2009: The Year of Commitment

Since meeting the love of my life, I write far less. After all, I have an alternative mechanism for reflecting and processing -- perhaps not achieving the same level of splicing my reality or deleting content from RAM as does the process of writing, but rewarding in different ways for different reasons. It's a balance: still a work in progress. But there is one rigid, inflexible, much-anticipated written ritual for which I *must* carve out time: my New Year's decree.

During the last week of each year since 2005, I open my electronic file of New Year's Resolution documents. I review each and every one of them, taking the time to re-inhabit where I "was" when I wrote them. What was important to me? What did I believe? What did I dream? How did I relate to the world around me? Who was I? What has endured, and what has changed? Then, I take stock of these previous goals in the context of the present: Did I achieve them? Did I fail? Why or why not? And does it matter, to the Present Me? And after reviewing and re-evaluating every single resolution I've ever set, I carve out an action plan for the year ahead -- informed by my previous values, achievements, failures, and lessons, transformed into the context of my present values.

On the eve of New Year's Eve 2009, I can reflect with confidence that I kept each and every one of this year's resolutions (for the second consecutive year, at that). They were informed, thoughtful, and behavior-oriented. I didn't aim to "be" a certain way; I aimed to "do." And at the time that I set out these "doing" aims, I had specific, step-by-step actions carved out to prepare and enable myself to do so. It was the best resolution-setting operation I'd ever undertaken, faciliated by preparing a "New Year's Empowerment" Spinning ride that proved to be the most [permission to be arrogant self-granted] creative and important contribution I've ever made as a coach.

Building on 2006 ("The Year of Change" - leaving my stimulating/rewarding career after appreciating how significantly it drained my creativity, self-advocacy, and ambition), 2007 ("The Year of Discovery" - dabbling in new experiences from which I abstracted no meaning until the year was over), and 2008 ("The Year of Putting it All Together"), I embarked upon 2009 with goals of establishing a sense of feeling "complete." Assembling the missing pieces, acquiring the opportunities and experiences I sought to learn from, and charging forward along an ever-evolving path. Along the way, I tapped into the metaphor of a red blood cell undergoing hematopoetic differentiation: influenced by "growth factors" along the way, maturing and developing in a certain direction, accelerating on its journey without possibility of going back. In effect, 2009 became "The Year of Commitment." (Only fitting that I would meet the love of my life two months from said year's conclusion, of course.)
In 2009, I carved out an existence that completely fused the values and experiences that were important to me as a physician-in-training, a coach, an athlete, a writer, a human being.

I learned how to apply my experiences in one realm of life to another, to find synchronicity and meaning and balance, and to connect with and inspire the same in other people.

I learned how to use my tools and resources to structure my experiences exactly as I need them.
I learned that by putting aside my perceived awkwardness and inadequacy and enduring but a moment (ok, a looooooong moment) of discomfort, I can and will achieve exactly what I want.

I learned how to critically evaluate how I measure up to my own standards, and when to re-evaluate those standards in the first place.

I learned how important it is to me to be "training for something," to be pursuing improvement - even for the satisfaction of improvement alone. I learned how critical it is to define "improvement" on a case-by-case basis.

I learned how to optimally learn from my experiences. Nothing is by accident. When I feel proud, or strong, or afraid, or incompetent, it's all for a reason. It's my job to identify that reason, internalize it, incorporate it into my processing of all future incoming stimuli, and to call myself out on it when I identify prospective challenges to upholding a given "life policy."

I learned how to splice and shape a story to tell myself, an edited version of reality that means more than its composite details.

And above all, I learned to experience myself as committed to a journey. A journey that evolves every day, a journey with no specific requirements other than to persist. I've ranged from blind optimism to epic doubt, to a (reasonably) quiet confidence that everything is exactly as it is "supposed" to be. And I've come to appreciate that, as harsh the reality of privilege that comes along with it, it's a pretty sweet journey indeed.

So now what?

2010 is the Year of Being Present on my journey.

What does it take to "be present?"

I will listen better, without anticipating or interrupting.
In my 2008 reflection document, I praised myself for becoming a better listener and dedicating myself to improvement to that end. I may be more perceptive now, I may ask more thoughtful questions - I may have a better sense for what I don't know and need to know in order to inhabit one's existence. But I'm not a better listener. I anticipate too much, think too much, track too much. Interrupt too much. In 2010, I will shut up and listen.

Since I anticipate interrupting myself every 30 seconds, I will establish a mechanism for re-focusing .
It's the same as I coach people to do in Spinning classes -- closing one's eyes, finding one's breath, and tapping into some detail -- any detail -- until the connection takes hold.

I will establish a reliable system for managing my commitments while protecting my RAM. RAM is reserved for medicine.
A predictable side effect of my 2009 resolution to "take action on new ideas within 24 hours of conception" (vs. sitting on them forever) is that I made a lot of internal commitments this year -- all of them meaningful, all of them rewarding. All of them time- and energy-consuming. Most of them exhausting. While I'm proud of myself for structuring a reality where I actually DO the things I think about, I need to be more mindful of my resources. I'm getting older: I have less energy, I need more sleep. I need more (as my boyfriend says) "nothing box" time. Instead, I consume all available RAM tracking these grandiose projects I start (and am committed to -- commitments are commitments, and entirely unbreakable no matter what). Since all available RAM is spent tracking work to do, there is no RAM available to actually DO the work. Hence my perpetual state of "pending." This is not to say that I get nothing done. I get more done in a given day than most people do in a month. But I have so many projects looming that inspire so much anxiety for no reason. If I would just DO them, they'd be complete. I already made time to devour a great book earlier this week: "Getting Things Done," by David Allen, which advocates a practice by which I lived in late 2006: keeping EVERY thought I had on a 8x14 legal pad, structured according to context and priority. I was far more productive, creative, and peaceful -- and I lost my keys far less frequently. I've already dumped my "pendings" of all realms of my life onto a legal pad, absolving my dorsolateral cortex from having any responsibility for any of it... until I actively seek it out. In 2010, I will protect my RAM and use it to be "present."

I will complete data analysis, write up, and publish my Psychological Effects of Heart Rate Training study.
'Nough said. The procrastination has reached levels of absurdity.

I will blog more.
This is a separate mechanism for "dumping" content from RAM. If I don't, I do not have the capacity to think the way I need to be able to think.

I will be more reasonable, realistic, and flexible in my self-negotiations.
Blog entries do not need to be novels. Data analysis for 226 subjects x 10 entirely open-ended questions does not need to be done in a single day. Articles do not need to be theses. I just need to DO things. The only way to enhance self-efficacy to DO things is to... DO things.

I will conquer new athletic exploits to build confidence and calmness.
This was one of the most important things I learned in 2009. So, must keep going. Legitimate transition to clipless pedals on my bike. First sprint triathlon in August 2010.

I will learn to appreciate that right now is "enough."
Commitment to continuous improvement is a great thing. That's why I have "Kaizen" tattooed on my back, after all. But here, now, this moment... by the end of 2010, I will find a way for complete satisfaction with the present to mutually coexist with the pursuit of something more.

Here we go.
2010: Best Year of My Life...

Too Quick to Dismiss.

"Don't blink if Shaquille O'Neal is on the Orlando Magic."
Nothing.
"See? He didn't blink. He's completely aware of what's going on."

A mother's desperate way of explaining her universe. The only way she could make sense of the fact that her first-born son lay before her in her living room, hooked up to a bunch of tubes and things that beep, after blowing off the back of his head in a kerosene explosion accident.

"Blink if you know we're here."
Nothing.
"Blink for us..."
Nothing.
30 seconds later, a random blink.
"See? He's right here with us. He's going to wake up any minute now."

She has been saying this for three years.

When I met this family on a house call over the summer that I made with my "med student hero," I felt physically ill from my inadequacy. What this poor soul was describing to me was, on its face, ridiculous. I'd never before seen how destructive hope could be, the desperate clinging to shards of nothingness. Nothingness that fueled a life of profound sadness, struggling, pain. Alcoholism. It was not my place to squash that hope. But when they asked me to reinforce that hope, I felt guilty and helpless. That wasn't my place either. I couldn't find a way to come up with the perfect response that neither squashed nor validated something I believed to have no scientific basis. (Fortunately, my colleague did, which I reflected on in the above-linked post).

In the five months that have transpired, we have discussed this family at the clinic time and time again. EVERYONE has experienced this as I have -- this sad, toxic hope that caused nothing but disaster for this family. EVERYONE has dismissed the mother's claims of all these "signs" of alertness, her attributions of brain stem reflexes to actual volitional movements. There was no QUESTION that these "signs" were completely random. EVERYONE was seeking the same balance that had eluded me. So when my preceptor invited me to accompany him and the clinic's neurologist to make another house call to this family, I was particularly interested in learning how these two REALLY smart, REALLY thoughtful physicians of whom I think the world would communicate with these parents. What could I learn from their magic?

We drove out in the snowstorm. They'd turned the wood stove, and left out pieces of stale cheese and crackers for us -- more food than I'd bet that any of them had eaten all day. I was humbled by their generosity. We exchanged small talk and then followed them into the living room. There, he lay - exactly as I'd left him five months ago.

Right away, she launched into her familiar routine. Basketball trivia. Blinks/no blinks. Mouth opening. Tongue protruding. All of it completely random.

"Wiggle your left pinky."
She reached for his hand. The neurologist encouraged her not to prompt the effort. Nothing.

Then, it moved. The left pinky.
I silently gasped.

"Wiggle your left index finger."
It moved. It really moved.

My preceptor's eyes started to bulge.

Just as we started to get caught up in reversing course on our assessment, the air was filled with more random reflexes. My doubt returned. As we started to leave, the father asked his son to wave goodbye.

AND HE DID.

Seriously. He picked up his left hand, and waved it. That's not a reflex.

We said goodbye and returned to my preceptor's truck. We sat there for a few minutes in silence.

"I always wrote them off...." my preceptor began. "Yeah, yeah, he blinks on command... right...."
He shook his head.

I was comforted by how mutually shocked we all were. These two people have seen INSANELY much -- and yet, they were just as unnerved as I was. This changed everything. This man was aware, and may have been aware for quite some time.

This also means that he can feel pain. Everything now was different.

My thoughts rewound back to a few weeks ago at clinic. My preceptor had asked me to go in and take a history from a new patient, with a goal of learning her entire life story in 10 minutes and coming back out to present to him before we went in to see her together. As if that were not unrealistic enough, this woman was ALL over the place. Probable schizotypal personality disorder -- seeing crazy patterns where they did not exist (as though I should talk!): her hand hurting every time she ate ice cream (due to the fat clogging her veins); her eye vessels bulging on command; her toe hurting every time she used a computer; her dire need to have all sorts of serum tumor markers checked because of a TV show she saw. And she was also certain that she was developing Alzheimer's disease (at the age of 35) because she kept losing her keys. I tried to get as much information as I could about her concerns -- founded or not, the things that were important to her needed to be important to us. I tried to reassure her about cognitive overload compromising the dorsolateral cortex (working memory), recommended a great book I thought she'd find interesting. She seemed to like that, and got back to talking about the ice cream clogging her veins.

At some point, I gave up. I went out to present to my preceptor. I began with the disclaimer that my history was absolutely useless, and that I had been inept at reigning in her tangential rantings. I prepared him for what he was about to experience. We returned to the exam room.

Within a few minutes, the woman launched into opening arguments for her Alzheimer's diagnosis case.
"Do you ever lose consciousness?" my preceptor asked her.

Oh my gosh. He was asking about seizures (i.e., a legit medical problem). I hadn't asked about any pertinent positives or negatives to support (or fail to support) a legit medical problem. It hadn't OCCURRED to me to do that. In the context of a medical interview, it actually hadn't occurred to me to ask medical questions. I was mortified. It hadn't occurred to me that this woman actually had anything wrong with her. I'd already written her off in my mind as a complete hypochondriac, which is NOT mutually exclusive to actually having a legit medical problem.

Really? *I* did that? For all my talk of inhabiting a person's existence, inhabiting their underlying fears and doubts and anxieties, REALLY?

Mortified.

Afterwards, I confessed my lapse to my preceptor. He laughed.
"Yeah, that happens...."

I don't want it to happen. That's not good enough. It's not okay.

But having experiences like this at this point in my training is important. Important reminders not to get sloppy. Not to discount, dismiss.

After all, I've now seen a man in a persistent vegetative state wave goodbye.

A Burden.

I walked into the room, and I wanted to snuggle him. Before me sat an 84 year old man, dressed to the nines with a tweed blazer, corduroy pants, black loafers and white socks. Beside him sat his son, a burly construction worker whose pained, glossy eyes penetrated my soul.

"Dad's memory isn't what it used to be," the son told me and my preceptor. He spoke softly and gingerly. The old man looked straight ahead, unfazed. "He gets confused."

As the interview unfolded, we learned of a life in isolation. The man lived alone in a trailer, which he kept immaculate. It's all he had. He was disconnected from his world -- he couldn't hear well enough, see well enough, process well enough to engage. His son did all he could, and they both knew that it wasn't enough.

We assessed the pressing medical issues and developed plans for the next steps to evaluate his memory, vision and hearing difficulties. We said goodbye, and approached the door.

"Should I bother keeping on?"

My preceptor stopped dead in his tracks. Slowly, he turned to face his patient.

"Absolutely. You have to. You have so much to live for. We're going to work together to get through this. I'm here with you."

My eyes glossed over.

"Sometimes I don't know if it's worth it. I can't do what I'm told. I'm stupid. I'm useless," he whimpered. "I'm such a burden on my family."

It was a textbook list of "common concerns" of which I'm supposed to be mindful when interacting with older people. Except it was real, delivered through desperate, painful, hopeless sobs. And I didn't know what the hell to do about it.

My preceptor left me alone with the man and his family, tasked with administering a Mini Mental Status Exam (MMSE). I've seen it done several times in my forensics life and had a lecture on it in school last year, but I'd never administered one before. I was nervous.

I sat down at the desk beside him, touching my sharpened #2 pencil to the first question. Breathe. Ready. I looked up at him. His eyes were glossed over, looking at me helplessly as if he wanted me to fix him. I didn't know how.

I ransacked the archives of my brain for prototypes of experiences like this one: discouraged person looking for answers he or she expected me to have. No, not that one. Not that one. No. No. No. Yes. Flash back to the day after Thanksgiving last year. One of my Spinning students in New York confided to me after class that she was struggling with an eating disorder. She felt helpless, and thought that I might have some magical insight to end her suffering. The responsibility of being trusted to share in her burden was heavy, painful. I felt inadequate. I couldn't erase her challenges; I didn't know how. But then I had a moment of clarity. I wasn't supposed to "fix" this. I was in control of how I defined my function, and I could choose a useful one. So I started asking questions designed to help this young woman frame her challenges within the context of her goals, and to identify the cognitive structures that helped and/or distracted her. Maybe it didn't make a difference in the long run. But for at least the next 10 minutes, she felt empowered to fight. And that was enough.

"It sounds frustrating to feel like you can't remember the things people tell you..." I began.
His eyes held my gaze.
"Have you ever tried repeating back the things people tell you, to hear the instructions in your own voice?"
He looked confused.

I simulated a conversation with the man's son.
"Dad, come over Sunday at 12pm."
"You want me to come over Sunday at 12pm?"
"Yes."

I explained how there are different pathways in the brain that are responsible for processing things we hear vs. generating speech -- and that some people's brains work differently, and are better at some pathways vs. others. I told him that, as a medical student many years his junior, I need to engage the other pathway in order to remember stuff. He smiled. So we practiced a few more rounds with his son, and I could feel the anxious fog start to clear.

I started the MMSE.
"What year are we in?"
"Year?"
"You know, the date... the year?"
"Huh?"
"2000 and..."
"Oh. 1002. I mean, 1007."
Gulp.
"Ok, what state are we in?"
"Vermont."
"GREAT!" I exclaimed, far too enthusiastically. I was so eager to validate him.
"What county are we in?"
"County?"
"You know, the part of the state..."

Silence.
Dread.
Frustration.

His eyes squinted, and he slammed his fist into his forehead.
"I AM SO STUPID. Stupid, stupid. I don't know anything. What am I going to do?"

I touched his shoulder.
"I understand that you're frustrated... because you expect yourself to be able to do this stuff. But a lot of people don't know their county. You don't ever have a cause to think about it in your daily life. And the thing is, the part of your brain that handles attention is affected by how frustrated you are. When you get frustrated, it doesn't work so well. So maybe if you try to be more patient with yourself and take your time, your recall will kick in. Take a deep breath and..."
"Washington County." he interrupted me.
"See? Perfect."
"You're right. It's really 'in there.'"

The rest of the exam continued. Word repetition, number counting, backwards spelling, instruction following. Most of it pretty dismal. Occasional episodes of forehead-slamming, lip-quivering. I felt awful; he felt worse.

The last step is to copy a figure of interlocked pentagons. I expected this to be painful for him. I told him that I think it'd be painful for me -- that this test is designed to assess many different domains of function, that some people just simply aren't "spatial." He began to draw.
"No... this isn't it."
"That's ok. Try again."
He tried again.
"Just one more... I can do it this time."
"Go for it."
And he went for it. Twelve more times.

When he finished those damned pentagons, he looked up at me and smiled triumphantly.
"See? I did it."

The pentagons weren't exactly pentagons. But there were 10 angles, and the shapes sort-of touched. It wasn't exactly what anyone would hope for. But from the look in his son's glossy blue eyes, it was good enough. Enough to affirm that there's nothing else I'd ever want to do with my life.

"Changing the Narrative"

We're all telling ourselves a story. This is not so much reality as it is the deliberate choices we make about how to respond to reality. Splicing it, spinning it, shaping it. Owning it.

That's what this blog is, really. Forcing myself, despite the burdens of time and resources, to tell myself the evolving story of my road to 'doctorhood.' It doesn't have a beginning, a middle, or an end exactly. But, so far, it's a pretty sweet story.

I wrote some time ago about story-telling in patient care, and how I saw narrative medicine -- the thoughtful, collaborative weaving of the themes and values that make up the broader context of a person's life (of which their illness is only one part) -- as a major influence in the way I hope to one day care for people. The symbols, the irony, the various devices to layer awareness and reflection -- all designed to empower people to heal themselves through the tools that doctors, patients and the characters of their lives all work together to develop.

Narrative medicine, of course, is just as powerful a vehicle for me as a trainee -- and will continue to be, for the rest of my life. Writing allows me to construct and reconstruct the formative events of my world, to give them meaning -- to frame it all in a way that teaches me as I go, and will continue to teach me as I look back upon it. Tapping into recurrent, intersecting themes is comforting for me -- the power and confidence of consistency is enormously gratifying. Last year, I had a "thing" about what I called "practicing commitment" (which is how my immunology course director used to describe the process of building confidence in coming to a diagnosis and standing behind it -- which I extended to apply to EVERYTHING that ever happened...). I found my "champion" symbol in the hematopoetic stem cell (en route towards various paths of differentiation -- unlimited possibilities, yet unable to turn back the farther along it proceeds). I practiced "practicing commitment" as an athlete, as a coach (HOW many training sessions have been specifically themed around commitment -- to a specific intensity, to a specific challenge, to a specific breathing technique, to an awareness -- over the past year? Hundreds. Commitment for the sake of commitment, even. The idea of demonstrating one's ability to husband all of one's resources upon a specific task -- how gratifying that can be.), as a medical student. As a human being.

As it turns out, we revisited hematopoesis last week in school. As slides of myeloblasts and lymphoblasts, and dozens of genetic translocations that result in their failure (that I'm magically supposed to encode for life -- or at least, for my Boards) flashed before my eyes, I was comforted by associating these "characters" with the way I conceptualized my life story. Or something like that.

Ironically, this coincided with quite a few epic developments to said "life story."

First, the process of TELLING it. At clinic on Wednesday, I had a fascinatingly subtle discussion with my preceptor about self-narrative. I am so lucky that I have a mentor who spontaneously slips into casual evaluations of self-narrative (what?!). His premise was how it's futile to deny how much of the stories we tell ourselves are inextricably linked to our biases, our expectations, and our dreams. We project aspects of our stories onto other people; we see what is consistent with what we want to see -- what we tell ourselves that we're seeing. I wanted to tell him that he was wrong. I wanted to tell him that I was confident in my objective analysis of reality at all times. But he wasn't wrong. I reconciled my dissonance relatively quickly. I came home and told Scott "my story," and heard his. In so doing, I 'owned' every single one of those projections, biases, and distortions. And it was a pretty sweet story, indeed.

The week continued. It was Primary Care Week, so I had the opportunity to attend a bunch of family medicine-related talks and interact with a number of characters who are starting to make quite the impact on me. I also set myself up to attend another family medicine conference, this one the Vermont state professional organization. I'd attended this group's meeting last year, as my first introduction to the community I'd come to experience as "my people."

Yesterday, I met with my advisor (one of the coolest human beings on earth). I found myself comfortably, casually recounting the past 6 months of my life. When summarized and editorialized (i.e., crafted as a story), I felt really "together." Even recounting my flop of a study (that I'm SERIOUSLY going to work on this week!) felt pretty good. He was amused by all of my masochism (i.e., three Centuries, deliberately seeking out awkward/unbearable/AWFUL experiences in order to get comfortable being uncomfortable). He observed my hyper-self-awareness (which I didn't exactly have the sort of relationship where I really should have felt comfortable reflecting at the level I was reflecting -- but I suppose he experienced my candidness as refreshing). Our discussion left me really proud of the story I'd pieced together. It may not have felt so fluid in real time -- but the version that lasted was a useful one.

Then, last night I went out to the clinic to have dinner with my preceptor, the PA who treats me like a daughter (she MET my mother a few weeks ago - it was pretty epic), and another friend. We got to talking about prostate exams (I do them all the time, unsuccessfully -- my fingers are too short!) and pelvic exams (I've done four now...) -- both of which I haven't been formally taught how to do at school, yet am regularly invited to practice at clinic. While I can comfortably discuss my history of anxiety and panic attacks, my love for my boyfriend, and my self-narrative style with my preceptor -- what I blurted out next was somehow outside of my comfort zone. I've written about it a ton. But blog fodder is not necessarily "say out loud to your hero"-appropriate.

"I feel so guilty every time I do a pelvic exam. I feel like I haven't done anything to earn this privilege. There's no reason that someone is being so generous. So I just want to get in and get out and get them done with being vulnerable to me. I don't spend time really learning."

With no more than 5 seconds passing, my preceptor responded:
"So change the narrative. Tell yourself that this patient made this choice because they wanted you to learn as much as you possibly humanly can -- and it's your job to honor that underlying basis for her choice."

Whoa. This man is BRILLIANT. That is an entirely crafted, distorted narrative. It's a version of reality that gets me to adapt my behavior, my attitudes and my emotions. It's a version of reality that's TOTALLY going to work for me. Is it exactly true? No. Is it false? No, actually. Is it more true than it's false? Yes. Is it going to make me a better doctor? Damned straight.

So, today was the conference. I woke up with a reprise of my lung-hacking cough. I had no appetite. My GPS got me lost. There was a country song on the radio, and I found myself kind-of LIKING it -- just because it seemed so movie-esque to be driving down a dirt road as the sun rose, en route to a symbolic event to mark "my future."

Turns out, I was the only medical student there. I didn't know anyone. I was awkward. Irony: it was held at the hospital where I deliberately accompanied my preceptor those nights over the summer, for purposes of "owning my discomfort." HA. I owned my discomfort for 9 hours today!

I didn't want to network. I just wanted to crawl in a hole and not be alone and out of place. But, at intervals, I changed the narrative. I was confident. I belonged. I had useful things to say. So I started... saying them. I met a handful of people who were really eager to encourage and support me. I talked with someone I'd heard speak a year ago, who really inspired me -- and there she was, eating lunch with me. There was another character, a junior doc, who probably recognized a lot of my young, naive, overly eager idealism. She inspired such comfort that I was able to ask her genuinely useful questions, and learn a ton from her experiences (i.e., elective choices, geographic options, etc).

Then, I had an idea.

A board member from the national umbrella organization for this state chapter was there, giving a talk on the future of family medicine. He started off with statistics about how very few people are choosing to go into family medicine and how it doesn't pay as well as x and y and z and blah blah blah. He then went into all of the mechanisms for reform under way, but completely omitted a discussion of efforts to increase the workforce (which tons of other speakers address). The difference is that this guy didn't expect a medical student to be in the office. But you know what? I was a medical student in the office. And suddenly, I felt compelled to be useful.

I spent 45 minutes during this talk plotting my next life event. My heart was pounding, unresponsive to breathing techniques. My legs were twitching. My vision started to blur. Own your discomfort. You don't need to make the anxiety go away. You just need to own it and keep going. You practiced this.

"Any questions or comments?"
Show time.

I raised my hand and in front of 60+ strangers, introduced myself as a second-year medical student for whom there was a 0% chance that I would do anything else with my life besides practice family medicine. I offered that I didn't know if my perspectives were useful, but that I felt compelled to speak up as the only student in the audience. I wanted them all to know that the reason I'm so committed to family medicine is because of experiences I've had with people like themselves -- the stories, the intangibles, the generosity of making time to give me the opportunity to learn from them and their patients. That I know they're busy and overworked, but that they should know that the time they make is invaluable to the future of family medicine -- that it means so much, that it goes so far.

I didn't stutter. I didn't cry. I didn't have a panic attack. And a few people came up to me afterwards and thanked me.

I got in my car and drove off, literally, into the sunset. I put "Who Knew?" by Pink on repeat for 45 minutes straight. Not because the lyrics mean anything to me -- but chords just kept striking the absolute perfect 'place' for me. I was tearful. Proud. Self-enamored. Peaceful. I even drove the speed limit the whole way home.

'Who knew' that I'd be telling myself THIS story? Or any of the stories that have directly led up to it? Every story of the experiences I sought to prepare me to do what I did today. The uncomfortable bike rides, the embarassing questions, the deliberate exposures to looking like an idiot -- just to get good at it.

Who knows what I'll be telling myself next?

Taking a moment.

It was right out of a movie. I met someone. And I fell in love. *BAM* And just like that, I have a whole new life. I've had this epic, cheesy, ridiculous over-the-top grin on my face for three straight weeks --glowin' on right through depressing renal pathology, indistinguishable hematologic cancers, and even a personal adventure with likely H1N1. (When I stopped hacking up my lungs long enough to have a conversation, a friend of mine accused me of glowing so much that I was emitting vitamin D). I'm just so utterly, ridiculously friggin happy.

Is my attention suffering? Maybe. Is my schoolwork suffering? Nah. Are my priorities skewed? I don't think so, either. Am I still making time for the things and the people I hold important? By and large, yes.

But there's one change that I don't think I'm okay with. I've not been writing.

In my last entry (a month ago!), I reflected on a concept in Jeremy Spiegel's book, Mindfulness for Medical Students, about how to own one's changes -- reflecting on them in real time, incorporating them into a larger context of "self" without being derailed towards another version of self that is inconsistent with one's original goals and values (as sometimes happens to doctors in training). Most of what Spiegel advocates, I've been doing for a while. But after internalizing his perspectives, I developed a framework that I decided would work for me:
1) "What's new?"
2) "Where did it come from?"
3) "Do I like it?"
4) "Is it consistent with my goals and values?"

In my last entry, I took the concept of "riding Centuries" -- this thing I apparently now "do." I identified these dramatic undertakings as a direct consequence of my perceived inadequacy as a future doctor -- and my strategy of deciding that if I could dedicate myself towards continuous improvement of a concrete, measurable task of riding a bike for 100 miles, that I could build the confidence I need to dedicate myself to the less concrete, more unnerving, ridiculously high stakes goal of learning enough to be responsible for a human being's life. Does riding three 100-mile rides in an 8-week period mean that I'm going to be a better doctor? Of course not. But do I think about it under conditions of extreme self-doubt and awkwardness? You'd better believe it. So this change -- do I like it? Damned straight. And is it consistent with my goals and values? It's, in fact, the most precise embodiment of my goals and values that I've ever practiced.

So, now "what's new?" Me, the writer with a huge chunk of her self-concept staked within the domain of self-reflection, self-awareness, written expression, and the active "remodeling" of life experiences, stopped writing.

"Where did it come from?" There's only x amount of time in the day. There's only x amount of energy. I've made an active choice to redirect that time and energy. I've never been happier with the results of my choices. But my happiness has come at the expense of choosing not to write.

"Do I like it?" I don't think so.

"Is it consistent with my goals and values?" One of the reasons I'm so happy in my new relationship is that I've been accomplishing almost ALL of what I accomplish by writing, just differently. But there's something very specific about reflecting in written form, creating a record of my life experiences (that I really do go back and re-read within a new context, afforded by another week or month or six months' perspective) that I really cannot, and will not, do without.
I think.

Over the weekend, I had an experience that I knew that I would never forgive myself for not making time to capture the way I've captured so many moments that have led up to it.

I attended a family medicine conference in New York. I shouldn't have been there. My fever had resurfaced and I felt terrible. Just as I was prepared to retire at 7PM for the night (lame...), I decided to take another lap at the residency fair. I'm not applying to family medicine residencies for another several years. There was no need to. But I was curious. I was curious about a program somewhere near my new boyfriend's hometown in rural North Carolina. So I strolled over, and started chatting with a third-year resident about her experiences. I was quite impressed.

And just as I started to walk away, a gentleman who -- no joke -- looked exactly like my preceptor at the clinic where I train (Irony: my preceptor trained in North Carolina) started talking with me. I told him I was from NYC, and shocked at how much I love Vermont, and how this has taught me to be open-minded about the experiences that will bring me a sense of rewardedness. He began to speak of what makes him feel rewarded as a family doctor...

"I'd been taking care of a woman for 35 years. One day, she came to me and said that her husband wasn't doing well. I went over to their home to see him. I said I'd be back in 3 hours -- but by the time I arrived, he had completely decompensated.

I told her that her husband wasn't going to make it through the night.

She was frantic. She started talking about needing to call this daughter, and that daughter, and this daughter and rushing him to the hospital.

'No,' I told her. 'There's no time for that. Here's what we're going to do. Call one daughter... and then ask yourself: What would your husband want right now? How would he want to spend this time?'

'He'd want me to hold him,' she said.
'Then go do that. Go into your bedroom. Close the door. And just hold him.'

And that's how he died.

Moments like that.... that's why I'm a family doctor. Life is a collection of these moments, these lessons you'll never forget, where people allow you into their spheres of values -- and it's your job to help them make choices that reflect those values."

My eyes brimmed with tears. I told him that, for what it's worth, that this moment was going to be one of those lessons that I'll never forget for the rest of my life.

After we parted, my immediate response was to go find somewhere to write. I didn't. I had H1N1. I went to sleep. But not before sending a text message to my new Alternate Reflection Mechanism. I felt at peace.

When I returned to Vermont and shared this story in person, my reflection had a special quality to it that was a "moment" in and of itself. A moment I didn't need to document on a blog (but apparently am, anyway). A moment that stood on its own as the version I'd remember, that I'd call up when I needed it. A moment that would last forever.

"I'm going to be here to share in these life-altering moments with you. And I'm going to make even more of them."

I may be okay with not writing so much, after all...

Acceptance & Loneliness... or Accepting Loneliness.

Amidst 1600 people, I felt very alone. As I crossed the finish line of my third Century (100-mile) bike ride yesterday, passing a receiving line of cheerers calling and waving signs bearing 1599 other people's names, my eyes brimmed with tears. My stomach knotted with dread. Dread that this moment really was all there was going to be -- that whatever feeling I had in that moment -- call it pride, call it accomplishment, call it emptiness -- needed to be enough. I needed to be enough. I wasn't sure that I was.

As I stretched and iced my assorted musculoskeletal re-injuries on the shores of the Atlantic, I thought about what this sad, lonely, anticlimactic moment was supposed to teach me:
* Another step of discomfort-immersion?
* Practice in distinguishing between 'thoughts' and 'feelings,' and practice accepting the latter?
* Keeping me honest in appreciating that this part of my life (i.e., riding Centuries) that I associate with PURE internal validation really isn't completely devoid of external influences?
* Practice accepting that experiences can be powerful and influential in addressing some of my needs, without requirement to meet all my needs?
* Prompting me to re-evaluate and re-define my concept of "inadequacy" in a more realistic, compassionate way (i.e., if one can feel "inadequate" after riding 100 miles on a bike, one has an unfair definition of the word)?
* Practice accepting that my spectrum of "continuous, incremental improvement" does not require that every experience "n" is forever trumped by an "n+1?" Or that "improvement" doesn't always need to be measured on the usual scales (i.e., "faster than last time," "prouder than last time," "more joyous than last time") but can qualify as improvement all the same: "more insightful than last time," "more compassionate than last time."

And when I thought about that moment's potential utility -- for all of those reasons -- I felt less alone. More appreciative that, although this moment was drastically different from how it was "supposed" to be (or how I expected it to be), perhaps exactly as it needed to be.

This was supposed to be my first Century, an organized ride out of Hampton Beach, New Hampshire up and down the coast of New Hampshire and parts of Maine and Massachusetts. I'd rented a beachside suite for a weekend getaway with three friends -- they'd hang on the beach while I rode, meet me at the finish line, and then we'd all have the next day together. Two deviations, right off the bat:
1) This was no longer my first Century. I've done three, in an eight-week period: The first one was an accident. The second one was a pseudo-spontaneous desperate (and successful) act to conquer some unresolved anxiety.
2) My friends bailed, last minute.

So after taking my pulmonary exam on Friday, I set off for my solo adventure to Hampton Beach. I'd been up since 5AM after cramming til after midnight the night prior, so staying awake behind the wheel was a major, caffeine-fueled feat. I spent the drive thinking about why I was doing this. I wasn't excited. I was exhausted. I was driving to a random tourist trap to stay by myself in a random motel, and ride 100 miles for no reason. But was it really "for no reason?" No. At some point, this meant something to me -- so it was a matter of reminding myself what that was.

By the time I pulled onto the beach -- literally -- I had some idea. After a series of surprisingly calm navigation of confusing one-way streets, I dumped my gear off at the motel (a comfortable, AWESOME suite right on the water) and headed for the sand. It was 60 degrees but as sunny as could be -- and, yet, there were no human beings around. I had an entire beach front to myself. I walked barefoot back and forth for an hour, thinking about what I wanted out of what sure to be a very strange, very random trip.

This included my plans that night to read a book I'd borrowed from my roommate: "The Mindful Medical Student: "Staying Who You Are While Becoming Who You Want to Be" by the psychiatrist Jeremy Spiegel. Upon initial skimming, this seemed to be documentation from someone-who-legitimately-knows-what-he's-doing of precisely "what I do all day with my life to preserve sanity." He even has a chapter on synchronicities -- that is, finding and exploring connections between seemingly unrelated concepts (i.e., my whole friggin' life purpose) -- and describes it as an adaptive extension of pattern-recognition (i.e., a major skill for medical diagnosis). Validation. Nice.

I literally devoured this book from cover to cover the night before the ride. Dr. Spiegel's premise is that medical schools focus on technical content of medical education, while lacking training in the equally important skills and processes for self-reflection, exploring strengths and weaknesses, and coping with the uncertainty, ambiguity, and unease that are inherent to the practice of medicine leaving many a new doctor unable to navigate the challenges of their new world, and wrapped up in new identities that depart from their underlying character and values. I am fortunate that this will most certainly NOT be my problem. I've been preparing for this for years, even before medical school, because I anticipated this exact issue arising. I've been reading gazillions of physician and patient-written memoirs, thinking and writing a ton -- developing a whole arsenal of thoughts, and a structure for evaluating and balancing them over time. I'm also beyond fortunate that my program does include "life development" as a component of our curriculum. Though I appreciate that I am in a better place of self-awareness than this book's intended audience -- and I rejected some of the author's pseudo-over-the-top psychodynamic interpretations of self-evaluation (the fact that I can filter in selective sources of inspiration vs. filter out others is an important skill that I readily appreciated!), it was gratifying to read endorsements of what I do and think and write about to keep myself grounded in the moment, and document my evolving perspectives on which to look back over time. I link to previous posts on this blog, and my other blog, to keep myself honest. I'm comforted by my own consistency -- but the structure is built in to allow myself to process, evaluate, and "own" my changes, for good and for bad.

Amongst other themes he discusses (that perhaps I'll write about another time), Spiegel talks about undertaking "quasi-spiritual quests" to evaluate one's evolving identity. Do you recognize yourself? What's new, and do you like it? Where did it come from? How does a present conflict relate to conflicts of the past?

Ok, then. What's new? I was about to ride my 3rd 100-mile bike ride in an 8-week period. THAT'S new. Apparently, I have become someone who "does" Centuries. Just as my self-concept behind the wheel of a car evolved to that of a "Real Driver," I had begun to conceptualize myself as as "Real Cyclist." That's a big deal. Do I like it? Hells yes. Where did it come from? That's another story.

Most people in my life, including the people I train, don't understand why it's a big deal to me to ride 100 miles on a bike. It's not as crazy or "unrelatable" as it sounds. To me, riding my first Century represented a dramatic, epic triumph over an intimidating challenge that, while intellectually in-reach, was psychologically outside my comfort zone. But instead of comparable life challenges (i.e., becoming a competent physician), this was a challenge that I had COMPLETE control over conquering -- and for which my progress had measurable, objective feedback mechanisms: How much work could I do at 80% of lactate threshold (i.e., an intensity I can sustain literally all day long)? How much could I increase lactate threshold? How many beats could I lower my heart rate by altering my breath? Indisputable, objective feedback breeds confidence -- confidence that I could apply to the rest of my life. Confidence that I can and will do the things I say I'm going to do, no matter how intimidating. And confidence that came from training more intangible, immeasurable skills: language to coach myself through discomfort, awareness of the interplay between my breathing, form and movement, the ability to focus and husband all of my resources upon a specific sub-aspect of a task.

So after doing it once, why keep going? Because I could improve. I had complete control over improving my performance on this concrete task, unlike my perception of control over improvement in my medical training. I read and listen and ask questions with intent motivation to one day be qualified to care for human beings -- sometimes incoming stimuli stick; sometimes they don't. I can see and try an exam skill or procedure a gazillion times -- sometimes it sticks; sometimes it doesn't. I take and occasionally create opportunities to build confidence -- sometimes I succeed; sometimes I fail. My performance is unpredictable. Practice makes anxious.

As an athlete, my performance is measurable. I feel confident and strong and alive. On a bike, I can be the person I want to be and accomplish the things that mean something to me -- and in those moments, I genuinely believe that this translates to the rest of my world -- even if it doesn't. In those moments, my perception is all that matters. Contrary to public opinion, it is NOT difficult for me to please myself: in fact, some of my proudest, most memorable moments as an athlete were "mere" 30 minute periods of maintaining lactate threshold. Or there was another experience where I held 106% of lactate threshold for 10 minutes. 10 minutes! The woman who says she needs to ride 100 miles in order to feel "accomplished" cites a 10 minute experience amongst her proudest moments? Really? Yes.

The difference with a Century, though, is its potential to influence my self-concept as a Real Cyclist. I wanted that confidence so badly, and I worked for it. It's "epic" enough of an experience that I associate as unique to a Real Cyclist. Lots of real cyclists don't ride Centuries -- but if you ride a Century, you're absolutely a Real Cyclist. I keep riding these things to reinforce this new part of my identity that doesn't quite seem real enough to last-- almost like I'm afraid it will melt away.

One can't just up and ride 100 miles, though. It has to stand for something -- something that earns commitment, something that inspires some feeling that goes above and beyond the normal span of routine, daily emotions. Dramatic efforts call for dramatic reasons, reasons that mean something dramatic. And so, as I took on this third Century, I decided to dedicate it to the themes of this book that resonated with me most. As though to permanently weave them as strands of my character, to protect them from fraying or unraveling against the mangling challenges that are to be my life. Yes, I'm entitled to a little drama: I 'do' Centuries.

Finding Meaning in the Ordinary
Off the top of my head, I can list more than 20 profoundly meaningful examples of synchronicity -- but I'd sound psychotic. And it doesn't matter. I believe in every single one of them, and that perception of order and structure is comforting. The world makes sense when there are predictable patterns to pick out, an order to the universe. Medicine is that way -- and I never conceptualized any of this as "pattern recognition" as this book calls it. But as I prepared for this "ordinary" ride, I knew that it would have to mean something. Like anything, it was a matter of deciding what I wanted it to mean -- and, as it would turn out, appraising what it did mean... and appraising how the discrepancy between the two would affect me.

It's All in the Editing
Spiegel suggests conceptualizing medical school as an iMovie -- that instead of collecting all the fragments in contextless chronological order, that one can edit them in real time into a useful form that is easily revisited over time. Thus, this conscious creation represents an evolving, maturing personal and professional self. That totally resonated with me. That's what this blog is all about. I capture stories for a context -- but by and large, it's not about the facts. It's about their meanings. The meanings are what are going to stick -- the influences upon which I will want to look back on and remember their roots.

I thought about that as I rode, not only when I finished. As the breeze of the Atlantic tickled my ears and the sparkling waters interrupted my rhythmic, continuous breaths, I was mindful of actively blocking out everything else about that moment. My throbbing ankle, my kinked neck, my sore butt. I encoded the concept that, there I was, cruising along the Atlantic Ocean on a bicycle. And that right there in the moment, it was awesome.

An Arsenal of Comfort
Spiegel also writes about developing mechanisms for comforting yourself under stressful circumstances - stroking your own arm, telling yourself it's ok. I do a lot of that already. I've made it a point, over time, of developing an arsenal of tools to convince myself that I can endure a particular challenge (including, of course, accomplishing 100-mile rides). My latest tool comes from Century #2 -- the memory of the 85 mile mark (where I saw a road sign that told me it was 5 miles to Williston, a town 10 miles from home), when I bawled with intense pride and intrinsic reward that I would indeed triumph over my suffering and finish this overwhelming feat. At a few points since -- in "life," in training, and now here during this ride -- I told myself: "THIS is your Williston." Fascinatingly effective.

I also found myself acknowledging my discomfort with more natural compassion than usual. Usually, I have to force it when I'm riding: "Stop being so negative!" (i.e., reprimanding myself for reprimanding myself). "I'm tired. I hurt. I hate this." Ok. "I huuuuuuuuuuuurt." Ok. That's ok. If you want to stop, you can stop. "Hell no! I'm going to rock this. Go." More compassionate, and legitimately more successful outcome. This is just like I've been practicing in my medical training: acknowledging my discomfort, accepting it kindly, and keeping on.

"I'm Gonna Get Better At This, Too"
I "celebrated" my (lonely, isolated, sad) achievement with a 10 minute stretch on the beach and a peanut butter/banana/rice cake sandwich. Then I promptedly biked another mile to my car, not-so-discretely changed inside of it, and hit the road. I'd done what I came to do: now I could go home.

Cruising down the coastline, the cool saltiness breezing through my open windows, I smiled for the first time since crossing the finish line. As I pulled onto the Interstate, rockin' out to my empoweredly titled "REAL CYCLIST" mix with my shades on and my uber-scarred elbow out the window (another proud emblem of a "real cyclist," of course), the sunshine scorched my left cheek -- so strong that it bordered on discomfort. I drove on, though, and acclimated to the glow.

People say that the discomfort of medical training (i.e., anxiety, inadequacy, incompetency, loneliness) gets better over time, too. That the more you do, see and feel, that you develop skills, intuitions and competencies. Part of me accepts this as a logical reassurance; part of me thinks it's bullshit. A lot of me expects to never get good at certain tasks, no matter how many times I practice them. In moments of failure, success feels so far away -- so unattainable. And exposure to things I've not yet tried (i.e., no opportunity to fail) -- from emergency tracheotomies to routine IV insertion -- have bright red "this is NEVER going to be something you can do" warning sticker on their card catalog entry in my brain. But you know what? People said the same thing about driving and about biking -- and in those moments, those skills felt just as realistically impossible. But they happened, all the same. A year ago, I would never have CONCEIVED of any single occurence of the past 22 hours. A year ago, I barely knew how to drive; now, I drove 3 hours to create an epic, purposeful adventure for myself. A year ago, I barely knew how to ride a bike; now, I'd biked through 3 states for my third Century ride. I never expected basic competency, let alone comfort and confidence. For the first time in my life, I entertained the concept that medicine really would work the same way. If nothing else, my 22 hour adventure prompted me to appreciate that.

Uncertainty
When I arrived home, I mapped out the route I thought I'd taken (accounting for all my missed turns and accidental returns to civilization). I didn't remember 75% of the random turns I made but I included what I could. 80 miles. Could it be? Had I really not completed a full Century? I'd taken 7.5 hours (the others had taken me 8 hours, and were 107 and 105 miles respectively) -- but this was entirely flat (as opposed to the mountains of Central Vermont, which I climb slower), and I was obsessive about maintaining a faster cadence than usual on flats. Had all my stops asking random passersby for directions really taken up the length of time I'd have expected 20 miles to take me (1.25 hours)? It couldn't be -- no way. But then again, 20 miles is a huge gap to screw up on a map.

Discomfort over uncertainty has plagued me for most of my life. What will I be when I grow up? What college will I attend? Will I get a job? Will I spend the rest of my life with this person? Can I really pick up and move to the far-away land of Vermont and be ok? How's this all going to pan out? On one level, I've grown more comfortable with varying degrees of uncertainty. On another level, I simply have fewer uncertainties as I get older -- and, to some extent, avoid situations associated with long-term uncertainty.

So how fitting it is to take this concept of the Unachievable Achievement, which allegedly exists for all of these reasons/sub-achievements independent of the achievement itself (that may or may not be even more important than the achievement itself), and let history bear that I have complete uncertainty over whether or not I actually achieved it. Talk about playing the irony card. And if I didn't really ride 100 miles, which symbolized all these great things, do all of those other reasons/sub-achievements still hold?

That's why I wrote this post. After writing this, I cannot possibly answer that question with "no."

If I had a specific need to accomplish the concrete task of riding 100 miles, maybe I accomplished it; maybe I didn't. I don't console myself with assurance that I've legitimately ridden 100+ mile rides twice prior in the past eight weeks, or with the promise of re-attempting this feat. It's not about that. It's about whether THIS one "counted" -- whether it meant something, something that will apply to the rest of my world and really, truly have staying power.

But after all I've described... how could it not?

I took this on to triumph over doubt, to impose structure on inflooding chaos, to build confidence amidst anxiety. I did that, and then some. It's not the facts upon which I'll look back; it's the meanings.

Everything is in the editing. It's less lonely that way.

"Own Your Awkward" -- not to mention your inadequacy, your anxiety, and your utter dread.

My current self-improvement project over the past few weeks has been to immerse myself in experiences that optimize my anxiety, discomfort, and outright dread. As I described last week, I am endeavoring to train myself to mindfully "accept" negative emotions without attempting to control them. Active acknowledgment; passive acceptance.

While the experiences I've been structuring for myself this week may seem quite drastic in the moment, they're actually quite subtle. In the true spirit of Kaizen, it's been the little things: Asking a question after class of an intimidating lecturer. Volunteering to interpret an EKG in front of 114 people (knowing full well that I would fail and embarrass myself). Accepting a task of injecting a screaming, kicking infant with a vaccine. Giving medical advice to a guy with heart disease about the proper way to use his nitroglycerine when he has chest pain. Asking my preceptor if I could accompany him, yet again, to the hospital late at night.

What these opportunities have in common: 1) I've not wanted to do them -- more specifically, I've wanted to NOT do them; 2) I anticipated that they would trigger my oh-so-familiar catecholemine surge, and its predictable consquences of physiological discomfort; 3) I recognized that exposing myself to situations that predictably inspire panic, to teach myself that it's not the end of the world to be uncomfortable -- with the expectation that, one day, it might be comfortable to be uncomfortable.

At the hospital on Wednesday night, I could NOT have been more awkward. I stuttered. I walked into things. I stood behind the nursing station while my preceptor checked labs on the computer, staring at the ground wishing that I weren't there looking like a moron. Stop. Who cares that you look like a moron? Just stand there and look stupid. You're gaining SOMETHING in this moment just by being there. So just be there.

I followed my preceptor across the hall to see our first patient. The room was dark. Before me lay a 42 year old woman who has been in and out of the hospital for the past 4 YEARS with uncontrollable vomiting and abdominal pain. Her moans slowed to heavy breaths as she nodded to answer my preceptor's questions. As she spoke, my eyes glossed over with warm tears. I froze. What are you doing? I'm frozen. I'm tearful. I'm awkward. I'm uncomfortable. I can't do anything to alleviate this woman's discomfort, or my discomfort. I suck at life. No you don't. Your task isn't to do anything; it's to stand there. So stand there. Why are you uncomfortable? I've never seen anyone in this much physical distress before. This is what you're going to do for a living -- see people in physical distress and try to help them. Remember? Right. So I then attempted to scan my brain systematically for the potential causes of this woman's discomfort. What's in the abdomen? Uhhhh... Really? Can you really not retrieve the organs located in the abdominal cavity? Uhhhh...

It occurred to me that there are some things that I'm not going to be able to accept. I was somewhat ok with the concept that my brain didn't work while in the presence of a crying, moaning person in pain. I could, in theory, ultimately remove myself from that setting and think outside of her presence. But what I could NOT accept was how poorly I was communicating. I expected that I should be able to say SOMETHING -- ANYTHING. And I couldn't. As my preceptor left the room, I turned to follow him. The pit of uselessness in my stomach made me want to crawl into the corner and cry.

Say something. Anything.

"I'm sorry you're in so much pain..." I started.
She moaned.

"Please help me.... please help me.... can't someone help m..." she trailed off.

I placed my hand over her wrist. People tell me all the time about how touch is comforting. I didn't necessarily believe that my touch would do anything - but I figured it was worth a shot. Maybe it did, maybe it didn't.

"We're going to do everything we can to get to the bottom of what's causing your pain."

"Please help me.... please....."

"We're going to try to figure out what's causing this, and help you get better..."

"Please...."

I could tell quite immediately that we could continue this inadequate cycle all night, and that the meek touch of my hand on her wrist and my empty commitments to diligence weren't going to achieve a blessed thing. Still, I allowed the cycle to continue a few more rounds, then capped it off with another "I'm sorry" and a goodbye. I have never felt so inadequate.

I returned to the nursing station where my preceptor was documenting his exam. I looked down at the floor, saying nothing.

When we left a few hours later, I stopped him at the door.

"Do you have any thoughts on how to prevent your brain from shutting down when you get emotionally affected? I found that I was so distressed in the room with that patient that I literally couldn't retrieve the contents of the abdominal cavity."

He smiled.

"That's how I've spent my whole life..."

We then had a fantastic discussion about preventing the limbic system from interfering with other higher-level cognitive pathways (he used the expression "going limbic," which I adored) and about my project of immersion in uncomfortable, distressing situations. He shared that this is exactly how he approaches his world: identify a weakness, and immerse entirely until it goes away.

I write this 30 minutes from heading out on the greatest physical challenge of my life. I am riding my bike 50 miles to the house across the road from the clinic (where I stayed for the summer), staying over, and riding 105 miles tomorrow. Century #2 -- just because. Just because I 1) don't want to do it -- more specifically, I want to NOT do it; 2) I know full well that it will inspire terrible, terrible feelings of panic during certain instances (I'm clipping in with both feet for the first time; I'm riding terrain I've never seen before; I'm riding by myself through areas where there are no people for hours); 3) I see it as an opportunity to practice EXACTLY what I've been talking and thinking and writing about all this time.

In my coaching life, I talk/write so much about identifying goals -- and more importantly, the REASON for these goals. I stress the importance of investing time at the front end to develop very clear, specific psychological fuel. That's why I'm writing about this ride BEFORE I do it, instead of after.

In theory, there is no good reason to do this ride -- except for MY reason. I see this, symbolically, as something that is going to represent conquering something that is important to me. I could try to talk myself out of my discomfort. Or I could just BE uncomfortable -- and keep going anyway. And when I've done it, I will remember it for the rest of my life. Every time I stand at the foot of a patient's bed and can't do anything to help him or her. Every time I fear that I've made a fool of myself. Every time I think I'm inadequate or incompetent or weak.

Completing this challenge isn't going to make me smarter or smoother, or a better doctor. It's just a structure, and an important structure. Conquering this is giving me a framework to expose myself to what scares the hell out of me, accept my anxiety, and do it anyway -- thus demonstrating, once and for all, that challenges can be conquered INDEPENDENT of negative emotions.

I have resources around me to make this (mostly) safe. My roommate has offered to come get me from "wherever," and I have resources around the halfway point. I'm doing the first 50 miles (the part of the trip I've never seen before) in sneakers. I have tools and physical fuel. My psychological fuel, of course, is a genuine belief that I will have an entirely different life outlook when I conquer this. I'm excited to KNOW that I've done this. I'm excited to talk about it in the Spinning class I'm teaching tomorrow night about triumphing over adversity.

I'm excited to be in an uncomfortable situation and remind myself that I did this, for the reasons that I did this.

So now, the only thing left is to DO this.

EDIT 9/13/09 4:10PM: I DID this. It was the most painful journey imaginable. But also the proudest.

The "Shoulds" and "Should Nots" of Awkwardness.

It might be said that my protocol for interacting with my environment is a tad rigid.
Perceive stimulus --> evaluate stimulus --> decide how stimulus "should" be --> rationalize/negotiate/strategize cognitive construct to make stimulus match intention. Translated as: "Reality is the way I say it is."

Most of the time, this serves me well. I decided I "should" be able to ride 100 miles on my bike -- so I rode 107 (just a few miles shy of the Canadian border) and am primed to ride 110 in 3 weeks. I decided I "should" be able to do a study on an obscure concept about which nobody admits to thinking about except me (even though it changes lives, and the potential to be applied to EVERYTHING), so I launched a survey that collected 230 responses from around the world. I decided I "should" be able to leg-press twice my body weight -- and, as of a week ago, I can. I decided I "should" be training at my fantasy clinic that I discovered in an obscure magazine article before I even interviewed for medical school -- so I, well, am. I decided I "should" spend tonight writing about my psychological strife instead of studying, despite having also spent the past 2 hours coaching people on a bike. Reality is the way I say it is, after all.

Yet. when I decide that I "should" be able to get through stressful life experiences without anxiety or any negative emotions -- any emotions at all, even -- this intention is not only unsuccessful but it's absurd. When I experience a response that departs from my intention, I expend a TON of energy to shut it down and control it -- forcing reality, in some way, to be as malleable as it is in 90% of my life circumstances.

So for the last few weeks, I've been trying to drop the word "should" from my vocabulary. As adaptive as it has been for some of the examples I've cited, its destructiveness has been way more profound. I "should" be useful at all times at the clinic, so as not to be perceived as a mooch off their energy and resources. I "should" feel more comfortable performing every single clinical examination I know about. I "should" sleep more, study more. Consternate less.

Instead, I've been making an effort to "accept" reality as it is -- not in spite of my intentions exactly; just independent of them. I'm not very good at this process. I "accept" that part, at least.

Last night, I was at the clinic really late seeing patients with my preceptor. Around 10PM, he announced that he had to go admit one of his patients to the hospital through the ED. I asked if I could accompany him. (See: creating opportunities). I told him that I had no legit hospital experience and that it made me anxious, and that I "should" get over this by exposing myself to it. He supported this plan. I think he's amused by my ready professions of what makes me anxious and what I intend to do about it. I think he's also quite perceptive about what makes me anxious. When I don't have a useful structure with which to organize incoming stimuli and/or I lack confidence about my abilities or decisions, these patterns quite predictably set me off. So he spent a half hour teaching me how to organize a hospital admissions note. He's so awesome.

So, 11:30PM. EVERYTHING about my arrival was awkward. It took me 5 attempts to park straight. I caught my stethescope in my car door. Upon entering the ED, I felt the wave of "awkward, useless, why am I here?!" wash over me. Yes, that wave. I timidly avoided interacting with human beings until my preceptor introduced me, lest I be faulted for draining attentional or oxygen resources me.

'I "should" not feel this way,' I thought. This is a great opportunity, and you are ruining it by being ridiculous. Stop it.

Then I remembered Operation: Acceptance.

Yes, I am anxious. Yes, I am awkward. It's ok to be awkward. This is the first time you're in this situation. You're fine.

My preceptor pulled up a CT scan of the patient we were here to see. 72 year old man with Stage 4 esophageal cancer -- which even a 2nd-year medical student knows is a really dismal thing. Though I often can't tell a heart from an intestine on CT, I knew exactly what I was looking at -- and it was bad. His esophagus had become completely obstructed by the tumor. Part of me felt confident that I knew what I was seeing; part of me felt guilty for possessing this knowledge.

We went in to see the patient. His frail, bony legs stuck out beneath his hospital gown. His sunken face looked up with indifference. "I can't keep food down, Doc. It comes right up."

That was the "real life" translation of what I had just seen on the computer screen. It aligned perfectly. I stood there, possessing knowledge that explained this man's world -- defined it, scripted it towards an ending that I could anticipate far more clearly than he could.

I gave myself permission to freeze and mindfully observe how I felt about this moment, a preview of so many moments just like it that are to come. Observing each sensation, without interpreting it. I was awkward and useless -- and whether that "should" have been or not was irrelevant. I was training to be right there in that moment -- that heavy, painful moment -- accepting every aspect of my reality.

And in that moment, reality was ok.

Power & Privilege

Drip. The septocaine dripped pristinely from my needle as it approached her shiny, pink flesh. I caught the drop with my gloved finger, then tightened my grip on the steel ring. Pulling back the patient's cheek pinched between my two fingers, I squinted one eye to verify the alignment of the most lethal thing I've ever held in my hand with the pterygomandibular raphe between her gum and her bone. Breathe. PLUNGE. Holy shit. I just injected a human being's jaw.

Yesterday, I injected a toe. The idea of sticking a needle into a human being -- having them trust you to literally seize control of a body part and insert a sharp object, introducing a dangerous substance into said body part -- is, on its face, absurd. Not as absurd as taking a pair of forceps, gripping a toenail, and peeling it off like an orange peel. But I did that, too. This somehow became my life.

Later in the day, I observed one of the PAs perform a physical exam on an adolescent girl. I contributed little; I was content to stand in the corner and observe a series of awkward interactions and then return to my regular scheduled programming of color-coded Excel spreadsheets. Suddenly, a voice interjected itself into my concentration.

"Sparky!" called a nurse (yes, that's what they call me at the clinic; and, yes, I answer to it). "Do you want me to do a vision test?"
"Huh?"
"A vision test. Like, with the eye chart. Do you want to order that for the patient you just saw?"

Order a test? Like, without consulting with someone else who's licensed to practice medicine or remotely knows what he or she is talking about? Am I even qualified to make this decision? No. Definitely not qualified. Wait. It's a vision test. Duh. You can totally decide to do a vision test. Why wouldn't you do a vision test? Why is this person even asking me? Oh shit. Because I'm a medical student; I'm a stand-in for a representative of medical decision-makers.

"Uh, sure, go ahead. Why not?"
"Ok, Sparky! Right away!"

WHAT?! Did that just happen? Yes, it did. And welcome to reality. This is how it's going to be: someone who knows a shit ton more than you about, well, EVERYTHING (i.e., a nurse) is going to look to default to your judgment just because you are en route to one day to a prescribed position of hierarchy. On its face, absurd -- just like peeling off a toenail. But this, too, somehow became my life.

I continue to spend a lot of time reflecting on the profound privilege, honor, and absurdity that is being trusted by people without expending any effort to earn it, apart from putting on a white coat. I didn't earn the trust of the two men who let me examine their testicles today. Or the woman who let me witness the unveiling of her painful, gnarly atrophic vaginitis. Or the guy who let me insert a lubed, gloved finger in his rectum. No, I did not earn any of that.

When it happens, I am always grateful. I thank people for their generosity in contributing to my education and development: I look them in the eye and tell them how much I appreciate the opportunity they afford me -- how I'm always so surprised at how generous people are, how I can never believe that anyone lets me do or see or learn half what I do all day. I rant and rave because a) these folks deserve to be thanked, and b) it's almost an act of earning trust/confidence in reverse order -- as in "See? I'm a good person! You let me do this absurd thing, and look how good a person I am -- you should feel great about your decision to let me do this absurd thing." In the end, it's the only effort I expend to earn their impression of me. I earn the warm and fuzzy smile I get next.

Today, a patient consented to let me observe the interview portion of her visit with a PA but not the exam. Totally understandable. I stood in the corner and tried to stay out of the way. I fixed my eyes on the woman, her pearl necklace and earrings in jarring contrast to her examination gown. In jarring contrast to her elegance, to her pride. I listened thoughtfully with my eyes. I smiled and nodded at appropriate intervals. She snuck sideways peeks at me.

"So when you said that you've had these symptoms for th..."
"Wait. When we get to the exam, she can stay," the patient interrupted. "I feel comfortable with her... you... now." She turned towards me and smiled.

It was a routine physical exam, with a routine pap smear. But it was one of the most memorable visits I've had the privilege to observe -- because I actually felt like I EARNED the opportunity to be there. When I thanked her afterwards, my words gushed with effusive gratitude.

"You're going to be a great doctor," she said.

I touched her shoulder on the way out of the room, knowing that this moment would touch my life forever.

Armed by this dose of validation and confidence later in the evening, I grabbed the chart of a patient who came to see my preceptor for a cough. Great. An acute problem. I am TOTALLY qualified to go in and take a history and do examinations of organ systems I've actually formally learn how to examine. Then I can come out and present to my preceptor and feel really great about myself. Yes. Good plan. Let's go.

I took a history, did a few basic exams, wrote up a pretty good note. Pseudo-awkward guy, a bit unfocused -- yet I found that I was able to reel him in, inject structure and chronology into his account, and connect with him about the context of his life. He's a cyclist: that was my hook. Just as I was about to go present the patient's case to my preceptor, he shot off a bunch of questions about the heart. What steps could he take to reduce his risk of heart disease? I totally could handle that but wanted to do it in the presence of my preceptor, so I validated his exercise habits and said that we'd talk about this more during the visit. Then he asked something about surveillance ultrasonography -- which I somehow, in that moment, felt more qualified to speak on. What?! So there I was, fielding his question which I have NO idea why on earth I felt comfortable fielding. Sure, I fielded it ambiguously and said we'd talk about it during the visit -- but responded with far greater detail than the diet/exercise (i.e., the things I know most about in the world) question. I gave him stuff to latch onto, stuff that overshadowed my "yeahhhhh, I'm just a medical student" disclaimer.

I left the room and presented the case to my preceptor, who praised me for my workup. Again, felt on top of the world.

We go back in, come up with a plan, wrap up the acute issue -- then I prompt the patient to raise his "heart questions." When he asks about cardiac risk prevention, I launch into an extensive discussion about fish oil, exercise, blah blah blah. Wonderful. Then he raises the ultrasonography question, and my preceptor's eyes widened. "Actually, there is no relationship between [insert EVERYTHING I said to this guy]." He continues by citing studies and important international bodies' positions on his question, distracting him from the fact that [insert EVERYTHING I said to this guy] was totally and utterly wrong.

Gulp. Breathe. Tongue on the roof of teeth, inhale (my new favorite trick, taught to me by my friend Shefali, to enforce diaphragmatic breaths). Exhale long. Breathing my heart rate down. It's ok. You didn't ruin anyone's life. You're allowed to sound like an idiot. Nobody expects you to NOT be an idiot. It's ok. Breathe.

Downside of the privilege of being trusted: Every word out of your mouth counts. If you don't have confidence in the words that leave your mouth, do not guess. If you think you know of a concept that is peripherally related to another concept, do not link them unless you have specifically seen them directly linked. I was mortified.

After my preceptor left, I apologized to the patient for misspeaking and thanked him for the prompt to learn something along with him. He told me it was no big deal. I then spent 30 minutes providing dietary consultation (we had referred him to a dietitian, and I doubted that he would ever go). I felt like I redeemed myself and re-earned the trust that I'd enjoyed before I decided I was a sonography expert.

I waited around an hour before my preceptor finished up with his last patient, so that I could apologize to him and assure him how careful I would be in the future. So that I could thank him for not embarrassing me in front of the patient, for finding a way to correct me without undermining my confidence.

He surfaced: "We need to talk."

Oh shit. This was worse than I thought. My whole relationship with this clinic was over. They trusted a first-year medical student to interact independently with their patients, and now look what happened. I failed. I disappointed them. I suck. How did I do that?! Why did I do that?!

I followed him to his office.
"I am so sorry..." I began.
"For what?"
"For misspeaking about the ultrasound. For disappointing you."
He laughed.
"That was so not a big deal. Come on, let's go meet about your project."

Crisis averted; lesson learned. Being trusted to answer a patient's question is the equivalent of being trusted to inject a potent, potentially lethal anesthetic into a patient's jaw. It requires just as much preparation and precision, assuming just as many risks. And when you do it right, just as many rewards.