Tuesday, February 24, 2009

So many symbols, so little time...

I don't exactly have time to write this post -- but if I let any more time pass, I'll be kicking myself.

A good friend of mine likes to call me out on my flagrant inability to tell worthwhile stories with punchlines and/or climaxes. I apparently never mastered the "beginning --> middle --> end" storytelling construct -- and, as it turns out, I don't see the world like that either. I see the world in fragments, meaningful and inspiring in their own right, and find a way to weave them all together through occasionally overly complex "life policies" and themes. I detect themes and symbolism wherever I go, especially when they don't really exist to anyone but me. (See also: the red blood cell "practicing commitment" to its career path).

Some might call it psychosis. Others, as it turns out, call it "narrative competence" and cite it as an essential part of taking good care of patients.

Today I read another great article by Rita Charon, M.D., Ph.D., founder of the narrative medicine movement, in which verbal or written narrative devices are used to provide both self-constructed and shared insights between patients and physicians. I've referenced Dr. Charon and narrative medicine in a previous posting, appreciating the mechanism by which the act of blogging truly does foster my clarity and focus as I process and cope with my training experiences. In the Feb 26 2004 New England Journal of Medicine, Dr. Charon writes:

A 36-year-old Dominican man with a chief symptom of back pain comes to see me for the first time. As his new internist, I tell him, I have to learn as much as I can about his health. Could he tell me whatever he thinks I should know about his situation? And then I do my best not to say a word, not to write in his chart, but to absorb all that he emits about his life and his health. I listen not only for the content of his narrative, but for its form — its temporal course, its images, its associated subplots, its silences, where he chooses to begin in telling of himself, how he sequences symptoms with other life events. I pay attention to the narrative’s performance — the patient’s gestures, expressions, body positions, tones of voice. After a few minutes, he stops talking and begins to weep. I ask him why he cries. He says, “No one has ever let me do this before.”
In the effort to help doctors understand what they and their patients experience in the presence
of illness, medical educators have been paying increasing attention to narrative competence, defined as the set of skills required to recognize, absorb, interpret, and be moved by the stories one hears or reads. This competence requires a combination of textual skills (identifying a story’s structure, adopting its multiple perspectives, recognizing metaphors and allusions), creative skills (imagining many interpretations, building curiosity, inventing multiple endings), and affective skills (tolerating uncertainty as a story unfolds, entering the story’s mood). Together, these capacities endow a reader or listener with the wherewithal to get the news from stories and to begin to understand their meanings.

I spend a LOT of time thinking about this, as it were. It makes sense. It is completely consistent with how I see the world, and completely consistent with how I interact with people who depend upon me in a non-medical context (i.e., the cyclists I coach). "Theme abstraction" impresses the hell out of me when I see it -- both because it's exceptional and out of the ordinary for a stranger to do, and because simple social psychological theory indeed dictates that we are drawn to "like" qualities and traits that are most "like" ourselves. I'm a theme-abstracter. Lo and behold, I ranted and raved a few weeks ago about my advisor spontaneously abstracting themes about my learning style. And come to think of it, the one doctor who has ever cared for me whom I've really really liked -- what I liked about her most of all was that she really DID actively attempt to piece together the story of my life.

By and large, doctors do NOT do this -- don't see the value in it. Takes too long. Is "irrelevant." Is "crazy." In my professional experiences to date, I've seen this a gazillion times -- that self-awareness is perceived to reflect psychiatric illness, specifically a mood or anxiety disorder. I've always thought that was bullshit. When my research patients have had lists of medications and chronology of symptoms and procedures, I've been tremendously impressed! What discipline it takes to encode one's world on an 3x5 index card. What self-awareness it takes to find one's own mechanism of control in a world of medical chaos. Those under whom I've trained never seemed to agree -- and I've learned from observing those perceptions and misperceptions enough to influence how I behave as a patient myself. I have to go see a new gastroenterologist soon-ish (sooner than soon-ish?)-- and, in so doing, will remind myself, first-hand, of how much of a burden it is to tell one's story from the beginning -- to capture all of the details, and to put them in context. And to do so while maintaining good impression-management skills. My story's not complicated. It's dressed up and ready to go, with all its bows and ribbons and "life policies." It'd be super-efficient to write down all the relevant dates and symptoms and associations -- and yet, that appears "crazy" and will compromise the receptiveness of my new audience (i.e., this person to whom I am entrusting my health). Nobody knows my story better than me. I have an exceptional mastery of the details -- details that I know, professionally, are important. I have themes and lessons to make sense of all the medical "fragments" I've lived through. And I know how to tell them well. Yet, if I tell it to the best of my ability, I would be categorized as "crazy." So I'll have to give a mediocre history and play along with this pathetic set of expectations.

I'm lucky. I'm being trained in a way that is consistent with MY values. For my Medical Student Leadership Group course today, our theme was Narrative Medicine. The idea was to go over to the hospital and randomly chat with patients -- just giving them a safe space to tell their stories, knowing that we'd learn something from whatever they spontaneously shared. The two men with whom I visited really DID love to talk. They liked the idea of serving as a resource for a doctor-in-training. They talked about their families, and how tedious it was to be in the hospital. Nothing tremendously insightful... except for the fact that the whole experience, for which I'd been incredibly excited, was SO awkward. Why? Because there I was, in my new white coat, imposing myself into a human being's world and asking for their story. It felt weird because it was clearly perceived (by the patient) as weird -- because "people in white coats" by and large do not ask for stories. They don't want to hear about how you rode a motorcycle 40 years ago and think about it, now that you have two artificial hips. They don't want to hear about where you took your grandkids on their summer vacation the year prior. The fact that "someone in a white coat" asked about these things and was experienced as AWKWARD... how telling that is.

Wearing my white coat for the first time around real patients was SUCH a big deal to me. I felt self-conscious. I looked the part fo' sure -- but on one level, I worried about being misperceived as actually having legit knowledge to match the expectations of the "look" I was pulling off. I was wearing the right things to gain "access" to this special world -- but VERY mindful of how much I didn't belong. (My understanding is that EVERYONE feels like this for a very long time. I'm okay with it.)

On another level, I was able to appreciate that nobody thought I knew anything -- which was good, because I didn't. Not really, anyway. A lot of my colleagues rant frequently about how little we know. We actually know a whole lot, which is crazy in and of itself. The way I make sense of it to myself is that we're at the point where we know and recognize a lot of really useful, complicated things -- but don't actually know what to DO about any of it. I'm always shocked, though, when I see something and know what it is. Little things: the chapped corners of the mouth of the woman with whom I visited when I shadowed the hospital chaplain, the clubbed fingers of the man I saw when I rounded with the chairman of Medicine earlier in the Fall, a random reference in a lecture that I really SHOULDN'T "get" but somehow do, a complicated article in the New York Times today on the precise mechanisms of anti-flu drugs. I know a lot of stuff that I NEVER thought I'd know a few months ago. That's a big deal to me, too.

After our patient visits, my colleagues and I walked together in a pack through the long corridor back to the medical school. I caught a glimpse of our reflections in the glass. My eyes misted a bit. This was actually my life. Walking in a pack of white coats, "belonging" there... without fully belonging.

During my White Coat Ceremony on Friday, our keynote speaker spoke of how just putting on the coat wasn't going to necessarily be this life-altering moment -- not to expect that of it. That it's just a symbol to mark this next chapter of our lives, the responsibility we are coming to embrace -- and that it will forever be a part of our identities. That, even if we don't wear it while around patients, that we'll never take it off. I bought that. But when I returned to my seat after being cloaked on stage in front of over 700 people, I really did feel like an entirely different person.

The powerful sense of responsibility, of commitment to my goals -- to myself, to the people who believe in me, to my future patients. It enveloped me. Shook me. My core heated up fast. My eyes perceived the soft glow of a migraine aura. My eyes burned with tears. This was my life. I wanted to scream and cheer and... sob. But I didn't even dare whisper to my classmate beside me, "This really feels different." I was just so sure that I didn't see this response matched, externally at least, by anyone around me. I felt almost isolated in my joining my new community, even if just for a few minutes. Isolated by my consumption with this symbol, with my insistence on abstracting themes and "moments" and requirements that everything that happens means SOMETHING.

But it was that isolation that allowed me a moment of solitude in a room of 700+ people. Clarity amidst unchanneled energy.

By the time I stood with my colleagues to take our oath, I felt empowered. Invigorated. Inspired by a genuine belief that I was going to be awesome at "this." Where "this" was my life.

Saturday, February 14, 2009

"Practicing Commitment" -- Part I

During my exam cram-induced nuttiness this week, I started to identify with a red blood cell.

I suppose I should explain: Hematopoetic stem cells start off with the potential to become ANY kind of blood cell; then, over time, they are exposed to various influences (i.e., chemical signals) to help it a) not die; and b) determine what kind of blood cell it's going to be. Now, as it continues down its given path, it becomes more and more committed to its final destination (i.e., less potential to become other things -- it has to be this kind of cell, no matter what, and it's going to be AWESOME at it. That's pretty much where I stop identifying. A red blood cell dies after 120 days; I've got way too many student loans for that to be the end of the road.

Hematopoeisis (see also: the process I just described) was the first lecture of "Attacks & Defenses," the course I finished yesterday: six weeks jam-packed with bugs, drugs, and the most stimulating and rewarding moments of medical school to date. Looking back, I cannot imagine a more fitting kickoff to set the tone for the course. One of my course director's explicit themes had been that of "practicing commitment" -- working from a broad-based differential diagnosis and then chiseling away at it in a deliberate, systematic way to figure out what's wrong; and upon making those decisions, based on evidence, to develop the confidence to hang your figurative hat on it. Committing to it. Owning it. Inhabiting it.

As an aside, I made this observation about the red blood cell "practicing commitment" as a reflection of the A&D theme to my course director. He was thoroughly amused that I'd given him credit for that sort of symbolic orchestration.

The past six weeks, for me, have been a period of major definition and re-definition. Coming off a refreshing and insightful 13-day trip to My Former Life, prompting a re-commitment to the things I decided were important, I suddenly found myself at this position of wide-open road -- where all of the things I'd say would "be" just... happened. Just because I said they'd happen, they'd happen. In the past six weeks alone, CRAZY things have happened: I launched my dream small group/personal cycling training program. I found really, really smart people to support my "pipe dream" heart rate monitor study. I connected with those insanely inspiring folks at The Health Center, my most idealized place on earth. I breathed a new life into my Spinning classes, and finally found a nice balance where I can coach here the way I coached in New York. I invested in my own training again, losing 10 lbs. and very much on track for my Century in a few months. I became a "real driver" (working definition = "not having panic attacks on the Interstate and being able to pull into a parking lot without crying"). I started making time to sleep, to cook, to date. To write.

And daaaaaaaaaamn, did I learn a lot.

The crazy thing is, I have a feeling that I'm actually going to remember most of what I learned in this course. It's still not rocket science; it's still volume. But the difference is that my brain finally figured out how to process and prioritize, and to store things usefully within an efficient framework. Too bad for those 1200 nerves and arteries and random holes in the head and neck; I just wasn't ready for them then. The other day during a practice clinical session with a standardized patient, I was shocked at how readily I had mild- to moderately intelligent thoughts and questions about the symptoms with which he was presenting. I felt the same way on the phone with my own grandmother today. It's surreal to actually KNOW stuff, even if it's a miniscule amount of stuff in the big scheme of things.

Just like that stem cell differentiating along its path, I'm exquisitely sensitive to the influences around me. As I accumulate more and more influences, both global and narrow in scope, I find myself latching onto specific things I decide I'm supposed to take away from my experiences. My advisor, for example -- a fantastically brilliant guy who makes the most astute, insightful observations about me even having only met me twice -- whose framework appears to be identifying the specific strategies my brain employs to get its job done. Being prompted to appreciate this, it occurs to me that I should pay closer attention to those strategies for optimal learning. Meta-learning: I dig it. Or, my course director, who so effectively imparted his "life approach" to think broadly and with sharply deliberate structure. Or, one of my closest friends who, despite months apart, is so damned good at abstracting general "life concept" themes from the minute details of my stories -- just like the key to success in A&D had been to abstract general themes about B cells and T cells and the duplicitous agents that test them.

Years ago, when most of my waking hours were spent at TFP, it was tricky to evaluate the relative meanings of the things that happened to me: everything was novel, everything was dramatic. There were no norms by which to measure anything against. I credit my former boss with so many of the adaptive coping mechanisms and skills I developed then, whether by good example or by necessity of avoidance. Why I detach so easily from the things that displease me. Why I'm so good at getting people excited about utterly unexciting things. But I also credit him with some of my worst habits: namely, getting so damned excited about so many things -- to the end of distracting myself from actually doing any of them. How many times did he speak of having "too many jealous masters," committing with both words and spirit to a gazillion different projects and causes, and following through with so few? How many people did he disappoint?

How guilty have I been, over time, of doing the same? Things I've really, really, REALLY cared about -- all the "best things ever"... until the next "best thing ever."

Not in 2009. 2009 is the year of committment. Committment to the specific passions I deem to be meaningful and compelling, actively carving out a clear path to get there. Rejection of the "noise" that distracts from them.

It has taken the better part of the past three years to no longer identify with the influences of TFP. I'm wired to be defined by my work, though, and have been so deeply fortunate that my life path has taken me where it has -- because my work as a coach is what most directly influences me now. Being prompted, or forced, to abstract my own take-home points, to structure experiences for other people to get them to arrive at the kinds of thoughtful questions they need to ask themselves, has been life-altering. Of all the talking I do about self-efficacy, nothing has more greatly contributed to my own than the experience of facilitating others' beliefs in their power to navigate the challenges of their own road.

I talk often about the dichotomy between coaching and training to be a physician -- how I struggle with compartmentalizing (take the two separate blogs, for example!), prioritizing where and how I invest my energy at different times. What has been interesting about the past six weeks, though, is that this is somehow ceased to be an issue. It's all the same.

We had a lecture last week on "Spirituality in Medicine," perfectly fitting after my experience last week shadowing the chaplain at the hospital. The epiphany I had during that lecture is thus:
Spirtuality IS self-efficacy. Empowerment, believing in one's self, appreciating one's place in the world and how to make sense of it all. The stuff I talk about all day long -- the concepts I try so hard to bring alive to my riders, the concepts I dream of bringing alive to my future patients. It's all the same. It's a commitment to one's self, to the things one holds important.

To being the best damned (blood cell) one can be, whichever path life's influences direct one to take.

Friday, February 6, 2009

Spiritual Care

For part of our Medical Student Leadership Group course, we were sent off in pairs to shadow the spiritual care team of our affiliate hospital – ministers, chaplains, priests, rabbis, etc. When our course director (one of my favorite med school characters!) gave a talk to my class introducing the Spiritual Care Team shadowing experience, I remember this warm and gushy feeling – an appreciation that the holistic care ideal that is cited amongst a list of priorities in my curriculum was actually real. Even before formally getting to see a patient for “medical care purposes” as a student, I’d have this opportunity to enter what is arguably MORE intimate sphere of existence for a human being. That’s a huge deal. I’ve never talked about my spirituality or general life philosophy with any doctor; I don’t think I’ve even had those kinds of dialogues with my family. I write publicly about my way of seeing the world (through my blog that has strangely come to be read and commented on by people I’ve never met) – at least the “private” thoughts associated with sufficient comfort and relevance to share, and the “spirituality” component of those thoughts is marginal. But, as I saw it, I’ve never shared with another human being the content of the conversations I imagined being privy to through this experience. It was huge.

Over the past few months, my classmates who have had their shadowing experiences already have vocalized sub-ideal experiences. I was able to write off many of their specific gripes as clearly non-applicable to me (“feeling awkward about praying” – big deal; suck it up and learn from the experience; or, “not getting to do anything” – listening to someone talk about their lives through the lens of their healthcare has yet to lose its novelty for me). But still, friends of mine cautioned me to stop hyping up the experience (as I hype up many experiences, and come to learn that expecting the “best thing ever in the whole world” is almost always going to result in sub-“best thing ever in the whole world” – even experiences that are very positive.
Expectations management is key.

At 4:30 today, my shadowing partner and I arrived at our designated spot to meet the chaplain with whom we’d be tagging along. Nobody was there. 5 minutes pass. 10 minutes. 15. Coping mechanisms kicked in: I wasn’t excited for this, I told myself. It wasn’t going to be that influential. It wasn’t a big deal. Whatever “take-home points” there were going to be – I already knew them. I could go home early. Yeah. That.

Down the hall shuffled a white-haired woman, a cross dangling upon her chest, clipboard in hand. “Was I supposed to have students today?” she asked, her face reddening. “I didn’t prepare anything!”

We assured her that we hadn’t been waiting long – that she didn’t need to do anything special, that we just wanted to soak up whatever we could from whatever she was going to do this particular afternoon. She told us, repeatedly, how embarrassed she felt – but before long, she began to appreciate that we were legitimately as open-minded and “expectation-less” as we said we were.

There had been two consults called in that day. The chaplain would visit them and ask if she could bring in us medical students to observe.

Then, it became real. This was really going to happen. With no conscious effort, I readjusted my expectations. I had specific goals I wanted to get out of this: 1) see ways in which people express their need to discuss their spiritual wellness; 2) see how a spiritual minister contributes, if at all, to a person’s awareness of those needs, if they’ve not yet surfaced; 3) ask questions, later, of this chaplain about these two priorities if I’ve not been able to observe these things myself. Modest, reasonable, specific. Perfect.

We went to see the first woman, a congestive heart failure patient, who graciously accepted us all into her room. As my colleague and I stepped into the room, I met by a forceful gush of odor. The odor of sickness. I paused, accepted its presence, and continued to enter – mindful of control over even the slightest crinkle of my nose. This was my life now. I stepped closer.

V. looked about 95 years old – though I’m absolutely useless at age-estimation. She looked frail, almost wasting away beneath the hospital sheets. Her lips were parsed, corners of her mouth crusty. Iron-deficiency anemia, I thought to myself. Her fingers were clubbed. I remembered being taught that you can detect lung problems, among other things, that way.

As V. spoke to us, it seemed difficult for her to get her words out. Her breathing was not labored but there was something very strained about it. I felt strained imagining what it would be like to not be able to communicate fluidly. She told us about her family, about her church – it was clear that her church was a key influence in her life, that she derived a sense of purpose from belonging to that particular group. I don’t relate to that myself. People in my life whom I know do experience that relationship haven’t elaborated on it for me; I’ve never asked. I made a mental note to explore this further with a non-stranger so that, when no longer in the role of a passive observer, I’d be able to be more effective.

Before we left, the chaplain asked V. if she wanted her to pray. The chaplain laid her hands over V’s clubbed, bent fingers. Her prayer contained both deliberately religious and non-religious, spiritual themes – energy, intention. I saw the corners of V’s closed eyes lift up, her cracked lips hopeful. She was peaceful.

My eyes watered. I felt guilty that I was so affected, knowing how many times I would be moved to moisture in this hospital.

I realized that I no longer noticed the smell in the room.

Our next patient was likely in her early 60s, recovering from a post-surgical infection. Her husband sat by her side. He looked more tired than she did, as he detailed the chronology of events leading to her infection. My classmate and I looked at one another knowingly – we both so desperately wanted to know what microbe had infected her, what drugs she’d been on, and then go rehearse their mechanisms of action and known toxicities – and were self-amused at our mutual appreciation for how inappropriate that would be. We stood silently.

The chaplain, intent to make specific teaching points, asked the woman whether there were any “lessons” she’d want budding physicians in training to know about. As the woman responded, the chaplain “summarized” the teaching point (totally unnecessary) – and I wondered whether this couple felt empowered to know that they were teaching us and serving as tremendous resources, which is how I justified the awkwardness the chaplain was imposing – that maybe it wasn’t awkward, maybe it was an effective device. I don’t think it would have been effective for me in the patient’s role – but I appreciated that everyone has different things that appeal to them. As the woman shared specific encounters, the chaplain pared it down to a single-word, rote adjective: “compassionate,” “caring.” The couple echoed the words, and agreed with the cursory paraphrase. I just wanted to hear them talk forever without being pared down to a list of adjectives that in no way add up to the sum of the original details. I appreciated the comparison to the lame, bare-bones notes I’d taken on yesterday’s lectures. Irony.

It was then time to pray. The chaplain took the patient’s hand, who took her husband’s hand. Instinctively, I reached down for his hand – hoping that I wasn’t violating any “rules” as a passive observer -- and my classmate’s on the other side. He completed the circle. I felt like I was a part of something bigger, a moment that would be with this person for a long time – she seemed like the kind of person for whom an experience being prayed for by the hospital chaplain in the “big city” would be a big deal. I didn’t relate to that, but appreciated it was a privilege to witness this woman's experience. As similar themes of energy and hope and balance were added to the circle through the chaplain’s words, I watched the woman’s face – her rosy cheeks lifted in a hopeful plea, the corners of her eyes similarly lifted with delight. Her lips were parted, and I saw her mouthing the same phrase over and over after each line of prayer.

Thank you.”

My eyes got watery again. But this time, I didn’t feel guilty.

Wednesday, February 4, 2009

Living the Dream...

I just had a life-alteringly amazing "life moment," set up by a series of life-alteringly amazing events composed of life-alteringly amazing subtleties. How could I not write?

Even as a toddler, I remember being told that I can be and do anything I want. As far as empowering, supportive parents, I have the best. Over time, of course, realism did rear its ugly head; no, I can't be a professional figure skater; no, I can't be a game show host; no, I can't be the princess of a country I invented. But also over time did I get pretty darned good at finding "that point" just the other side of the realism line -- that was just enough unrealistic to be qualified as a pipe dream but close enough to actually do. Wouldn't it be cool to quit your job and teach Spinning all day? Wouldn't it be great to just DECIDE that your greatest life weaknesses just... wouldn't exist anymore? Wouldn't it be sweet to become a doctor, despite having taken no science courses ever?

Fast-forward. November 3, 2007. It's three nights before my UVM admissions interview, and I'm prepping like the all-star interviewer I am. I decide that, since the majority of Vermont is rural and I the New York urbanite know absolutely nothing about rural medicine, it's pretty unacceptable for me to NOT change that before I showed up. That night, I reviewed probably 50-something articles, commission reports, governmental policies, etc. that came to bear on rural healthcare in Vermont -- I couldn't get enough. I read one article three times. A Dec. 2006 piece in Vermont Business Quarterly about a clinic started by a Vermont physician, who trained somewhere fancy but decided it would be his life goal to set up an interdisciplinary center in the middle of rural Vermont that would be the go-to place for everyone's needs. He had NOTHING -- but brought all these people and resources together and just DID it. It was the best thing I'd ever read, ever. And I decided that I simply needed to be accepted to the University of Vermont so that I could somehow go meet this guy and learn from whatever enabled him to accomplish this ridiculously amazing feat.

I didn't tell my interviewer this. But I did tell him that I absolutely couldn't train anywhere else, that it had to be here - that it was an absolutely perfect fit, and how I've never been more excited about anything ever in life. Bouncing out of my seat and talking at the speed of sound probably lent some authenticity to that representation.

January 3, 2008: I get in. I'd learned about a program for first-year med student at UVM called "Doctoring in Vermont" - wherein you get assigned to a primary care preceptor and shadow him or her and start to interview and examine patients under supervision. Perfect. I'd write this guy, tell him how awesome I think he is, and get out there. Did it matter that the clinic was an hour away and I didn't REALLY know how to drive? Nah.

Except I never wrote. Fearing rejection, I was simply too intimidated to write. I figured that I'd get assigned somewhere random -- somewhere closeby, no less -- and that any clinical experiences was going to be good experience, and that was that.

January 2009: I go hear a talk from an organization that, among other important activities I don't actually know about, funds medical students to help healthcare organizations with research/public health projects. One of the projects listed? Outcomes assessment (my pet research area) to reduce drug interactions at... this clinic. No way.

After several effusive emails, I get hooked up with the medical director. Super-nice guy. I effusively rant that I'm stoked about this project, that it's right up my alley, and I'd love to spend all my free time with him and his colleagues and soak up whatever I can. He's probably amused by the anxious overeagerness of a first-year medical student. But he tells me that I can carve out whatever experience I'm looking for, and they'd love to have me -- and will even put me up at a house they own nearby.

I skipped school today to drive out there. 45 mins on I-89, my former arch nemesis, and about a 10 minute drive through completely wide-open space. This marked the first time that I was so comfortable on the interstate. I was rockin' out, cruisin' along, changing lanes up the wazzoo... with NO panic attacks. I was even able to employ my peripheral vision to enjoy the absolutely breathtaking views (previously UNHEARD of! I NEVER turn my head even for 0.5 seconds when I'm driving or biking... I don't have the motor skills). The whole time thinking, "Daaaaaaaaaamn. I'm really going to this place." This place that I "simply had to be."

I was a little bit early and was famished, so I stopped at a local general store to pick up some nuts or something. My first-ever general store experience. The store clerk was very plain-looking; no smile. I said hello and smiled, and she reacted awkwardly. I felt uneasy -- as though it became quite clear that I did not belong in rural Vermont. I'd planned for this: dark colors, as plain as can be, right on that line of "business casual but I can't tell if you're dressed up." No makeup. But it wasn't my look; my energy level was what set me out of bounds, it became clear. Note to self: tone it down.

I get there and the doc I'm supposed to meet isn't there yet. An administrative assistant takes me around - introduces me to a few PAs and one of the other doctors. Doctor says, "Hey, want to come see a patient with me?" WHAT? I clarify what my purpose there is - that I don't actually know anything, and that I will be in no way useful to her.
"Nah, don't worry, just sit quietly in the corner and observe. Come on."
UM, WHAT? Best thing ever? Yes. Couldn't believe this was happening.

We saw an 70-something year old woman. I knew nothing about her going in, so I just tried to pick up what I could from the conversation. They discussed her meds -- and I actually knew what they were. They were things I'd actually learned about, even from that heinous biochemistry course I took. Allopurinol for gout. Warfarin as an anti-coagulant (made a mental note to self to wonder what her diet was like). I scribbled down any drugs I didn't know, made a mental note to look them up later. Scribbled down a reasonably intelligent question I'd eventually ask the doctor. The woman was trying to quit smoking, tried everything. Seemed to be setting back every time she was stressed; hadn't developed any alternative coping mechanisms over her 60 years as a smoker. What impressed me most was how on top of her medications and their effects she was -- and it turns out, that's because it's an actual center-wide policy to train their patients to be that way. They have med cards that need to get filled out and reviewed. One aspect of my summer project is going to be to optimize this. More later. Anyway, shocked at how much I recognized. Shocked at how comfortable I felt. One tricky issue was setting a life policy that I would NOT speak -- that my role was to quietly sit in the corner. This was hard when this lovely woman made any self-deprecating comments about her inability to quit smoking. I so very much wanted to encourage her on her progress thus far and reassure her when she said something over-the-top. The physician I was observing was very empathetic and supportive, but her style was not as interventional as I would have been. So nobody counteracted these self-deprecating comments, and I felt awkward NOT saying anything -- yet hadn't been given permission to actually speak. But this was so unofficial; when I'm observing for real, I'll know to clarify the talk vs. silence issue in advance.

So I come out of the exam room. The medical director had arrived. I cannot describe him other than the coolest human being I've ever met. So laid-back. Just so AWESOME. Right away, tells me all about this project and how it relates to the clinic's impressive outcomes in challenging areas, things that I had actually already just seen in practice in the exam room. He offers to get me hooked up and funded to go to a conference on this topic, tells me I can do anything in the world I want, validates an idea I had to incorporate (integrating my interest in measuring dietary awareness as it relates to drug interactions), gives me a tour (imagine? He didn't even have time for lunch, but walked me all around and introduced me to everyone). Physical therapists, dietitians, neuropsychologists swarming -- and he tells me I can hang out with all of them whenever I want. Offers to be my "Doctoring in Vermont" preceptor so I can start hanging out next month, instead of the summer. What?! AMAZING.

Our conversation is interrupted by the doctor whom I had just observed, now initiating a discussion of a difficult patient. I am then treated to a serious discussion of what to do about the drug-seeking behavior of an abusive patient, and the legal ramifications. Just like that.

"What do you want to do with your summer?" he asks.
I have no idea. I'm so overwhelmed by the sheer volume of opportunities afforded to me just by having access to this one place. I tell him this. He smiles and says that this is a great thing.

He then took me in to attend his staff meeting, where all the doctors and PAs discussed challenging cases of the day. Including That Guy who inspired me to uproot my whole life and move to Vermont on the random chance I could get to meet him.

I see, right then, why this place is so amazing. It's little mini-consults like the narcotics abuser. It's practice-wide consults. Bringing really brilliant people all together to brainstorm. It's systematic quality control by communication. At the end of the meeting, That Guy circulates about 25 different articles on recent research -- they do this weekly, to ensure that even in their rural isolation, they're on top of what's going on in academia. Again, quality control by communication.

Couldn't believe I was sitting in a meeting with all these awesome people talking about such awesome things. Couldn't believe this was my life.

I get back in the car. Sunglasses on, beautifully gorgeous sun shining - warming my face through the windshield. Coincidentally, the song I most associate with "empowerment" cued up on my stereo. I break onto I-89. I'm tearful. This is my life.

What that moment was, right there, was an appreciation of how utterly limitless "what I'm going to be" really is. That "what do you want to do with your summer?" question really was "what do you want to do with your life?" Because like that toddler version of myself was told, I actually in fact really can do ANYTHING. That's huge. I'm tied to nothing. Absolutely nothing. I'm in this completely new world, with a completely new sub-culture, and there's absolutely nothing interfering with my ability to immerse myself COMPLETELY in it and try it on for size.

Is it important to me to avoid being tied to something? No. I've always been able to make time for the things I want to make time for. Is it convenient that I don't have a person, place, or thing committing me to any particular life course? Absolutely. I've been spending time with a new character lately -- and, to be honest, it's refreshing to approach the acquaintance-making with a breath of detachment.

I thought about something pseudo-cheesy (but pretty awesome when I got the dramatic timing down with the music... which honestly was only really one time) I said during my New Year's Eve ride. During the start of the third climb, I asked my class to give themselves permission to dream -- what do they want more of? What do they want less of? What would they do if they knew they could not fail? I actually need to start thinking about that. I can hang out with these people and haphazardly "soak up" things -- but how much more effective would it be if I had specific things I wanted to see and learn about? How much more focused could my efforts be to collect the data I need to decide what I want to do and where I want to be?

I was behind a huge-ass FedEx truck, going too slow to not obstruct my view but going too fast to safely pass. I tried several times but really couldn't justify going fast enough to pass him, as the interstate was quite winding. In the left lane, I couldn't do more than to ride on-pace with him -- and when I did, I caught up in the truck's shadow (the sun was at the perfect angle to get obstructed). Not exactly claustrophobia but it's the word that comes to mind. I trailed behind and returned to my awful spot behind him in the right lane. Tried again. Same outcome.

Third time's a charm. Straight stretch -- visualize it, accelerate, NAIL it.

Wide open road ahead...

Tuesday, February 3, 2009


Is there such a thing as "too much information?" I've been asking myself this question for a week now (and, on some level, for the past six months), and decided that it was time to write about it.

The other night, a friend of mine told me that the physician for whom she works came out of a examination room exclaiming, "TMI!" -- presumably after hearing some kind of uber-personal story from his gastrointestinally afflicted patient. My friend felt embarrassed because she'd never heard the expression before ("Too Much Information"), and thus didn't recognize it. It was clear to me that one reason she'd never heard the expression is because, for this friend (and for me), the concept just doesn't exist.

I can't remember a time, both in my personal and professional life, that I've ever been put-off by a human being's personal disclosure about something intensely intimate, awkward, or "disturbing." In contrast, I experience these moments as tremendously rewarding -- the privilege of being trusted with the intimate details of a person's life, the profoundness and depth of the responsibility that comes along with it. It's a huge deal to me. When it happens, I'm very mindful of its significance -- even if that significance is not attached by the disclosing party -- every single time it happens, and it ALWAYS surprises me: a casual acquaintance, a research patient, a Spinning student. It's always special.

This isn't necessarily a great quality of mine, actually. Part of my appreciation for the "specialness" of those moments is that, admittedly, there's a layer of grandiosity that reflects that I actually DID something to earn that trust. Maybe I did -- but, mostly, I didn't. Sometimes people just have something to get off their chests, and I happened to be standing in front of them when they needed to air their thoughts. And, actually, when I am QUITE certain that I absolutely, definitively did NOT do anything to earn someone's confidence, I don't feel so rewarded. Do I gasp "TMI!" -- of course not. I'm still not off-put. But do I feel warm, fuzzy and proud of my listening and confidence-inspiring skills? Absolutely not.

There's a fine line already, and it's going to get tricker to distinguish. I've written a lot already about the very strange, unnatural "access" to people afforded to me by my status as a medical student (which will drastically increase in two weeks when I officially am awarded my white coat). I accept that, even more so, people are going to want to tell me stuff. Am I afraid that the sheer frequency of these events are going to in some way kill the novelty? No, actually. People have been telling me stuff for the past 25 years, and it hasn't gotten old yet. But SOMETHING will be different. How can it not be? So I'm giving some loose thoughts to exactly what that "something" might be, is all...

Not all disclosures carry with them an attempt for a solution. Sometimes people just want to vent. One of my character flaws that I've spent a lot of effort working on over the past few years is that I inappropriately pose potential solutions within contexts that did not seek them. I had an old boyfriend who used to call me out on it a lot: "I'm not telling you this because I want you to do anything about it. I'm just telling you for the sake of telling you!" I didn't get good at shutting down that default interpersonal style until I started coaching, actually. When I wear my "coach hat," I primarily ask questions designed to help an athlete use his (or her) OWN mind clearly -- to arrive at his own questions, even. The way I see it, people arrive at their own solutions when they ask themselves the right questions. So that's what my questions are designed to do. When I take my coach hat off, though, I don't always carry myself the same way -- and I should!

But when I wear that coat, the context is going to change. The expectations are going to change. More often than not, disclosures will come attached with a pursuit of resolution. At first, I'm going to have maybe a 0.05% improvement over my lay abilities to be helpful to a person. My white coat would reflect otherwise -- but at the end of the day, there will be absolutely no difference in my knowledge base between February 19 and February 20 (White Coat Ceremony).

The intensity of those disclosures may also change. Up until now, "confidentiality" has been an implicit value. When I have that coat on, it's a legally binding value. What impact will that have? I don't know. There have been plenty of times when I was not so moved to disclose even medically relevant details to my physicians, simply because I didn't "feel" it. Assurance of confidentiality has played almost a 0% role in those decisions of mine. The implicit values -- lack of judgment (my top concern!), skewed interpretation, general approval-seeking -- have carried the day, for me at least.

Approval-seeking behavior is the value I think about the most. I've absolutely withheld details from my doctors over time, particularly when those details were really damned relevant and I knew better. How am I going to tease that apart from the other end? No matter how non-judgmental I can convey that I am, that's always going to be an issue of which to be mindful.
To some level, that white coat is a burden. People don't try to please me now; they're honest. "It is what it is" -- unless you're wearing a white coat.

Everything I've said thus far would reflect an unconditional belief that there is no such thing as "too much information," independent of source or purpose or context.

But that's not actually how I see it.

Now, this blog is not supposed to require disclaimers, I now appreciate that there are a lot of people who actually read this (even people whom I've never met, which is incredibly humbling and worth the occasional mindfulness of my audience-less reflections actually having an audience). But alas, a disclaimer: what I'm about to say is going to sound AWFUL.

One of the most profound shifts since commencing my medical education is what I call an acceptance of mediocrity. My first 1.5 years of training are graded on a Pass/Fail/Pass with Honors scale. What that means is that a 75 is the equivalent of a 92. Except that guy with the 92 GPA isn't teaching 4 Spinning classes a week, reading for pleasure every night, maintaining two blogs, exercising, cooking, or spending hooooooooooooooooours investing in her interpersonal relationships. And I am.

Adopting a "bare minimum" mentality actually requires a lot of self-discipline -- and I will go so far as to argue that it requires MORE self-discipline, in that it requires a deliberate suppression of one's curiosity. By aiming to know big picture concepts that can be practically applied to clinical situations upon recognition of key starting frameworks -- and to learn how to go about looking up all the details in between when they're needed, as they're needed -- you are essentially disciplining yourself to not learn as deeply and thoroughly as you've ever learned before... or ever imagined yourself learning. Today, for example, I had two hours of lecture on hypersensitivity/allergy. Totally dig it. Had relatively intelligent questions beyond the scope of the lecture... Googled what I could, but then deliberately didn't take it to the next level of asking the lecturer. I know that my brain needs priorities. And this wasn't one of them. Big picture = PASS + maintain mental clarity and perspective.

The difference, I think, is that here "bare minimum" is actually a RIDICULOUS volume of specific content. It's just, obviously, not everything that one could ever learn. How could it be? So "slackerdom" equates with an insane amount of learning. But am I mindful of how purposefully non-inquisitive I am? Absolutely. Does it bother me? Sometimes it kind-of does.

Even "too much information" isn't enough information. It's just a question of what's worth-it. Input vs. output. Expected payoff, predicted on the basis of something you don't actually know anything about. Everything's a gamble...