to live for a year in Europe; travelling to other parts of Europe is easy and generally cheap, and London is one of the most exciting cities of the world to live in. Why not? I'm single and have no dependents. And I am borrowing so much money for med school that the cost of living in the UK really doesn't make that much of a difference.

-The culture of medical education in the UK is different from the US. Much less is required of medical students over here in terms of working hours and the amount of scut work. My job (this is made very clear by the vast majority of docs I work with) while in the hospital is to learn, not to help run the hospital. It's a subtle shift in emphasis, but has huge implications. The downside to this is that no one is checking up to make sure I show up and actually learn, so my own motivation and direction is much more important than it might be in the US. But I haven't found this to be a problem. As medical students, we are basically given the run of the hospital; if we want to head down to A&E and do H&Ps, we can, if we want to wander into theatre and watch surgery, we can, if we want to join a random consultant's clinic, we can, if we want to wander into radiology and review images with the docs there, we can. Basically, if we introduce ourselves to any doctor in the hospital and ask to observe and be taught, they will more often than not be happy to, regardless of whether we are assigned to that doctor or specialty. The choice is actually a bit daunting sometimes. And this is in addition to the schedules we are given for the particular rotations we are on, which always have a fair bit of down time scheduled into them.

-Medical education in the UK seems much more humane than in the US. While docs ask questions and use the Socratic method to teach, I have not come across a single one who was interested in pimping ~~because they have a small penis~~ for humiliation's sake. I haven't seen the sort of bullying and hazing behaviours that my colleagues in the US describe that seem designed to put the medical student in their place. And while I've encountered grumpy docs whose bad moods influenced the clinic or OR they were working in, I can genuinely say that none of their ire was directed at me. Most of the doctors I have worked with, from first year F1s to senior consultants have been pleasant and happy to teach.

-As a Canadian, I was interested in observing how the NHS works, because in general the Canadian system and the British system are more similar than the Canadian and US ones.

These were my reasons in making the decision. I have to say that one reason I chose my particular Caribbean school was because they offered the opportunity to rotate in the UK. It was a decision I was seriously considering before starting school.

Now that I'm here, my decision has been confirmed. I think the UK is an excellent place to be as a med student. There are a few things I wasn't expecting:

-The docs that came over from the UK while we were still on the island to promote their rotations talked a lot about how much med students in the UK get to do. And for the most part that's true, but what med students get to do in the UK is very different from the US. Here, med students get to do a lot of procedures: i.e. taking bloods, inserting IV cannulas, taking ABG's, inserting urinary catheters, etc. We are expected to become proficient at these sorts of tasks (which are done mostly by nurses in the US) by the time we are finished. We also get to scrub in for surgery. I now have several first assists in my log book, which is pretty cool and (in my understanding) not that common in the US.

-One major different from the US is that we are not assigned particular patients to follow while we are with a particular firm. So if we do a H&P on a patient and present them, that does not mean that we have assumed responsibility for that patient.

-There is also a lot of observation. We spend a lot of time observing ward rounds and clinics as opposed to actually doing them, which works for me, because I am a fairly strong visual learner. So while we get to do some things that US students do not, there are some things that we generally observe instead of practice.

-While it is interesting to see how the NHS works (and it generally works quite well for the average patient), there are some deep-seated problems in the administrative culture of the NHS that make it a very unattractive place to work. I would not want to be a doctor here in the UK. Mostly because given the top-down and politically driven way the NHS is run, health care professionals in the UK face an almost daily erosion of their professional autonomy.

I am enjoying this experience, and am grateful for the opportunity to see different health-care systems in action. By the time I graduate, I will have seen how the UK, US, and Canadian systems work. It will be interesting to me to see the strengths and weaknesses of all three, and, IMO, knowing that there are many different ways to arrive at the same result will make me a better, more flexible, and creative physician.

I'm actually not looking forward to heading back to North America for my fourth year. I have enjoyed being treated like a valuable member of the team whose job is to learn why the rest of the team is doing what they are doing. I am not happy about getting back home and being treated like a moron and/or slave labour. Hopefully it won't be as bad as the horror stories I have heard!

Surgery

2009-10-14T07:00:00.000-05:00

I got a migraine the other day. Right in the middle of my first clinic with my vascular consultant. By the end of the afternoon, I was incapable of speech. I'm sure she thought I was a complete moron. She kept asking me simple questions that I knew the answer to, and I just. couldn't. answer. them. Oh well. Hopefully I will be a little more coherent next time I attend her clinic. It annoyed me, because she is really good at what she does and is interested in teaching. At one point in the afternoon, when she'd asked me a simple question about what the vertical scar on a patient's neck might mean and I suggested that he might have had some work done on one of his carotids, she said, "well now you're thinking." Um, yes.

I have only two more weeks to go and then I'm done my surgery rotation. It's been an interesting experience! I started surgery a little worried that I might fall in love with it. After all, I really enjoyed anatomy on the island. And every surgery is, among other things, a big anatomy lesson.

I have fallen in love with surgery. But have no intention of pursuing it as a specialty.

There are several things I have really enjoyed while doing a surgical rotation. As I suspected, I have really enjoyed the relevant anatomy. It made my first few months of medical school come alive in a very real way. As I retracted an important nerve, or had to keep the various planes of tissue retracted so the surgeon could suture the one just below the retractor blade it occurred to me (again) that very little of what I was taught in my first two years was irrelevant. (Although if you read posts from my first two years, you might think otherwise...ok, I was an ~~arrogant~~ stupid med student.)

I enjoy the immediate feedback and generally quick resolution of surgery. You have cancer, we can take it out. You have a broken bone, we can fix it (I really, really liked orthopaedics; especially hand surgery!). Unlike medicine, where there are many times when a patient has a chronic illness and won't be getting better any time soon, in surgery it is not uncommon to actually make a patient better.

I really enjoy the sense of ritual and cohesion that exists in a well-run operating theatre; how this large cast of highly skilled individuals work together to provide the best patient care possible. There is a feeling of age-old ritual, from the scrubbing and the gown tying dance to the patient-draping. And it has been instructive to see how an unpleasant personality can destroy that cohesion very quickly. (Thankfully, there have been very few moments like that!)

But there have been times when I really, really didn't enjoy surgery. I think mostly because of how brutal it is. My first few surgeries were, to put it bluntly, traumatising. Not because of the surgeons or the team (they all went out of their way to make me feel welcome and involved), but because of what we were doing to these patients. We were cutting them open, moving their insides around, putting them back together (sort of), and hoping for the best. I kept thinking of how much pain they were going to be in when they woke up, and how miraculous it would be if they regained some form of normalcy after this.

I wonder if I have a bit too much empathy. If my artist's training to explore the pain of another person is just a bit much for a surgeon. Of course, for those surgeries where I was scrubbed in with a job to do, it was much easier to focus on the relevant anatomy and not on the person I was sticking my hands into and suctioning blood out of.

I found myself standing in theatre, forcing myself to pay attention to what was going on in front of me, while having one ear focussed on what the anesthetists were doing; their sort of physiology-heavy medicine being endlessly fascinating. Perhaps that was a sign.

So while I have enjoyed many aspects of my surgery rotation, I know it isn't for me. I find myself at the end of these 12 weeks tired, sick, and very ready for a break (two weeks in France in the middle of nowhere with my sister). Until next time!

Giving Thanks

2009-10-13T06:12:00.003-05:00

So I just got back from a weekend in Ireland with a colleague from AUC who is also here in the UK for her third year. It was a good trip to Dublin and parts beyond, where I got to visit my cousin in Dublin and a friend, albinoblackbear, in her new life as an irish med student. I met ABB online, and then in person when she came down to the island to check out the Caribbean med school thing. But she decided to go to Ireland instead...

While in Ireland for the weekend, I cooked a big pot of gravy for a 50-person Thanksgiving extravaganza during which we introduced the wonders of Canadian Thanksgiving to some real Irish med students, went to the Cliffs of Moher (again, although this time on a spectacularly sunny day), and hung out with some really cool people! We pissed off the GPS computer lady by making too many wrong turns in the middle of nowhere, and for revenge she led us astray in a scene that wouldn't have been amiss in a Jason Bourne movie...

I managed to catch a cold, which I am successfully fighting...so far. And am now back for my last two weeks of surgery. Wow! How time does fly. And how little am I looking forward to the next two weeks!

Another TED talk...

2009-10-08T05:59:00.001-05:00

A new favourite blog

2009-10-04T03:22:00.001-05:00

Written by an elementary school teacher...

Up the Down Staircase in the digital age

Another TED talk

2009-09-23T14:34:00.001-05:00

The science of motivation...

2009-09-14T20:13:00.001-05:00

A fascinating talk from TED

More on this subject in a day or two. Today is my first day of Orthopedics.

Some of my favorite posts...

2009-09-13T03:38:00.006-05:00

I have several ideas for posts percolating through my brain, but am not ready to write them yet. So, here's some of my favorite posts from the archives:

Gross Anatomy

On Belonging

Sonnet

Memories

The Wine Dark Sea

The Art of Medicine

Thoughts of a Generalist

Sonnet

I will make a horrible doctor - part 1 and part 2

and coming full circle...

We are the dead

Enjoy!

A great poem...

2009-09-06T14:16:00.003-05:00

Reference Range
by Veneta Masson RN

Your tests show
the numbers 73, 90, 119 and 2.5,
the letter A,
the color yellow,
a straight line interrupted by a repeating pattern
of steeples and languid waves,
a gray asymmetrical oval...

Check out the whole poem. Enjoy!

My once-monthly post...

2009-09-05T12:56:00.001-05:00

The cliffs at Kilkee

I'm in the middle of my surgery rotation. I started out slowly; so slowly in fact that I took a long weekend to Ireland with a colleague and my cousin D, who we persuaded to come with us while drinking G&Ts in Liverpool. Ireland was wonderful, as usual, and we had a pleasant road trip through the South, to Cork, Limerick, and the cliffs of Moher. Guinness really does taste better in Ireland.

Then my surgery rotation started in earnest, and I've been busy ever since. I'm enjoying myself, although I'm finding surgery much more tiring than Medicine. I'm trying to figure out whether I'm just tired from having done half a year of rotations, or whether I'm tired from surgery not being a great fit. I must admit, though, that the few occasions where I've scrubbed in for surgery and actually been able to assist, I've enjoyed it MUCH better than observing. Right now, I'm doing a urology rotation, so unfortunately, those surgeries are mostly observing...lots of nasty metal tubes...

But for the most part, I'm enjoying the medical parts of this rotation much better than the actual surgical. I spent a morning last week in a prostate cancer clinic with a prostate oncologist, and another in a prostate biopsy clinic. So I've gotten a lot of good experience in some bread-and-butter things.

So next week, I've a large exam, so I'm in full-blown procrastination mode. Anyway, I'm really too tired to care. Right now, I'm just glad I'm not doing rotations in the US, where I'd be doing far more scutwork and spending far more time in hospital.

Last week was fun. I spent Friday singing Evensong at St. Paul's Cathedral in London (with the Estherhazy singers), and on Saturday, I went with one of the nurses from the hospital and some of her choir buddies to the opera at Glyndebourne, which is a cultural experience. It was really fun drinking champagne on the lawn in my dinner jacket, with sheep grazing in the field next door. And the opera was well done too, and although I liked the tenor, he wasn't spectacular. But then again, I'm a bit of a snob. And I was offered a solo gig for Nov, which I had to turn down because the scheduling didn't work.

Oh well. Anyway, more later (if my posting record has been any indication, it'll be a lot later).

A brief update

2009-08-05T06:27:00.005-05:00

So I'm done my medicine rotation. It was a good experience. I learned a lot (though not enough), and had a good time (mostly). Then I took a week off and went to Scotland with my cousin, which was good. I made it all the way up to Loch Ness, saw a bunch of castles, and slept in some pretty interesting hostels. I also got to meet up with one of my former profs, who's now teaching in Glasgow. I got a personalised tour of the anatomy dept at Glasgow Uni, and saw some of the Hunterian collection. Cool! (For the uninitiated, this is a 300 year old collection of preserved, dissected body parts in quaintly labelled jars). Cool!

Anyway, medicine was good. I hung out with the HOs a lot (interns), sat in on clinics, watched endoscopies, and did call in A&E. I learned how to take blood (venous and arterial), insert catheters, write progress notes. I brushed up on my physical exam skills, and interviewed patients.

Most of the docs I worked with were really cool, knew a lot, and taught me a great deal. Many of them were enthusiastic about teaching and making sure I was learning what I needed to learn. Unfortunately, a few of them taught me a great deal about how NOT to be a doctor.

But it was a learning experience. I only hope that the stresses and demands of my training and professional life won't push me to forget these lessons; that the doctors who actually listened to their patients, read the notes, and talked to their patients are the ones I want to be like.

I've moved on to surgery, and in an unfortunate schedulling oversight, the two consultants on the GI firm I'm attached to are both on vacation. For two weeks. Out of the three I'm assigned to their firm. So I'm having to work to figure out what I'm going to do every day. Yesterday I spent the day in A&E. Today, it's a ~~blogging~~ study day. Tomorrow, I'm going to theatre to observe anything I can.

Ugh. The joys of rotating in the summer. In other interesting news, today is the first day the new HOs start work. So I am in the interesting position of knowing more of how the hospital works than the docs who are supposed to be supervising me. Fun.

An anniversary

2009-07-26T16:58:00.001-05:00

Copyright Kent Tisher 2009 all rights reserved.

This blog is now officially two years old. There have been some excellent posts, some great comments, and a lot of naval-gazing drivel. Thanks to the few individuals who actually still read what I write!

A tear jerker...

2009-07-16T16:27:00.003-05:00

From the founder of El Sistema, a system of music education for children in Venezuela. I watched this with tears running down my face.

And then to see the results:

A Medical Funny

2009-07-06T15:13:00.000-05:00

From Dr. Val:

A neat food website

2009-07-05T11:48:00.003-05:00

full of random articles on cooking. Enjoy.

In other news, I start my last firm of Medicine tomorrow; GI. In three more weeks, I will have a week off! I can't wait. Going 18 weeks in a row is pretty intense, not that I should be complaining, because it's all down hill from here...

Cool talk

2009-07-02T16:07:00.000-05:00

Happy Canada Day

2009-07-01T00:49:00.001-05:00

My parents fly in today for a few days. And like the slightly befuddled moron that I sometimes am, I was convinced they were coming next week. Oh well, this week works better for me anyway. :)

And for a few those of you who are old enough to remember this era, I give you: Яolcats. Enjoy!

Happy Irish Cows

2009-06-29T14:23:00.000-05:00

Organ Pipes

2009-06-28T14:21:00.000-05:00

An interesting performance

2009-06-26T14:55:00.001-05:00

From TED. It's interesting to read some of the comments.

Check out the side menus

2009-06-26T10:38:00.001-05:00

I've added some stuff (sorry about the adds), including a place for you to see some of my photos, and purchase copies of them if you're interested. It'll take me a while to upload the one's I want, so do keep checking back for more photos.

Giant Thyme

2009-06-25T14:08:00.000-05:00

The value of the liberal arts in a modern democracy

2009-06-25T02:58:00.000-05:00

Dunluce Castle

2009-06-24T14:01:00.001-05:00

Looking North toward Scotland

2009-06-23T13:59:00.000-05:00

We are the dead

2009-06-21T02:44:00.001-05:00

When I first started this blog, way back in my first semester, I wrote and even waxed poetic about my experience with the dead in anatomy lab.

And while I was a TA in anatomy lab and tutored (somewhat haphazardly) anatomy during my last semester, and even though I was around the cadavers quite a bit, I found I had made an uneasy peace with their (and my) mortality.

I find that now I am on the wards, I am having to revisit these thoughts and emotions. I have seen a patient pronounced three times now (once doing the tests; it's a little strange listening to someone's chest and hoping to NOT hear anything), been to the morgue, and broken a patient's ribs doing ultimately unsuccessful CPR.

What has struck me as a difference between the anatomy lab and the hospital is the business-like approach. When I'm ~~tagging along behind and generally being a nuisance~~ working with the House Officer on call, pronouncing a patient or examining them in the morgue before writing the death certificate is just one stop they have to make between putting a canula in bed 14 and writing up PRN meds for the demented lady in bed 5. In the anatomy lab, we were all a little conscious of a sense of purpose. Some of us in an over-intellectual, naval-gazing isn't-life-a-profound-journey sort of way; others with a sense of how-cool-they-were-and-what-great-orthopods-they-were-going-to-be-and-didn't-they-have-an-enormous-penis?

But on the wards, with too few nurses, and too few junior doctors, and too many patients, the sense of purpose is replaced by a sense of something I can't really define. It's not haste, or unconcern. It's not denial, or boredom. Or maybe it's a combination of all these things. It's mostly a fleeting sense that something profound has just happened tantilizingly out of our reach; a feeling of faintly gnawing dissastisfaction. One lady who my HO pronounced had been left in her room, the sheets drawn up over her thin hospital gown and a plastic rose placed on her breast (I assume by one of the nurses, or by family?). I remember feeling a mingled sense of warmth and impatience at this act of humanity; warmth that in this often terrible place someone had recognized the journey this person had been on and was marking its end, and impatience that I was being forced to confront her humanity when I didn't have time to deal with the emotional implications of what we were about to do to her. Although it's not really about not having time. It's about the demands of the evening shift that require that I don't confront her humanity in any meaningful way; a few minutes later, I will be sticking sharp metal objects into another patient, as he flinches in pain and begs me to stop. I will never forget the pain in his eyes and the warmth of his hand as I tried (and failed) to get the cannula into his vein.

I've written before about the need to maintain connected to our emotions, while not being mastered by them, and I'm still working that out now that I'm in actual contact with real patients. It's not an easy balance to strike. Susan, over at Rickety Contrivances of Doing Good writes about her interest in Narrative Medicine and how writing about their experiences allows health care professionals the space and the time to work through what they have seen and done in the name of "health care." And I suspect this is one reason I write on this blog, however infrequently. It gives me a place to try and come to terms with the emotions I am feeling. The guilt especially.

I feel guilt for ~~torturing~~ performing CPR on the patient whose heart had stopped beating. I feel guilt for feeling a smug sense of satisfaction that I got to do CPR on an actual patient while most of my colleagues haven't gotten past Annie, and for being the keener who stayed late to do it. And I feel guilt for the high fives and back-slapping (and the sense of pleasure and belonging) that came from my colleagues with my admission of breaking a rib. I feel guilt for poking needles into people who are already in pain, knowing that in my inexperience I will probably miss their vein; all in the pursuit of more experience. I feel guilt for my inexperience and lack of knowledge, and I feel like a fraud when I stammer some plattitude to a relative or patient because I don't have any answers or the courage to give those answers I do have.

I feel enormous guilt for the patient, who in the intimacy of my taking blood from him whispered to me, "Tell me the truth, doctor, am I going to make it?" And I, who had only seen him once on rounds and only knew about his history of poor self-care, could only mutter something about not really knowing his case and not being sure. If only. If only I had cared enough to check on how he was doing before I'd headed blithely into his room to take his blood, if only...but then we were off again to write up those meds for the demented lady in bed 5, who was getting increasingly more agitated.

I feel guilt for my impatience when confronted with death and a white plastic rose.

After we had performed the indignities of death certification and replaced the sheet over the thin hospital gown, I put the rose back on her chest. It was the only thing I could do for her.

"Pity is not in my repertoire"

2009-06-20T11:40:00.003-05:00

From A Day In The Life Of An Ambulance Driver comes this very moving post that captures many of my feelings about seeing patients who choose not to care for themselves.

Two of my favorite expressions are, Life is hard, and then you die. and Suffering is optional.

It takes courage to live a good life; to make decisions that honour oneself and others. It's far easier to give in to the myth that life is supposed to be easy, and that we're supposed to be happy all the time.

But life is hard, shitty things happen, pain and disappointment happen every day, and the only power we have is how we react and the choices we make. But that's the most powerful thing of all.

Edited to correct stupid linkage error.

Just a quick note

2009-06-16T12:58:00.001-05:00

to say that the new title picture was taken this last weekend looking West from the ramparts of Dunluce Castle, on the North Coast of Northern Ireland.

What's in a name?

2009-06-08T04:16:00.008-05:00

In a previous post, I was writing in response to a post on the Anesthesioboist Blog. In the last paragraph of my post, I referred to one of the commenters on the AB who said they felt degraded by having to call a doctor by their title. That individual has done me the honor of reading my post and writing a lengthy and interesting comment (which I have reproduced below in italics) so I thought I would respond. Thank you Anon for a stimulating conversation!

I am the person who posted on T's blog about feeling degraded by having to call my doctor, Dr. X. I hope that I misunderstood what you said, and that you did not take my statement of a feeling as a sign of disrespect.

Anon, while I acknowledge your feeling of degradation (which is a very strong word to use and intrigues me), I do take it as a sign of disrespect. It may be unconscious or unwilling on your part and I realize that, but that does not take away from the fact that you are unwilling to call a person by a title they have earned. I am unaware of your history, and am conscious of the fact that you may have cogent personal reasons for resenting physicians.

There are many other instances where professionals or leaders are given titles that reflect their achievements or position. I would be interested to know if you would feel degraded at having to call a Judge "Your Honor" or the President of the US "Mr President." These titles do make a separation between people; segregate if you will. And this is not a bad thing. Because while equality is an excellent idea, it does not mean we are all equal in achievement, ability, knowledge and professional standing.

Anyway, my comment was more related to the Institute of Medicine's aims for improvement listed in Crossing the Quality Chasm, specifically, "Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions." (p. 40)

So here there is an aim of "patient-centered" care, and yet there is a barrier set up in health care where the clinicians on the "team" address each other by first name, but the patient is segregated out of that team through the use of formal titles.

While I am obviously of the opinion that calling a physician "doctor" is a sign of respect, I believe that the formality it engenders serves a much more important purpose than stroking the ego of an insecure doctor. For the record, I am NOT in favour of a patient calling their physician by their first name (at least in a patient care setting), and believe it to be potentially dangerous. And I am in favour of using professional titles in a health care setting precisely because the formality of their use creates a barrier between the patient and their health care provider. This is not economic or class snobbery that I am talking about or an attempt to paternalistically exclude the patient from making decisions about their own care; this is a barrier that is necessary for the smooth functioning of the doctor-patient relationship (indeed the relationship of any health care provider and their patient).

The reason for this lies in the very intimate nature of the physician-patient relationship. A visit to the doctor or a stay in hospital is often a very unpleasant experience, which must involve a loss of dignity and a unnatural intimacy that is unlike any other professional-client relationship. Within seconds of meeting your physician, they will be asking you deep personal questions about your most private thoughts and bodily functions, and will then ask you to take your clothes off to allow them to examine your most hidden spaces. This rapid and odd intimacy requires very careful handling to avoid its becoming too intimate.

It is my opinion that the formality inherent in the use of professional titles in a medical setting creates a helpful set of parameters that assist health care professionals in managing their relationships with their patients. Of course, calling someone "doctor" or "nurse" is not going to make transference or countertransference or a false sense of intimacy go away, but it can help create an environment where it is easier to recognise and guard against.

Setting up boundaries (of all sorts, not just the use of titles) protects both the health care professional and the patient. It allows the patient some space and a dedicated place where this awkward intimacy can be at the very least, sort of normal, and at best where the patient feels safe and unlikely to be taken advantage of.

There are many examples of tragic outcomes in patient care that happened when the observations of patients and family members were dismissed because they were not valued as members of the health care team. Maybe the titles used have nothing to do with these examples. Maybe that segregation would exist anyway.

But in the off chance that the titles used are a detriment to patient safety, isn't it worth at least exploring the possibility? And wouldn't that fall under being respectful of my preferences as a patient?

We hear a lot about "patient centered care," and while I am a passionate adherent to the philosophy that everything we do as health care professionals MUST be devoted to giving patients the best possible care, I have always been somewhat of a loss to know exactly what "patient centered care" actually means. Does it mean that as health care providers, we MUST do anything the patient wants, even if it would be bad for them (i.e. prescribe antibiotics for a viral infection)? You say that the patient needs to be a valued part of the "health care team." While I agree strongly that the patient needs to be actively involved in decision making about the care they receive (and needs to be actively involved in maintaining their own health), I disagree that they are part of the "health care team." It may be arguing semantics and quibbling on terms, but IMO, for the patient to see themself as part of the "team" risks a dangerous intimacy that doesn't solve the problem of "patient centered care." And I see several other possible complications, including allowing a patient to abdicate responsibility for their own health to others.

For me, "patient centered care" has to do with practicing medicine so that in as much as is possible, I allow my patients to maintain their autonomy and never rob them of their personal power. But this does NOT mean that I do everything they want me to do for them, or agree to every demand they make of me. (This is an entire post, or series of posts, so I won't enlarge this theme here...)

Your point about communication is well taken, and I agree with you that often physicians do not (or do not seem to) really listen to their patients (sometimes with nasty consequences). But I would disagree with you that the way to solve this particular problem is to start calling your physician by their first name. In fact, when looking at the example you give of a physician not listening to their patient, it is somewhat difficult to see how calling a physician by their first name would solve the problem. The problem in such an instance is not that a social barrier exists between the patient and their physician (or even that the patient is feeling undervalued), the problem is that the physician has more important priorities than listening at that particular moment. And the reason (and solution) for that problem is enormously complicated; sometimes given the demands of the profession, the demands of other patients, and the demands of life itself in all its messiness, listening to a patient will slip from the top of the priority list. NB, I am NOT arguing that this is a good thing, just that calling your doctor Tom or Nancy is unlikely to make them more likely to listen to you if they are not already so inclined.

You raise some important points about physicians listening to their patients and allowing them to maintain their autonomy while being cared for. But, IMO, addressing a physician by their first name is entirely beside the point in terms of making real change to how you are treated and act as a patient, and could quite possibly be dangerous in the long run.

Thanks again for a stimulating discussion!

I love the British

2009-06-05T11:46:00.000-05:00

They use words so very well.

top down, micro-managing, egg-sucking twaddle

From NHS Blog Doctor.

Do read the whole post.

On achieving excellence, or why don't people like to hang out with doctors...

2009-06-04T11:10:00.004-05:00

I’ve been reading with interest the conversation over at T’s blog: Notes of an Anesthesioboist. T started the conversation by posting about her perception that friendship is difficult to establish as a physician due to a restraint non-medical people may feel when interacting with a physician in a social setting. The many comments were fascinating and illuminating; both from physicians and non-physicains.

There were several themes that came up in the discussion, but while many agreed that this phenomenon exists, there were few explanations as to why. I have a few ideas. I agree with those who commented that this is not something confined to the medical profession; other professionals experience it as well.

I have experienced this sort of thing as a musician; upon introducing myself as an opera singer, I invariably encounter a deprecating laugh and the admission from my new acquaintance that “I am a horrible singer.” I have experienced that sense of withdrawal after my awful admission that I have achieved a high level of accomplishment.

I think there are a couple of factors at play. In our current culture, there is a celebration of mediocrity that labels any individual who achieves a high level at any endeavour as “elitist.” As a passionate proponent of an “elitist” art form, I can happily say that one of the things that drew me to opera performance was the fact that it is so extraordinarily difficult and takes decades to master. Opera is the “slow food” of singing styles, and as such, requires dedication, perseverance, dogged determination to proceed despite lengthy setbacks; in short the antithesis of our modern fast-food, instant-gratification culture. Opera is an artform and a lifestyle that requires its devotees to be in it for the long haul. And like fine wine (which we also have no appreciation of any more) a singer (and a listener) can only develop properly when prepared to wait.

And as an elitist, I will cheerfully assert that some singing is really, really bad. That even if you like it, it's still bad. (If having standards makes me an elitist, then you can bite me.) I find the comparison between medicine and art interesting though, because while many people would cheerfully label me a snob, they would much prefer to visit a physician who actually had standards. There is a curious double standard here. But I digress...

I had a voice lesson last night, and had an excellent time. But in addition to being able to exercise my creative muscle briefly and spend some time with a congenial human being, I was able to work on and partially master several technical issues that have plagued me for well over a decade. I love the fact that it if I put in my work, do my part, sometimes I will have to wait for the answer/solution; sometimes years.

When I was in university, I used to play the piano at Christmastime in one of the swanky Shopping Malls in Vancouver. One Saturday, I was improvising a set of Christmas carols when a lady came up to me and said something to the effect of, “I would love to be able to play like you do, what can I do?” Now, I often lack tact when performing (because my filters are not engaged), so I told her the truth, “I have been studying and practicing the piano for almost 20 years, am almost finished a degree in music, and have found that the better my understanding on music theory is, the better I sound when I am improvising.” Poor woman. I’m afraid she was rather insulted. But I wasn’t trying to be rude or condescending. I was simply pointing out that in order to play at my level, certain requirements had to be met.

And I think that many in our society are uncomfortable with the notion that some things cannot be had without real sacrifice. If I had to guess, I’d say that this discomfort stems from guilt, regret, insecurity, and a very real lack of respect for honest work. The guilt and regret are easy to understand. Many are called, but few are chosen. I’ve often thought about the ones who aren’t chosen. In my long journey to get into medical school, I have spent my time in the ranks of the not chosen. It’s not a comfortable place to be. When I was feeling most demoralized by my inability to get a med school admissions committee to even use my application as a doorstop, being around doctors and med students was often painful. (It doesn’t help that my family is littered with doctors.) And I’ve often had people speak wistfully to me about an early love of music that they did not cultivate. In either case, it can be painful to deal with an unfulfilled dream; and the guilt comes in when that dream is unfulfilled due to a lack of perseverance or poor/unenlightened choices.

And sometimes, it seems to me that individuals who are awed by someone who has achieved a great deal devalue their own work to such an extent that it allows them to give in to their own insecurities. There is no question that the training, perseverance, and dedication required to become a physician far outweighs the requirements to become a janitor, for instance. But the janitor who takes pride in their work should be able to stand shoulder to shoulder with a physician without any embarrassment. If someone is operating from regret, guilt, or insecurity, however, then it becomes a problem.

Or, like the commenter on T’s post who is degraded by calling someone “Doctor”, sometimes a person is so disrespectful of the perseverance, dedication, and sheer hard work required to achieve excellence that they aren’t worth knowing anyway.

What do you say?

2009-06-02T01:03:00.003-05:00

So I'm working with my F1 (intern) on call last night. And she's teaching well, and getting me to do stuff. So the Reg (senior resident) asked us to do some blood cultures on a patient, so we went in, and I, having just learned to take venous bloods, was getting ready to take the blood. In the course of our conversation, the patient revealed they were on chemotherapy. My F1 asked what the chemo was for, and the patient (probably fifty-something, fit looking, and not that unwell) said they were on palliative chemo for inoperative pancreatic cancer. I will never forget the wistful expression in their voice when they said, "I'm trying to buy myself eight months."

And there I was, quite excited by the opportunity to take some more bloods (I know, I'll soon get tired of it), and pleased with getting the vein on the first go. My excitement seemed almost a betrayal, knowing my patient at that point would be dead within the year.

What do you say? "Thanks for letting me practice on you! Have a good one!"

It's been a long time

2009-05-17T14:38:00.002-05:00

When I last wrote, I was just starting my psych rotation. And after the first week (which was somewhat of a bungle), things went much smoother. I met the consultant I was actually assigned, and I started my work. It wasn't a bad rotation, but as I said several times throughout the rotation, "I'm not loving psych, but not hating it either." Part of it may well be the consultant, who wasn't mean or upset at having me around, but didn't go out of his way to offer any teaching opportunities. It took me a while to figure out that any opportunities I would get, I'd have to push for. Which was fine. I learned a fair bit, though not as much as I could have; and I learned that I didn't ever want to do inpatient psychiatry.

I found myself disheartened seeing the chronically mentally ill come in and out of hospital, with no real possibility of their leading a semi-normal life at the least, or of recovery at best. Just an endless cycle of hospital admissions and discharges. One of the things that struck me was that the truly unwell were the most likely to want to pretend that they were sane (and not take their meds). There were many patients who really wanted to remain unwell. For whatever reason, being in hospital worked for them, and they did everything they could to stay in hospital.

It also struck me how little personal contact the team had with the patients. We sat in a locked room and adjusted their medications, often without even seeing the patients. It struck the bleeding heart in me as a little cold (although the pragmatist in me knows that this is probably the best way to proceed).

Anyway, I finished psych at the end of April, and started my Internal Medicine rotation with a Respiratory firm.

Also in April:

I took a brief weekend trip to Paris, where a colleague from AUC and I saw most of the touristy sights, including the Louvre, la Tour Eifel, Monmartre, etc. I think my favorite part of the weekend was simply wandering around the Sorbonne, and soaking up the ambiance of Paris; a truly enchanting city. My allergies went nuts though, and I sneezed the entire weekend (I actually had to borrow a puff of some random stranger's inhaler on the train back to London to stop a coughing fit).

I went with an online aquaintance to the ENO (she managed to procure amazing (200 pound seats for a pittance through her agent) and saw Jenufa. There was some wonderful singing, and I do enjoy the opera. I keep meaning to go see something at Covent Garden, but haven't managed to yet. The ENO is doing Peter Grimes right now, so I may pop in and try for some cheap tickets sometime this week.

I went with one of my med student colleagues to see A Little Night Music. It was a great production, Sondheim is wonderful, the acting and dancing was excellent, and the singing was mostly abysmal. I hate going to a very professional show, with performers who have a resume longer than my arm, who couldn't sing their way out of a paper bag. The best singing of the night was by the actor playing Desiree (the irony being that hers was a role written for a non-singer). Anyway, I fell in love with the musical, if not the cast.

Now for May:

I've been doing a Respiratory placement. The consultant has been excellent, the junior doctors on the team are all excellent and enthusiastic about teaching, and the other med students (from a UK med school), have been excellent colleagues. I've had a great two weeks. I have one more week with this firm, and then I move on to other medicine firms. I believe I will miss this placement.

I am enjoying working in the hospital, and have done my first few procedures, including ABGs (Arterial Blood Gasses). This is a somewhat tricky (and painful) procedure, and I was rewarded by one of my patients telling me that mine was the most painless he'd ever experienced.

Also in May:

I've been playing the organ for services at the Anglican church across the road from my flat. It has a lovely little organ, and while my pedalling still isn't up to snuff, it's much better than it used to be. It gives me a chance to go practice the organ (and a place to sing in), and exercise my artistic side once in a while; which is really very satisfying.

The Music Director at the aforementioned church conducts several choirs in the area, and she happened to mention a Haydn concert that one of her choirs was singing. So yesterday, after only three rehearsals, I sight-read the choruses for Haydn's The Seasons. In the hall of Eton College (which is literally down the street from Windsor Castle). It was somewhat surreal and (as the tenor who sat next to me in the choir said), Eton is one of the few places in the world where wandering around the streets at dusk wearing black tie could be considered normal. The Queen was in residence at the castle, and although I wandered around Windsor during my break, there was some big to do on the castle grounds, so I didn't go in for a better look. I'll have to go back and do the complete tourist thing some other time.

I really enjoyed singing the Haydn, especially as I've never sung that particular work before. The tenor soloist was a typical English "throat on legs" and I found myself wishing I was up in front doing justice to the solo stuff... I have hopes of some of my networking bearing fruit, however, so I do not despair of getting some actual solo work while I'm here in the UK.

My allergies are much better (the inhalers and drugs I'm taking may well have something to do with it). Better living through chemistry! I am starting to reduce the irritability of my airways, and am breathing much better and not sneezing nearly as much. I've taken a week off from the gym, so must needs go back to the gym starting tomorrow. Ugh. It'll be good for me, though, and I do enjoy it when I get there.

I had planned to go to Amsterdam this weekend to visit a friend from University days, but postponed that trip because of the chance to sing the Haydn. So I'll probably be heading to Amsterdam at some point in the next few weeks. I'll keep you posted.

Sorry for the long time between posts. I would promise to write more regularly, but won't, as I'd be forced to break that promise. Thanks to the few who still check for new posts...

Many blessings to all of you!

The first week

2009-03-27T13:29:00.002-05:00

Well, I started psych this week. And for a variety of reasons, it wasn't a great week. I had been fighting a chest cold last weekend (which I suspect I brought with me from Canada) and as the week started, it got worse and worse; to the point where I have been coughing nasty gunk out of my lungs for most of the week. Under normal circumstances, I would have called in sick, but as this was my first week, I figured I should soldier through. I needed have worried.

I showed up on Monday, to discover that the undergrad admin person who was supposed to orient me and show me where to go was off sick. So with the help of some other people at the hospital, I figured out where to go, which doctor to meet, and headed over to the psych wing to meet them. Of course, the doctor I had been assigned had never heard of me. And because the coordinator person was away, I couldn't really figure out what wires had been crossed. So my first day was a bust, but I wasn't feeling great anyway, so was happy to do some research in the library for a few hours, and then head home to bed to nurse my cold.

The next day, I headed back to the hospital to meet a new doctor I'd evidently been reassigned, only to discover that not only were they not at the hospital, they were also not prepared to take me on. The admin person still being sick, I sent him my phone number and headed home to bed.

I spend the rest of Tues, and all day Wed in bed, and by Thursday, was feeling much better. I then went to a different hospital to spend two days with another team, and another doctor. This actually worked, and I've spent the last two days working with a Early Intervention Team that works with young people who are experiencing psychosis. It's been an interesting experience, seeing how a multidisciplinary team like this works. This group is made up of Social Workers, Nurses, OT's, Admin types, and a consultant Psychiatrist.

So I sat in on Rounds, and went on home visits, and did a lot of reviewing my psych drugs while waiting for things to happen. But it was a good two days. And I still can't remember my psych drugs.

Monday, I'm supposed to start with another firm, back at the main hospital. We'll see how that works. The admin guy is supposed to be back at work, so I can get id, and locker keys, etc. Hopefully things will go a bit smoother next week.

This weekend, I was supposed to have a voice lesson, but because of my cold, have been playing it by ear. I sang a bit today, and think I've got a bit of singing in me for tomorrow, so may do a short lesson. And then we'll see what happens.

I'm feeling lonely, and very bored right now. Hopefully things pick up in the next few weeks.

Dublin Thoughts

2009-03-19T11:25:00.002-05:00

So I’ve just spent four days in Dublin. It was a great time. I flew in on Saturday, and got into Dublin in the evening. I was staying with my cousin, and we’d planned to go out for a quiet pint when I got there, but we ended up partying with friends and classmates; a truly good start to the weekend. I learned a new drinking game that involves fake money and Jaeger-bombs, and had the interesting experience of dancing in a pub while wearing my backpack.

We were both up early the next day, despite the beer and shots of the night before, so we headed out to explore the town. We basically wandered around, and my cousin showed me around his medical school. RCSI is a neat school with a wonderful history, both politically (it was occupied during the Easter uprising of 1916; there are still bullet holes on the front facade), and medically. It was interesting to walk past the Colles Room (of Colles fracture fame), and other similar anatomical and medical greats. And the Anatomy corridor smelled extraordinarily familiar, for all the posh surroundings, of phenol and formaldehyde.

After wandering around Dublin all morning, we met up with a classmate and one of his friends (currently in his first year at SGU’s satellite campus in the UK), and we headed out to Howth, a peninsula north of Dublin, where we walked around the cliffs, ate some wonderfully greasy fish and chips, and shopped in the open air market for supper fixings. Then we went to the classmate’s apartment where we got ready for another party. I made bruschetta.

The next morning, we wandered through St. Patrick’s Cathedral, and my cousin dropped me off at a museum, and headed out of town. I discovered that many museums are not open on Monday, but I managed to spend several hours in the National Gallery. I think my favourite exhibit was a room with three paintings in it; all from Holland. My cousin being out of town meant that I was on my own, so after wandering around town for a bit and doing a bit of shopping, I went back to St. Patrick’s for Evensong (the choir wasn’t bad, and it reminded me of singing at St. Paul’s), and then headed back home and crashed for an early night.

Tuesday morning was St. Patrick’s Day. It was fascinating wandering around the city, seeing how Dubliners and the rest of the world celebrate. It appears that most of the thousands of people who were there for the festivities were from elsewhere. One of my cousin’s classmates, who is Irish, said that many Dubliners head out of town for the day, and I could see why. There were people everywhere; mostly young people from all over the world. It was interesting trying to place all the languages that were being spoken all around. I started the morning in the National Archeology Museum, looking at the collection of bronze age gold and Viking stuff, and then headed out to watch the parade.

I met up with some of my cousin’s classmates near city hall. We were about 10 people back from the parade route, so we didn’t see a lot, but it was fun none-the-less. The theme of the parade was “the sky is the limit” and it was somewhat loosely and incomprehensibly adhered to; there were lots of birds and flying machines in the parade. When the parade was over, we drank margaritas in a nearby Mexican restaurant, and then after discovering that I still hadn’t had any Guinness, my cousin’s classmates took me to their student hangout pub and I had several. Later on that evening, I got together with one of my classmates, who has just written his Step 1, and is in town on holiday, and had supper with his family.

My last day in Dublin, my cousin headed off to class, and I packed and headed up to the Kilmainham Gaol, an interesting 18th and 19th Century building in its own right, but with a fascinating political history, tied to the fight for Irish independence. I did the tour, which was worth it. I found the transition between the 18th and 19th century portions of the jail fascinating; you could see the change in societal attitudes written in the architecture. From Kilmainham, I walked back into town, past the Guinness factory (I didn’t have time to go in and have a tour or a pint) and to the Chester-Beatty Library, one of the most fascinating museums I have ever been in. It houses the collection of Sir Arthur Chester-Beatty, a well-known 20th century manuscript collector. Some of the Arabic and Latin manuscripts are overwhelming. I swung back around to the National Archeology Museum to see the bog people and the masturbating fertility statues that I’d missed the day before, and then headed to the airport.

After an uneventful flight, and a long train ride back to Epsom (the guy at Gatwick told me to get on the wrong train, so I spent an hour backtracking to get on the right train), I’m back in my dirty apartment.

I enjoyed Dublin. I had amazing weather the whole time I was there, and it’s a really neat city. I walked a lot! And have the blisters and sore feet to prove it. I thought I was in good shape when I left, but I think that all this walking is going to make me even fitter. The one maddening thing about Dublin is that there are no street signs (there are some, but many intersections don’t have anything). So while maps of the city are fairly easy to use, you’re never quite sure exactly where you are.

The St. Patrick’s Day Parade was a really interesting experience. I suspect that it’d have been even more interesting if I’d already had a couple of pints, but I’m glad I did it. It was interesting to me to see all the young people in town. I saw a couple of the same people at museums and attractions all over the city during my four days there; one group was at Evensong at St. Patricks and showed up at the gaol when I did two days later. In that respect, and in the respect that you can walk pretty much anywhere in the main part of the city, it feels like a small town still.

The strangest thing I saw was a "Happy St. Patrick's Day" t-shirt with Obama on it. But the crowd was pretty young and from all over the world.

All in all, a good weekend. Now I'm back in Epsom, getting ready to start Psych on Monday. I'm a bit lonely. It was great being able to hang out with my cousin and join his social network for a bit. Oh well, I'll rebuild mine. On Saturday, I'm going to the opera with an online friend, so that'll be fun!

That's all for now.

Here I am

2009-03-13T10:28:00.002-05:00

sitting at the computer at Epsom Public Library. It would seem that public library computers are the same, the world over. I feel an interesting sense of deja vu, from my penniless days in London, ON, where my only internet access was the public computers at the library. In fact, I wrote my last set of medical school essays in the Westmount Library.

It's my second day here. I flew in yesterday, after a relatively uneventful flight. I was seated in the last row of the airplane, so by the time I got off the plane and through immigration, there wasn't that much luggage left on the carousel. And I hadn't stood there very long when it stopped. I was standing in the lost luggage line thinking evil thoughts when the guy behind the desk said, "there are 4 more bags coming through." And sure enough, the carousel started moving again, and my bags came through. There is a God!

So the taxi the hospital sent to get me took me to the hospital, where after a bit of wandering around, I found the housing office and picked up my key. I then went over to my dorm room, dumped my stuff, and headed back to Epsom and the hospital, to sign my lease and meet the coordinator. The hospital seems very nice. It's not huge, and there are some parts of it that are quite old, but there seems to be a very lively undergrad training program, with students from AUC, AIM?, and UK schools. Most of my flatmates are from a Polish school, although they're from all over the world.

Speaking of my flat, it's pretty grim. The walls are filthy, and the carpets stained. That being said, the carpets are vacuumed, the bed is clean, and the bedding spotless. It begs comparison to the dorms at Worchester University (some of you will know what I'm talking about). My next stop this afternoon is the grocery store, where I intend to buy some bleach at the very least, and possibly some other heavy-duty house cleaners.

So after I toured the school, I wandered around the town centre for a bit, bought some bread and cheese, and went back home for a nap. I only slept for 30 minutes, because any more would have defeated my design to stay up all day. Then I headed back to Epsom, got on a bus, and headed to Kingston, where I met a colleague from AUC and bought a phone off of him. Then, a bunch on AUC students who are rotating in the UK and I went out. I didn't get back to Epsom until about 10:30, whereupon I went promptly to bed.

This morning, I got up a bit later than I'd planned and went for a run. My flat is literally across the road from Epsom Common, so I had a wonderful run through fields and trees. I'm looking forward to getting to know this little piece of wilderness. Now I'm back in town, taking care of business. I've got a usb internet stick for my computer, so I should have internet access in my room. And I'm exploring my options for my cell phone.

I'm not sure what I'll end up doing tonight, as I have no convenient colleagues to hang out with, but I'm sure I'll be able to think of something. More later...

Tying shoelaces

2009-03-08T07:32:00.002-05:00

So it appears that I've been tying my shoelaces wrong for the past mumble mumble years. I found a very interesting website that is dedicated to all things shoelace.

My initial thought was, "Dude, you have way to much time on your hands." But I found myself drawn in in spite of myself; the passion the website owner demonstrates for shoelaces and inefficiently tied shoelaces is instructive. Would that we would all live with such passion!

So here's to my retraining my shoelace tying!

Mistakes and Guilt

2009-03-06T11:23:00.002-05:00

In a very interesting post, Dr. Alice muses on the moral weight attached to mistakes in medicine. While I read her blog with interest (she has some excellent things to say), I often don't agree with her.

In this case, I'd have to say that I both agree and disagree. I agree, in the sense that actions in the day to day practice of medicine, even tiny ones, can have enormous negative (and positive, let's not forget the positive) consequences. Where I disagree is in the utility of wallowing in guilt over mistakes (even major ones).

I come at this from the perspective of an artist; where guilt over mistakes can be crippling and self-flagellation is never productive. When I make a mistake during a performance (NB when, not if), if I start to beat myself up about the mistake, the rest of the performance is shot. Instead of pouring my energy into communicating with the audience, I am now preoccupied with something that happened pages ago. And the audience is treated to a preoccupied, nervous, apologetic, and perhaps even angry performance.

What is far more productive is to practice (in the words of one of my voice teachers) "instant forgiveness." When the metronome is ticking, and the performance is underway, when a mistake happens, you have to drop the mistake, forget it happened, and keep going to the end of the concert. It's a difficult, but valuable, skill to learn.

Now, it goes without saying that the next morning, after the concert, any artist worth their salt will be analyzing the offending passage and making sure that it won't happen again. And it's this response to a mistake that I find far more productive than wallowing in guilt and self-pity; a clear-headed examination of what went wrong and how to prevent it from happening again.

In my limited understanding of how medicine is practiced, I can see clear parallels. To use Dr. Alice's example, say you got morning labs late and a patient died as a direct result. Of course, you'd feel awful. And it might make you want to sit in a dark room for a month saying to yourself, "I am a bad doctor." But this serves no one. It does not serve the memory of the patient who died, it does not serve your current or future patients, and most of all, it does not serve you, the physician. It allows you to perpetuate a self-concept based on the idea that you are worthless, which can have only negative implications for your practice and life.

A far more productive approach is to practice "instant forgiveness" and then pour all the energy you might have poured into feeding your guilt into making sure that this never happens again. A clear-headed, unemotional assessment might make you realize that you are indeed a bad doctor. But without the guilt and negative emotions attached, you are free to work to change that; free to work at becoming a better one. And your clear-headed self-assessment might make you realize that you are actually not a bad doctor, but one who occasionally screws up(insert minor character flaw here). Again, without the crippling sense of guilt, you are now free to work of making yourself into the person you choose to become.

So while I agree with Dr. Alice that even tiny decisions in medicine can carry enormous weight, and that mistakes and errors in judgement can have cosmic significance, I don't agree with her prescription for dealing with them when they occur. Besides, hours of second guessing isn't really all that fun.

The countdown is on

2009-03-05T12:03:00.002-05:00

It's been a busy couple of weeks. Last week was spent getting my visa application together, and doing various housekeeping tasks. I prepared my will, and updated my powers of attorney. I had a physical, and got some suspicious skin lesions removed (one of which was another BCC, sigh). Add to that, I was dog/house sitting, and it was a busy week.

This week, I've been stressing about my visa. It was granted on Tuesday, thankfully. So now, I'm just waiting for it to be couriered to me. I got an extra pair of glasses (funky, artsy frames that my sister hates, although she tries to be polite), did some more shopping, got my hair cut, had an ultrasound to investigate a possible umbilical hernia, and have been sorting, filing, and getting ready to go. No actual packing yet, though.

I'm going to be flying out next Wed, arriving in London on the 12th. I have a couple of days to get my feet on the ground, and then I'm heading to Dublin for St. Patrick's Day. I have a cousin there in med school, so I have a place to crash, and some local guidance. He is sure to know where the best beer is to be had. Then back to London, and starting my psych rotation on the 23rd.

I'm in somewhat equal parts really excited, and really terrified. I'm excited because seeing patients is the culmination of two years of hard work. More, if you count all those years of undergrad and trying to get into med school. I'm terrified, because they will actually expect me to know things. I know so little.

I spent a few hours last night in the ER shadowing my uncle. After my initial panic, I was able to do some ok interviews, although I was embarrassed by how much I forgot/didn't ask. But I calmed down a little bit, and realized that although I didn't know a lot, I did know some things.

The weirdest/funniest thing about last night was the 3rd year medical student who was rotating with the day ER doc. He was a student that had practiced his physical exam skills on me when I worked as a Standardized Patient. The last time he'd seen me, I was probably in my boxers, getting poked and prodded by a roomful of medical students. I didn't really emphasize my medical aspirations to that lot, so he looked slightly bemused to be introduced to me (now fully clothed) as a newly minted 3rd year, off to London next week. So much for the actor/opera singer.

I'm already in the process of setting up a voice lesson in London for late March. There's a teacher/singer I've been emailing for some years who's based in Berlin, but occasionally flys to London for a weekend of teaching. I'm looking forward to meeting him, and singing for him. I'd love to do a bit of singing while I'm in Europe, but as the networking required to get gigs is really a full-time job, am not sure how much time I'll be able to devote to rustling up singing. We'll see. I'm already thinking about practice space, and whether or not local churches would let me use their space in exchange for free organ subbing for services. I'll have to play it by ear.

Ever since I've been back from Panama, I've been going to the gym 5 days a week. My aunt has hooked me up with her personal trainer, and he's fantastic! So in a few short weeks, I've lost a significant amount of body fat, and have gone down two belt buckle holes. So one of my first tasks when I get to the UK, will be to find a decent gym. I've heard that gyms are expensive, so I'll have to see what I can find.

Back to the sorting. Be well!

UK bound

2009-02-25T08:41:00.002-05:00

So I am scheduled to start my Psych rotation on the 23rd of March at a hospital in greater London. I'm in the process of getting things in order, applying for my visa, and sorting/packing.

Blogging may be sporadic.

Living the creative life with divine input

2009-02-19T11:13:00.000-05:00

A wonderful talk from TED, by the author of Eat Pray Love.

Thanks to Yankeediva for posting this!

It's been a month...,

2009-02-18T10:02:00.003-05:00

an eventful month.

After taking Step 1, I spent a couple of days in London (complete with an unplanned dash into Toronto to see the opera, thanks to free tickets from a friend who was singing in the chorus). I then flew out to Vancouver to spend time with my brother and sister-in-law. That was nice, but complicated by the fact that we were getting ready for my grandmother's funeral. My parents flew out for that, so instead of a quiet week with my brother, I had a week with family, and the funeral at the end. Which was good in its own way, though not the week I had planned.

Aside from a few family dramas as we planned the funeral service, it went quite well. I played for the service, and my brother and sister and I sang. It was a meaningful time, and nice to see lots of relatives. But because of the funeral, I didn't get to take the train back to Toronto. So that remains on my list of things I'd like to do someday.

Back in Toronto, I spent the rest of the week with cousins, shopped, and went to see another cousin's play.

Then a bunch of us (sister, aunt, uncle, and assorted cousins and cousins-in-law) got on a plane and flew to Panama. There were nine of us, and we spent an enjoyable week in the heat. While resorts aren't really my thing, it was kind of nice to not have to worry about anything. While I was there, my Step Score came through, and after a bit of effort to get them downloaded, I discovered that I'd passed.

I did reasonably well on the exam. I didn't get a spectacular score, but neither was it embarassing. So, especially since I want to specialize in family practice, I'm pleased. My score does rule out dermatology and other uber competative residencies. So here's hoping I don't develop a passion for derm during my rotations.

So I'm back up north, watching the snow fall, and waiting for my (slightly inefficient) school to contact me for setting up rotations. Hopefully, I can start next month in the UK.

More to come...

It's done!

2009-01-20T20:55:00.002-05:00

It was an interesting morning. I was wide awake at 5:30 this morning. I stayed in bed for half an hour, mostly for form's sake, and then I got up and walked a couple of blocks to the grocery store to get some food to take to the exam with me. I had a feeling of deja vu; both from the time I spent living here and walked this same path to the same grocery store, and from the morning before my MCAT. The morning before my MCAT, I was awake in the wee hours and went for a run while it was still dark. Granted, the morning before the MCAT, it was a rainy Vancouver morning; this morning it was snowing rather heavily.

So I got there early, and they let me in right away. I started at 8:30, and was done at 2:15. So it took me just under 6 hours (that includes break times). I took a break between most of the seven sections.

It didn't seem as difficult as I was expecting, which may be a bad sign. But I'm now going to not think about it for a couple of weeks until I get my results.

There were three of us taking the exam in this testing centre; the girl sitting next to me is going to med school in Australia. The lady who was running the centre said to me, "I'm glad to see some actual Canadians taking this exam." I wasn't quite sure how to respond to that.

After the exam, I did an hour and a half of yoga, and went out to dinner with a friend. It's been nice being here in London (Ontario); I'm staying with a friend and former roommate, and have been interspersing my time here with meeting friends and visiting old haunts.

I have a haircut tomorrow with the guy who cut my hair when I lived here, and I'm going to my favourite French restaurant tomorrow night. Then on Thursday, it's off to Vancouver to spend time with family and go to my grandmother's funeral.

Ta.

Step 1

2009-01-19T16:03:00.002-05:00

So I'm taking the USMLE Step 1 tomorrow. It's an 8 hour exam, and kind of stressful. It won't take me 8 hours, though, so I'm planning on going to yoga directly afterwards. I am so ready to be done.

Of course, today, I feel like I don't know anything. But hopefully that will pass tomorrow. It's a lazy day today. I went to yoga class (and was surprised at how well I did, considering how little I have been practicing while I was on the island), did a bit of shopping, and am now hanging out.

24 hours from now, it will be over; for good or ill.

Competition

2009-01-16T14:42:00.001-05:00

From Kevin MD

...suppressing competition will remove any incentive for hospitals to improve...

Wow. Says who?

Is "competition" the only possible motivation for improvement?

In the fundamentalist capitalist system, it worries me that the doctrine of "competition" is never questioned; never seen for the deeply flawed assumption it actually is.

The idea that improvement and increased efficiency can only come about from competition is an interesting extrapolation of evolutionary theory. And while the theory is elegant in its stark reductionist simplicity (that when two entities are competing for a limited pool of resources, the stronger, more efficient one will out-compete the lesser), it doesn't take into account the inherent illogic of human nature, or the complicated dynamics of delivering health care.

(On a side note, there is much hand-wringing when hospitals are forced to close, but isn't that a logical and desired outcome of competition? Hospital closures are an excellent sign that "competition" is working, and working well. The strong and economically viable will survive, and if people can't get health care, well that's too bad but it isn't competitive to try and do anything about it. Why are people so upset?)

I have several problems with the assumption that "competition" is essential for health care delivery in the 21st century.

First of all, it reduces every human transaction to dollars and cents. It gauges our individual worth, and the worth of every human encounter we have by the financial cost. Edwin Leap, in his interesting Grand Rounds Post, writes about the medical profession's lost sense of eternal purpose. But, as I see it, this lost sense of purpose is the logical consequence of embracing fundamentalist capitalism. If the only thing that matters in every patient encounter is how financially competitive it is, then that's the only thing that matters. The medical profession has taken a generation of young, idealistic physicians, stripped them of their professional autonomy, reduced their patient encounters to stark, financial (and legal) terms, and then wonder why they are obsessed with money.

In my cynical world view, this very reductionist view of human existence seems to benefit very few. It benefits government and politicians, because by abdicating their responsibilities of oversight, foresight, and prudence to the magic of "competition," they have much less work to do. It benefits people who want to make money with as little constraint as possible, because by abdicating their duty to their community, they can operate as recklessly or as unethically as possible. (We have recently seen the consequences of fundamentalist capitalism play out in the world economy; "competition" with no restraint does not lead to magical competitive nirvana, it leads to chaos and ruin, fueled by a healthy dose of greed.)

On a smaller scale, this dogma benefits lousy administrators. It means they do not have to actually lead their organisations or motivate their workforce; as long as they are providing an atmosphere for competition (and making money), they can sit on their ass. IMO, "competition" is a recipe for a toxic workplace. I enjoy reading Paul Levy's blog, Running a Hospital. As far as I can tell from his writing, he exemplifies the very best in an administrator; someone who cares about his patients, his workforce, and the bottom line. I have always maintained that the solution to reducing inefficiency in the workplace was not some sort of nebulous "competition" but hiring better administrators. If you want to increase productivity and efficiency, don't invoke the mantra of competition, hire an administrator who can motivate the workforce to increase productivity and efficiency.

And if competition does increase efficiency, you have to ask yourself, what kind? It certainly can increase the efficiency of profits, and money-making can go up. Now, although it may not be obvious from this post, I am not opposed to doctors and other health care professionals making money. But I think there is a balance to be struck between making a living, and profiting from the pain and suffering of others. And there is certainly room for reducing waste, streamlining red tape, and providing for individual autonomy (whether it is patient or physician). But reducing waste, streamlining red tape, and celebrating autonomy is, IMO, actually achieved through building a culture that allows for them. Again, these benefits result from the skill and vision of administrators, not the magic of "competition."

What fundamentalist capitalism does, in addition to reducing our existence to our worth as consumers, is take away our nobler instincts; as a society, we have embraced a worldview that allows for only two motivations: lust and/or greed. Watch a half hour of television, and you will see advertisement after advertisement that sends the message "this product is so desirable that it is worth giving up your integrity (honesty, intelligence, loyalty, respect, family, promises, etc.) to obtain it." What happened to the nobler motivations: caring, respect, kindness, loyalty, restraint, moderation, duty, sacrifice? Our fundamentalist world view does not admit these as possibilities.

(I think that this is one reason that president-elect Obama was able to capture the stage the way he did; he was able to embrace and encourage the idea that we are more than the balance of our checking account.)

In the workplace, people like knowing that the work they do serves a purpose. When we don't see purpose in what we do, there is no incentive to keep doing it. I think it is entirely possible that the constant struggle and dialogue about money has allowed physicians to come to believe that this is all that matters. Have we lost sight of the nobler motivations? And have we lost a sense of personal integrity? Going back to my original question, is it no longer possible to motivate change by appealing to an individual or an organization's pride in their work? Is it no longer possible to motivate change by invoking a sense of community and purpose?

And what does competition really mean in a health care delivery setting anyway? Economic competition is easy to understand, and hospitals and physician practices are falling like dominoes as a result. But, health care in the twenty-first century is expensive, and aside from skilled administrators cultivating a culture of efficiency and restraint, how is this supposed to play out? Are hospitals supposed to compete for patients like some sort of time share sales pitch?

"Come to our hospital and have the best stay of your life!"

"Visit Dr. Jones and get an upgrade to an MRI!"

I think that this attempt to woo patients is patently false, and the public can see through this attempt to improve the bottom line. The fact of the matter is, there is very little about receiving health care that is pleasant. Even the most innocuous check-up in an outpatient setting requires a certain loss of privacy and forced intimacy with a stranger. Add any sort of procedure, and most patients experience a profound sense of indignity and loss, regardless of how skilled or humane their care-givers are.

These advertisements trying to woo patients into the hospital are a bit like the Inquisition advertising splinter-free stakes for burning. Advertising is pushing an emotionally charged image of happy-happy-joy-joy, and frankly, the blood, sweat, piss, and shit that is the reality of health care can never measure up.

What is to be done? I think that mindlessly invoking "competition," the magickall cure for what ails the health care system, is to be intentionally blind. For me, the solution lies in building a culture of personal integrity, real, honest care for patients that goes beyond their potential as paying customers, and communal responsibility. This is IMO, both a personal responsibility, and one of management. What is needed is a rejection of the extremes of fundamentalist capitalism, and embracing the idea that there is indeed a higher calling.

But that would require hard work; and vision. And it's a lot easier to just let "competition" take care of it.

A horrible doctor - part 2

2009-01-11T10:40:00.001-05:00

In a previous post, I described my reactions to a list of qualities described as useful to physicians: "Good Doctor Qualities."

control
perfectionism
competitiveness
dedication
perennial caretaker
emotional remoteness

I found the few comments interesting and some of them deeply disturbing. Most appeared to say that while not necessarily desirable traits, they were ones that would make life easier as a med student/physician. And as a result, the admissions process selects for medical students who possess them. GCS15 wrote that these are "traits that keep you going when things around you become intolerable."

I don't disagree with this; in fact, I do agree that these sort of traits in any human being will help them deal with intolerable situations. It would be interesting to explore whether these sorts of traits are also common in individuals who survived concentration or POW camps.

What I found most disturbing about some of the comments (and the one in particular) was the underlying assumption that medical training and practice was and will continue to be "intolerable."

I went into medical school with fairly open eyes; I have a number of doctors in my family, and I am probably as aware as an outsider can be of the personal cost to practicing medicine. I know how difficult medical school is, and I have seen how difficult residency is and how difficult the daily practice of medicine is.

But as difficult and challenging (and sometimes even impossible) as medical school and medicine is, why is it so hard to draw the distinction between difficult/challenging and intolerable? I have often wondered why doctors put up with so much crap. Of course, sometimes they have to put up with crap because otherwise patient care would suffer. But other times, it seems to me that doctors put up with crap for no good reason. Is it because they derive some sort of masochistic martyrdom from putting up with intolerable working conditions? Or is it because as controlling perfectionists who are emotionally withdrawn, these doctors are incapable of realizing when conditions have become intolerable?

As I get ready to start my clinical training, it amused and saddened me to have a series of lectures last semester, the purpose (ok, one of the purposes) of which was to teach us how to best respond and react to ~~hazing~~ pimping. IMNSHO, there is something seriously wrong with an educational system that requires training in how to handle inevitable emotional abuse from your instructors. And there is something wrong in the culture of how medicine is promulgated and practiced when it carries with it the underlying assumption that conditions will be intolerable.

Before you dismiss me as a lazy ass who doesn't want to learn anything or to be pushed into growth, let me say that I make a firm distinction between demanding excellence of students (and being hard on them when they don't live up to expectations), and emotional abuse (characterized by personal attacks that makes the student feel small and the teacher big). If you are my teacher, please demand excellence from me, and let me know if I have fallen short of your expectations. But don't try and tear me down just because you ~~are a lousy teacher/human being~~ are having a bad day.

In an interesting post about the culture of medical education, T. writes about how to (and how not to) teach in a medical setting. Her blog post is a beautiful description of how to teach well; set clear expectations, modify them to suit the student, make sure the learning environment is supportive and nurturing, and then give the student the boost required for them to grasp the concept.

Would that we would strive to be that kind of teacher (and physician). Open, caring, emotionally in touch, and willing to fight for a tolerable environment to learn, teach, and practice in.

Mmmmmm Bacon

2009-01-07T10:27:00.001-05:00

So I'm in the process of making homemade bacon. It's wet curing in the fridge as we speak. This afternoon I will dry it off and smoke it. I'm doing a pork loin, so it should end up as back bacon (aka Canadian bacon).

The recipe I used, except i used maple syrup instead on molasses.

Food Porn, homemade bacon; a dry-cured version.

A few more recipes:

Another dry cured one

A wet cure

One that doesn't smoke the bacon

Insanity:

Bacon flavoured vodka

Bacon flavoured bath salts

Cities and how we think...

2009-01-06T11:14:00.002-05:00

A fascinating article from the Boston Globe on how urban environments affect the way we think. Good stuff!

Now scientists have begun to examine how the city affects the brain, and the results are chastening. Just being in an urban environment, they have found, impairs our basic mental processes. After spending a few minutes on a crowded city street, the brain is less able to hold things in memory, and suffers from reduced self-control. While it's long been recognized that city life is exhausting -- that's why Picasso left Paris -- this new research suggests that cities actually dull our thinking, sometimes dramatically so.

A good year...

2008-12-29T10:01:00.003-05:00

I write this with my left wrist in a splint (the victim of a cross-country skiing incident yesterday). I damaged my left MCP joint, which (in the grand scheme of things) isn't a huge injury. But since it is an important piano playing joint, I'm going to be especially paranoid about it. I am also sore in several other places (due to an active weekend; including working out, badminton, bowling, and skiing) so am feeling rather proud of but sorry for myself.

Led by the example of HM of Unprotected Text, I thought I'd do a retrospective on 2008. But this silly wrist/thumb may make me give up in disgust.

January

Back to school after a wonderful Holiday back home. It was nice to get back to the warm weather. Classes were a lot better, after I made it through genetics/biochem hell. In fact, the semester started out with endocrine physiology taught by one of the best teachers it has EVER been my privilege to experience as a student! Of course, she was from Canada (a visiting prof from Memorial, of all places). Thanks Dr. H! Micro was fun, not the least because I'd done a fair bit of micro in undergrad. And we started path, which started to feel as if we were doing real medicine stuff now, not just science minutiae.

Lots of kayaking, and some diving.

February

Still enjoying classes, not wanting to study. Lots of kayaking.

I had family who were planning on coming down in February, but due to an extraordinary series of events (including broken lights on the airport runway, a condemned resort in Venezuela, and ~~corrupt~~ inefficient customs in Venezuela) they didn't make it and flew back to Toronto.

Started getting migraines.

March

More of the same. My family finally made it down. So I spent a lovely week with my sister, uncle and aunt, and assorted cousins (going to classes in the morning, and hanging out at their resort for the rest of the time). A big storm blew in, so we had to cancel our diving trip to Saba, but the rest of their time was pretty cool.

April

The final push to end third semester. I did fairly well, I even honoured micro. I got to spend a couple of weeks at home, and aside from some shopping in Toronto (and a lovely voice lesson with a new teacher), spent most of it at my sister's place.

Right in the middle of finals, I sang the "Star Spangled Banner" at graduation. I sang well, and it was a little boost of motivation for me; to see the grads lined up, who had been where I was only three years before.

May

In which I start my fourth semester. I didn't want to come back to school to start this one. I wanted the summer off. I was also recovering from a nasty unrequited crush. Ugh. I did a lot of kayaking, starting to really train hard for a long race in Sept. My kayaking buddy and I tried to hit the beach twice a week, and the gym at least that many times. I was also running a couple of times a week. I was in great shape.

June

More of the same. Kept kayaking, stopped running, because of an old knee injury flare-up.

Insomnia started to get annoying.

July

Still kayaking, not working out as much. Tired and burnt out.

Classes are going ok, but mustering up enthusiasm is increasingly difficult.

August

Finals, the end of the semester, and a vacation. I wasn't prepared for how tiring this fourth semester was going to be. The break was needed. I had another voice lesson, and sat around on the couch a lot.

September

The last semester starts. Wow! This has been quite a journey.

I kind of stopped kayaking, because I had exams scheduled for the day after the big race I was training for. So, while I did some kayaking at the beginning of Sept., I didn't do any for the rest of the semester. I makes me unhappy, but there is only so much time and energy to spend.

Did a first aid course, joined the honour society, started tutoring anatomy.

October

Hurricane Omar. We didn't get that hard hit, so it was kind of fun. And to be able to say that I got a hurricane day in medical school like other students get a snow day is pretty cool.

We finished classes this month (except for a few random seminar type things). and we took the NBME Comp exam, which I did quite well on.

November

Last minute things. Seminars, clinical skills small group discussions, started work on a small research project into the ongoing Dengue Fever outbreak.

December

Wrapping up, taking my last exams, packing, sorting, selling my car, working my Dengue research project. Flying home.

I studied for a few days before Christmas, and spent a couple of days in the ER. One afternoon was particularly memorable, with my sister and uncle working, and my cousin and I shadowing. (My cousin is in 1st year meds in Ireland.) The ER staff had several things to say about "family medicine." I got to see my first code, and actually got to bag the patient.

Scheduled STEP 1 for Jan 20.

Christmas and New Years with family. Now it's time to let my thumb heal, study hard for my step, and then go on vacation.

Have a blessed and wonderful new year!

Fun with anagrams...

2008-12-28T12:52:00.000-05:00

From Bent Blog, a link to a wonderful anagram machine. Enjoy!

Did you know that an anagram for Beach Bum is Babe Chum?

Onward!

2008-12-20T08:02:00.005-05:00

In the bleak midwinter, snow had fallen; snow on snow.

I'm no longer studying on a beach in the Caribbean. The beach in the picture above, and in the blog banner, is the southern shore of Georgian Bay. A bit different from the sunny, white sand beaches of the Caribbean, isn't it? And instead of just being home for a few weeks and heading back to the Caribbean, I'm not going back.

I'll be here for the next few months, studying for Step 1, and taking some needed time off. It's a bit bittersweet, this whole leaving the island thing. I had a good time on the island. Unlike some of my colleagues, with their palpable if-it-isn't-like-the-good-old-US-of-A-and-doesn't-have-a-Walmart-it-is-beneath-contempt attitude, I enjoyed the slower pace of life, the inefficiencies, and the island culture (the little of it I participated in). But I was raised in Africa, and I found the island culture (and my experience) somewhat similar to my childhood. And as I mentioned in my last post, I tend not to stress about things over which I have no control.

So I'm not going back to the Caribbean. And, for the most part, I am now done with classroom work. That is a good thing. As generally good as classes were for the last two years, I feel ready to start seeing patients. Not because I'm ready to care for them, but because I'm ready to learn how to.

I spent the day in the ER with my sister and uncle today. I got to interview several patients and saw a couple of interesting cases. And what surprises me is how much I actually know.

I had a similar experience taking one of my exams last week. Halfway through the exam, which is a fairly comprehensive exam, I was struck by the breadth of my knowledge. Now, I'm the first to know that I still have a LOT to learn. In the ER today, I was constantly recognizing things, but not knowing the actual answer. Or I knew the mechanism, or molecular interaction, but not how this would actually impact the patient's treatment.

But I am conscious of a sort of satisfaction at the amount I have already learned. And while I still stand in the back during a code, and feel useless (because I am), I don't feel like an impostor any more.

And thanks to the medical blogs I read, I was able to recognize my first drug-seeker.

I will make a horrible doctor!

2008-12-19T13:00:00.000-05:00

A recent post by FreshMD (who is, incidentally, an acquaintance from undergrad and married to a former dormmate of mine) got me thinking about personal qualities and medicine.

In the last few weeks, I've also been speaking to several people who didn't get into medical school in North America, and had to do the Caribbean/Overseas route, about why we didn't get in and what it is about us and our stories that make us poor candidates.

In her post, FreshMD, listed attributes that make a good physician (as described to her at a conference she attended):

control
perfectionism
competitiveness
dedication
perennial caretaker
emotional remoteness

And in looking at her list, I really don't identify with many of these; this is not who I am. It's no wonder that admissions committees threw my application out. I am clearly not good doctor material.

Disclaimer: In using this list to riff on what makes a good doctor, I am not implying anything about FreshMD; in fact, I have always had enormous respect for her, as a enormously talented and wonderfully humane person.

And in my riff on what makes a good doctor, I am using these words in their more negative connotations. I know there are positive connotations to all of these words, but that wouldn't make an interesting blog post, now would it?

control: I am fairly laid back, and don't struggle for control. I ascribe to the idea that the only thing I can control in this life is myself; my actions, thoughts, and emotions, and that trying to control things outside of me is futile. I also ascribe to the idea that in getting things done in a team situation there is a huge difference between control and leadership; the one being micromanaging bullshit, and the other empowering other people to be and perform their best.

perfectionism: I reject perfectionism as a deeply unsatisfying and ultimately soul-destroying philosophy. I do embrace excellence; knowing, however, that in my pursuit of excellence I will never reach perfection. In my own personal experience and in my own observation, individuals who are perfectionist are usually deeply insecure and use their unattainable pursuit of perfection to validate their own sense of worthlessness. By never achieving the perfection they so desperately pursue, they are able to say "See, I was worthless after all."

I say this as an artist, who has had to come to terms with the fact that the art I wish to create will never be realized; that even when I am performing at the very highest level, my performance will NEVER match the vision and ideal I have in my soul. Perhaps it's too Platonic, but it is the reality on the ground. Perfection is impossible (and quite possibly boring), so why pursue it? Excellence, on the other hand, with it's inherent possibility of disaster, is imminently desirable (and possibly a bit more exciting) and I embrace it wholeheartedly.

competitiveness: I was always the kid picked second last for choosing teams in the playground. As a child, I was viciously uncoordinated and suffered from undiagnosed exercise-induced asthma. Needless to say, I was not a good athlete. I developed an intense hatred for team sports, and preferred those athletic endeavours where I was competing solely against myself; track, badminton (singles), etc. I was also a good musician (blessed with parents who recognized my gifts and sacrificed a great deal to provide me with a way to train them), and loved the fact that when I was performing, I was the only person responsible for what happened. (That changed when I started to work with conductors and pianists, who can be [and often are] completely incompetent and can singlehandedly wreck a fine performance. There is an element of teamwork to music making that cannot be ignored. But I digress...)

I still don't get why I should be forced to compare myself with someone else. Their journey is different from mine, we both have different experiences and opportunities. We both have different strengths and weaknesses. And while in medicine, we can not ignore those aspects we are not good at simply because "it's not part of our journey," I think a much healthier approach is to measure ones self by comparing my performance today with my performance yesterday. If I see an improvement (and if there is an improving trend) in something where I need improvement, then I am happy. If I am not improving, or am remaining the same, then I have something to work on.

As part of our clinical skills training, as a member of a small group of students, we were given the opportunity to conduct a patient interview with a standardized patient. The few times that I interviewed, I did very well. Several members of my group complimented me on my interviewing skills, and while I appreciated their comments, I was somewhat uncomfortable with their praise. As a private music teacher, I'd spent the previous 7 years conducting one-on-one interviews with my students in a very similar environment. They came to me with something they wanted to improve, and it was up to me to figure out what was wrong and how to fix it. That experience (and the fact that while shadowing my sister, I had interviewed several patients) meant that the interview was not a scary thing for me, and I had skills honed over several years that allowed me to do well. We all come to medicine with various experience and abilities that help define our strengths and weaknesses; why should I compare myself to someone else and beat myself up for not being that person? It is my job to determine what my weaknesses are and work to correct them. And why should I be singled out for praise when the reason I am good at something amounts to little more than an unconventional background and a series of coincidences?

dedication: Dedication is a good thing. But there can be such a thing as too much of a good thing. I was never one to consider immolation. I suppose I am one of those lazy new types who isn't willing to give up everything for the sake of my career. I will be dedicated to my patients. But I will also be dedicated to growing as a human being and as an artist. I will be dedicated to living a full life in my community. I see life as a constantly shifting priority list, with medicine at or near the top. But while medicine will often be at the top of my list, it will sometimes lose place to other priorities. Does that make me less dedicated? Perhaps. But I suspect I will gain more than I lose.

perennial caretaker: Also a good thing. But again, there can be too much of a good thing. I believe strongly that in order to care for others, we have to care for ourselves. To use a slightly hackneyed metaphor, if we pour our energy into others, we have to find a way to replenish what we have lost. I believe strongly in feeding my own soul so I will have the energy and compassion for others.

One of the labels I use to describe myself is "Healer." But in trying to heal others, I am completely aware that I cannot force change on individuals. I cannot control their choices. My only tool for effecting change is my powers of persuasion. In many respects, I consider myself more of a salesman than a healer. After all, what are we doing beside selling miracle cures?

emotional remoteness: I see what the author of this list is getting at with this one. It is impossible to enter into all this suffering around us as medical professionals without being destroyed. But I object to the word "remoteness." It carries with it the idea of withdrawing, of being apart from our patients, of not being there when they are hurting. I think a much better word would be "stability." It's a hard concept to explain, but I am a proponent of being there in the emotion, acknowledging it, perhaps even experiencing it, but not being blown away by it.

It's probably my training as an actor that gives me this perspective. One of the methods of acting training popular in North America is to find the emotion inherent in a particular character/scene/line, experience it, and let it inform the choices we make on stage. So what we do on stage is about exploring the emotion, without letting it overmaster us. I don't want to remove myself from my emotions. I want to maintain emotional stability, and even emotional control. But anything more than that, and one runs the risk of suppression or repression.

I found this list interesting. It's clear to me that I don't possess many of these attributes in a strong way, and that I am clearly not fit for medicine. Or does this list represent what is wrong with how physicians are recruited, trained, and mythologized?

In discussing with singing colleagues on how to build a career as an opera singer, a phrase came up that I have never forgotten. "In order to make a living as a singer, you have to be psychotically determined." In many respects, medicine is similar. One really does have to be crazy to inflict this on ones self. But as we undergo our training, and reshape ourselves in the image of our profession, I don't want to become someone who is controlling, perfectionist, ubercompetitive, psychotically dedicated, a perennial caretaker, and emotionally stunted.

So here's a new list:

A true leader
Pursues excellence
Dedicated
Balanced
A healer
Emotionally stable

What do you think?

Break time

2008-12-13T18:50:00.004-05:00

I write this in the Philly airport, my layover on my trip home to Toronto. It's an interesting time of year, when all the Caribbean schools are finishing up, and student from all over the region are heading home for their break. There were students from probably at least 4 or 5 schools on my flight. It's funny how an experienced Caribbean med student can recognize thier own kind, amid a flock of tourists.

On the plane today, there was an article in the in-flight magazine about good books that nobody reads.

Uncle Silas (Joseph Sheridan Le Fanu)

Oblomov (Ivan goncharov)

Hauntings, Fantastic Stories (Vernon Lee)

Red Cavalry (Isaac Babel)

Augustas Carp, Esq., by Himself (Henry Howarth Bashford)

Cane (Jean Toomer)

I finish this up at my sister's place in Ontario.

So, I'm back home. Yesterday, I scheduled Step 1 for Jan 20, so I've got a bit of time to study, and celebrate Christmas. I've been heading to my aunt's office (and using an empty room to study in). It's amazing how much studying I get done when there's nothing else to do in the room. I'm a bit scared of this. First of all, based on my test scores this last semester, I am ready to pass the exam if I wrote it today. So not only do I not want to lose any of my current knowledge, but I want to improve my performance. Study, study, study.

I've also been cooking. Today for supper, we're having baked squash, apples and sausage, with arugula salad and pumpkin pudding for dessert. I think it'll go over well.

This weekend, I'm heading into the ER to do some shadowing (my sister and my uncle are both on, so I'll have two docs to follow). It's going to be fun. My cousin (who has just finished his first term of med school in Ireland) may be there as well, so it'll bring new meaning to the term "family medicine."

I'll try and post some new pics soon. Shooting in various shades of white and grey will be a change from the saturated Caribbean, but it should be fun.

Flying

2008-12-13T13:50:00.002-05:00

By the time this posts, I should be on an airplane, and flying over the atlantic. I leave tomorrow and should get into Toronto late tomorrow night. After a night at a relative's place, I'll head up to my sister's, where I'll be spending most of my time.

Stay tuned...

I'm done!

2008-12-11T10:15:00.002-05:00

My basic sciences and 20 months on the island are done! I wrote my last exam yesterday, and while it was an awful exam, I passed it and am on my way. I'm heading home on Saturday for some time off and some studying.

I should be packing, but am catching up on blogging...

The "what have you done with your life?" meme

2008-12-11T08:54:00.003-05:00

You know the drill, copy this to your blog, change the stuff you've done to bold, make witty little comments, etc. I thought I'd done this one, but maybe I did it a while ago 'cause I couldn't find it in my recent posts, anyway, I found it on Respiratory Therapy 101.

1. Started your own blog.

2. Slept under the stars. I still regret not doing this when I was in undergrad. There was a crazy Russian dude in the dorm next to mine that had a thing about sleeping outside; he thought it was all healthy and stuff and invited me along. I was in my up-tight scarf-wearing SINGER phase and thought the night air would be bad for my precious vocal folds. Now, being older and wiser, I'd say screw the vocal folds for a bit of star gazing in a dewy field. Ahhh, regrets!

3. Played in a band. Many

4. Visited Hawaii. Four weeks on Maui, baby. Coral Reef Biology, and Tropical Botany.

5. Watched a meteor shower. Two in the morning on a country road in rural Alberta in the middle of winter. Lonely, cold, and glorious!

6. Given more than you can afford to charity.

7. Been to Disneyland.

8. Climbed a mountain. Nothing spectacular, just local Vancouver mountains.

9. Held a praying mantis.

10. Sang a solo. Oh wait, I'm an opera singer.

11. Bungee jumped.

12. Visited Paris. For twelve hours.

13. Watched a lightning storm at sea.

14. Taught yourself an art from scratch. If being taught how to crochet by one's sister counts.

15. Adopted a child.

16. Had food poisoning.

17. Walked to the top of the Statue of Liberty.

18. Grown your own vegetables. Purple potatoes, yellow beets, pink chard, red and white carrots. I like cartoon vegetables!

19. Seen the Mona Lisa in France.

20. Slept on an overnight train. From Swizterland to Calais, when I was a kid.

21. Had a pillow fight.

22. Hitch hiked.

23. Taken a sick day when you’re not ill. I swear, it was a mental health day.

24. Built a snow fort.

25. Held a lamb.

26. Gone skinny dipping.

27. Run a Marathon.

28. Ridden in a gondola in Venice.

29. Seen a total eclipse.

30. Watched a sunrise or sunset. My favourite has to be sitting on my kayak in the Caribbean Sea, watching the sun go down and trying to see the green flash, and then paddling back to shore.

31. Hit a home run.

32. Been on a cruise.

33. Seen Niagara Falls in person.

34. Visited the birthplace of your ancestors.

35. Seen an Amish community.

36. Taught yourself a new language.

37. Had enough money to be truly satisfied.

38. Seen the Leaning Tower of Pisa in person.

39. Gone rock climbing.

40. Seen Michelangelo’s David.

41. Sung karaoke. I don't know any pop music, and karaoke lists never have anything I know on them, so I usually end up singing Celine Dion songs (which is scary) in the key she sang them in (which is even scarier).

42. Seen Old Faithful geyser erupt.

43. Bought a stranger a meal at a restaurant.

44. Visited Africa. I was born and raised in Africa.

45. Walked on a beach by moonlight. And skinny dipped too...

46. Been transported in an ambulance.

47. Had your portrait painted drawn.

48. Gone deep sea fishing.

49. Seen the Sistine Chapel in person.

50. Been to the top of the Eiffel Tower in Paris.

51. Gone scuba diving or snorkeling.

52. Kissed in the rain.

53. Played in the mud.

54. Gone to a drive-in theater.

55. Been in a movie.

56. Visited the Great Wall of China.

57. Started a business. Does running a music studio out of my living room count?

58. Taken a martial arts class.

59. Visited Russia.

60. Served at a soup kitchen.

61. Sold Girl Scout Cookies.

62. Gone whale watching. Does seeing grey whales and porpoises off the side of a ferry count?

63. Got flowers for no reason.

64. Donated blood, platelets or plasma. Until the folks at CBS decided that my malaria blood was too dangerous to even use for plasma.

65. Gone sky diving.

66. Visited a Nazi Concentration Camp.

67. Bounced a check. Starving artist...

68. Flown in a helicopter.

70. Visited the Lincoln Memorial.

71. Eaten Caviar.

72. Pieced a quilt.

73. Stood in Times Square.

74. Toured the Everglades.

75. Been fired from a job.

76. Seen the Changing of the Guards in London.

77. Broken a bone. If my nose counts.

78. Been on a speeding motorcycle.

79. Seen the Grand Canyon in person.

80. Published a book.

81. Visited the Vatican.

82. Bought a brand new car.

83. Walked in Jerusalem.

84. Had your picture in the newspaper.

85. Read the entire Bible.

86. Visited the White House.

87. Killed and prepared an animal for eating.

88. Had chickenpox.

89. Saved someone’s life.

90. Sat on a jury.

91. Met someone famous.

92. Joined a book club.

93. Lost a loved one.

94. Had a baby.

95. Seen the Alamo in person.

96. Swam in the Great Salt Lake.

97. Been involved in a law suit.

98. Owned a cell phone.

99. Been stung by a bee.

100. Read an entire book in one day. Many times!

Well, there you have it. Entirely self reflective, but kind of fun.

Cowardice

2008-12-07T18:03:00.003-05:00

Well,

We're winding down. I have an exam tomorrow, for which I am not studying. And then on Wednesday, I have the last of my Comprehensive exams. It's hard not to get excited about either, because for the former, I suspect that I am already passing the course (and don't need it at all). And for the latter, I have only to achieve a 45% on the exam to pass.

Now a comphrehensive exam on two years worth of material is nothing to sneeze at, but since I got a 75 on the one I wrote in October, I'm not really worried. I am trying to muster a little bit of enthusiasm for studying this week, but am only slightly winning.

So this week, I have to clean and pack, sell a few more things (or give them to charity), host an online acquaintance who is checking out the school and the island, and do some playing. Right now, I'm thinking of a quick trip to Saba on Friday, some horseback riding on Thursday, and perhaps some diving added to the mix. (And maybe a quick trip to the casino to get rid of my bowl full of quarters.) We'll see!

I'm starting to panic about my licensing exam. I had planned to sit the exam before Christmas, but am panicking that I don't know enough, and am contemplating waiting until January. But postponing the exam would require that I be diligent about reviewing for the month of Dec. It could be done. Right now, I'm playing it by ear, and waiting to see if my ECFMG certification comes through on time. Evidently, they're taking longer than usual to process them, so I may have no choice.

I am fairly sanguine about medicine being a discipline where it is impossible to know everything, but right now, I'm feeling like there are some fairly important gaps in my knowledge. Mostly related to some of the classification of rare neoplasms and weird pathologies. I'm reviewing my path, but may not be as ready as I would like. But maybe I'm just being stupid.

In any event, in less than a week, I will be back in Canada. The forecast for today was -13C with a snow squall warning. It'll be a rude awakening. I've already sent out an urgent request for my down jacket to be waiting for me in Toronto.

Popera

2008-12-07T07:33:00.003-05:00

Generally, I don't enjoy the sort of opera lite that opera singers call Popera (think Bocelli, Brightman, Groban, el Divo, Russell Watson, et al). But I came across this the other day. It's a song by the Columbian pop singer Juanes. Beautifully sung, with really cool images.

I ask of God
For the days that I have left
And the nights that have yet to arrive,
I ask of God
For the children of my children and the children of your children
I ask of God
That my city not shed so much blood and that my people rise again
I ask of God
That my soul never rest when it comes to loving you my dear
I ask of God
A second more of life to give you and my whole heart deliver to you
A second more of life to give you and by your side for ever be
A second more of life I ask of God
And that if I die it be of love
And that if I fall in love it be with you
And that to your voice this[my] heart belong, every day I ask it of God

A new PM for Canada?

2008-12-02T08:58:00.000-05:00

It appears that less than two months after our general election, Canada may be getting a new Prime Minister. For some background (for those of you unfamiliar with Parliamentary democracy) check this article out.

I love politics in Canada. It can be really, really boring for years, and then without warning, can surprise the socks off you. I'm not sure whether this potential new government will work any better than the current (rather dysfunctional) minority government, but I love the fact that it is possible.

Of course, many Canadians who are uninformed about how their Parliament works (and/or who watch too much US television and think our system should be like the US) are up in arms about a "coup" destroying the fabric of democracy. They obviously didn't pay enough attention in social studies class in junior high. Or perhaps they are just ignorant.

And for the record, I am appalled at the Harper Government's attempt to revoke the political party funding measures. They were an excellent idea at the time, and remain so; reducing the influence of lobby and special interest groups. In fact, I may write the PMO and vent a little.

Representative Democracy. I love it!

A car hurtling toward the cliff edge...

2008-12-01T12:32:00.002-05:00

That's how I feel my life is like right now. I've been insane this semester (as you may have noticed from my posting frequency this semester). Partly because I really have been busy, and partly because I'm really tired, and ready for a real vacation. (One of the drawbacks to the Caribbean system is that there are no real scheduled breaks, like the summer break in most N. American schools. So I've been going hard for almost two years, with only a handful of 2 week breaks. Ah well...)

It's been an eventful semester, but it's almost over. If you take a look at the counter near the bottom of the blog, I have less than two weeks to go now before I leave the island for good. It's a bittersweet parting. I have enjoyed living here, what with beaches and kayaking, great restaurants, great people, and wonderful weather.

I'll be heading back to Canada, and snow. And from there, probably to the UK for my clinical clerkships. But in the next few days, I have to sell my car, pack, get rid of stuff, wrap up a research project into the current Dengue outbreak, study for my last two comprehensive exams, and (more importantly) study for USMLE Step 1, which I hope to take before Christmas.

Most of my class is taking a lot of time off to study for their Step 1. I am going to try and take it as soon as I can, which means I have a lot of work to do in the next few weeks. I'm not going to take much time to study for a couple of reasons: the most important being that I'm lazy and giving myself months to study would not be any sort of a guarantee that I would actually study for months.

So best to take it soon, while the information is still fresh. And then have a real vacation. I've promised myself the month of January off. I may do some travelling during that time, arrange a voice lesson or two, and some shadowing with docs in the family. But for the most part, I think my ass will be firmly planted on the couch.

I can't wait.

Quote of the day

2008-11-28T06:17:00.000-05:00

If you are going through hell, keep going.

Winston Churchill