Thursday, March 26, 2009

Champion of the Subclinical?

Ask any pre-med why they want to be a doctor, and they hate you. If you ask a pre-med whether that's true and he denies it, he is lying. EVERYONE hates that question. Why? The med school admissions process conditions it. It's the most obvious question in the world that, through one's application/interview process, one is forbidden to answer honestly. One is forbidden to say all sorts of basic, common, wonderful things: "I want to help people," "I want to care for sick people," "I want to make a difference." All of that is perceived by admissions committees as bullshit and, if you say it, you get shot down from accomplishing your dreams. Instead, you get creative. You talk about intellectual challenges, opportunities to tap into unmet needs, to embrace psychosocial challenges, etc. You're not bullshitting at all, even though it sounds like you are. And you hate that you're forced to sound more fake than your real answer. Once you get accepted, you can technically start admitting that you want to help people... except the problem is that your old answers, your new answers, your answers in between -- somehow they're not good enough. This is real now. Why, really, are you here?

I've decided to start being more honest with myself about the "WHY" of what I want to do with my life. It's the "why" that keeps people on a stationary bike for hours, as it should be in life. That's what I tell people at least.

Lots of smart people in my life have told me that the way to really make an effective impact on the world is to carve out a niche -- a niche that many define as something unique and interesting, specifically that few people are doing. I conceptualize a niche slightly differently: that is, it has nothing to do with whether there are 4 million people doing it or 4 -- so long as it is something meaningful and compelling to YOU, that YOU are uniquely qualified to do in the unique way YOU are going to do it. I'd argue that marketing power is often a function of the enthusiasm and charm one exudes, regardless of how many other people are doing it.

I decided this week that my niche is not the idealistic "I want to help really really really really sick people" that might come out in a pre-med personal statement. I've been giving a lot of thought to the notion that my role in this world may very well NOT be to help really, really, really sick people. Rather, it may very well be to guide and empower the person who is living juuuuuuust under the radar -- functional but limited by SOME aspect of their health-- to enhance their lives. Not only preventing illness but truly optimizing their non-ill state. People pay a lot of lip service to the merits of the big "p" word (PREVENTION... oooooh) and yet, nobody talks much about the difference between prevention and optimization.

At the clinic, my preceptor always encourages his colleagues to alert me when something "cool" happens. Do I want to see erythema multiforme? Zoster lesions? Yeah, it's all cool. But the visits I attended yesterday, where I felt most comfortable, inspired, and genuinely well-suited to contribute were the everyday, run-of-the-mill physicals and vague complaints that are largely dismissed just because labs eliminate physician concern for anything DRASTIC --but do nothing to assuage the concerns of the actual people afflicted by them. And, yes, I will use the word "afflicted" -- because to a given person, that's how it feels.

Truth be told, of all the amazing things to which I was exposed yesterday (including another house call -- where I got tearful watching my preceptor hold the hand of his dying patient), the only thing I feel compelled to write about now is how "at home" I felt to be training on the optimization front.

I am not JUST talking about making the healthy healthier. That's not it. I'm talking about the subtle everyday details of everyday life that compromise health -- actual consequences, referred to as "sub-clinical" yet are hugely important to the person experiencing them. Micronutrient management. Lifestyle management. Breathing control and mindfulness. Proactivity. Hell, I even got to have a conversation about HEART RATE TRAINING with someone yesterday -- and it was the best part of my day.

I think about the athletes I coach -- whose "subclinical" complaints are often dismissed because their doctors know that they exercise, and are thus healthy. These folks have unique micronutrient and cardiovascular needs that are not reflected in their labs, but very much reflected in their lives.

I have a fitness instructor colleague with a history of chronic migraines. Tests to date have been normal but her entire world is turned upside down every other day. She shuts down at work, she shuts down at home. She feels powerless. As a first-year medical student, I technically know NOTHING - but I have some thoughts about the interplay of diet, hydration, the straining of specific muscles, vascular constriction, and heart rate. I don't know ANY doctor who knows any more about that than I do. Her doctors see: "athlete" and assume all that "diet/exercise stuff" is well under control and clearly not within the scope of their duties. I've certainly experienced this with my own physicians: oh, she's a fitness instructor and her cholesterol is good, no problem here... even though when my heart races and my neck has a weird bulge or I just feel generally "deficient" in SOMETHING, I am not maximally armed to navigate the challenges of my world... and it's my doctor's job to help me do that.

Yesterday, I saw a patient with a different doc at the clinic -- GI distress, vague psychosocial complaints. Labs normal. Dismissed as IBS by exclusion, and not at peace with the diagnosis at all. Expressed that she felt that she was not heard by her GI doc. THAT person -- that's the person I want to spend my life caring for.

I don't think this is idealistic to declare myself a Champion of the Subclinical. I think it's a legitimate niche population, and need to start making choices enhance my own ability to uniquely serve their needs.

Saturday, March 21, 2009

Promise to Stop Procrastinating

I coached a 1 hour, 45 minute Spinning ride last night, about which I was uber-petrified. I struggle to hold my own attention that long, let alone a room full of 25 people who don't have nearly the amount of intrinsic buy-in to the physical and mental benefits of that type of endurance training.

An under-appreciated point about coaching a Spinning class is that anyone who's worth their weight in your mineral of choice expends an extraordinary, even CRAZY, amount of time preparing: theme, heart rate training parameters, music, and... cues. That is, the stuff you say. It's huge. When I was a full-time Spinning instructor, I spent hooooooooooours and hours every day just reading and taking notes. Books (sports psychology, technical cycling, interpersonal communication, business management, self-help and spirituality -- a host of other genres), blogs, e-zines, quote websites -- you name it. It was a full-time job in and of itself. A full-time job with killer benefits, as it were: namely, an appreciation that I was contributing to people's lives as a function of the time and creativity I invested; and, in so doing, contributing to my own spiritual, cognitive and emotional growth. Truth be told, the richness of the subtleties that shape the way I see the world and my role in it were borne and crafted directly out of my preparation to guide other people.

And so, this week, in anticipation of my daunting undertaking, I planned to read a book I'd had on my shelf for a while: Stephen Covey's "7 Habits of Highly Effective People." Except life got in the way -- working at the clinic, making cameos at school, that whole sleeping thing. But yesterday I took off from school entirely to "cram" for my ride. Once I started reading, I couldn't put it down. There is something so psychologically gratifying about reading a text of a reputable writer describing, with exquisite detail, your specific concept of self-concept, self-advancement, and self-efficacy. Something so gratifying that I canned the theme of my ride, for which I'd been preparing for a weeks, and began anew with an hour til showtime.

I called my ride "The Promise." The idea of making a commitment to yourself and honoring it as a reflection of the very fiber of your integrity -- the idea that just framing it that way makes ALL the difference. I structured the ride in five blocks, each with a different sub-concept: 1) awareness (of thought patterns, synchronyzed breathing and movement, subtle influences on mood and concentration, of the deep-rooted principles and values that guide all of the above); 2) proactive choices (reflective of responsibility to further that which one has set out to do); 3) self-discipline (remembering what one wants, and why -- and tapping into the empowered strength that guides choices to hold fast to those things); 4) being responsive vs. reactive (giving one's self permission to be influenced by the things around him or her -- but within the framework of the principles and values at one's core); and 5) synergy (putting everything together, embracing the joy of control and achievement and the advancement of self-understanding). Yeah, not going to lie -- it was the best ride ever. It was that good.

And now I'm distracted. I had all of these ideas just reading the first 50 pages of this book. I want to keep learning and discovering and thinking and talking and writing... but, as it turns out, I'm a medical student. I have to do that "studying" thing, given that I've read self-help books all week and have a GREAT sense of how life should work and how happy and inspired and empowered I am, and blah blah blah. Hello. You're a MEDICAL STUDENT. GO LEARN MEDICINE.

Where's the disconnect? There shouldn't be one. So now I'm taking the time to synchronize the things that are making me happy yet distracting me from the realities of my life -- the realities that, in theory AND in practice, I actually like.

I think that perhaps I find that "life as a whole" is more masterable than, say, the liver. On its face, that sounds absurd. It actually is absurd. But that may be at the root of my procrastination: that is, my self-handicapping. If I can't know everything, why bother knowing anything? If that's what it is, this is a safe place to be. I can work with that.

One of the things that blooooooooooooooooooooows me away about my preceptor at the clinic is that he has just the most extraordinary memory. Random crazy insanely "trivial" details about obscure associations between x and y and z; he knows them all. He just spouts them out. He's brilliant. I know that my brain can work like that, and works like that all the time. I just don't deeply encode enough new material anymore. It's almost like physical overtraining, a concept I coach and write about ad nauseum: your muscles, your heart, just get tired. You can't reap the benefits and pleasures of movement under those conditions. Is that what is happening to my brain? Or has it just forgotten to look for those details, forgotten to organize them meaningfully? Copping out before it has a chance to succeed?

At the clinic on Wednesday, we saw a patient who had burning in the entirety of both her legs. She described the burning as a numbness, tingling, and "cold fire." I thought of my nerve adhesions in the aftermath of my iliopsoas tear and bulging vertebral disk, especially as the patient described the onset as following a deep tissue massage. My preceptor agreed with my thought that it was worth asking a physical therapist about. But then the next day, in a small group session on cholesterol and cholesterol-lowering drugs, we learned about muscle toxicity in use of statins. Cue the light bulb.

One thing about medical school is that there are so many damned drugs with so many different mechanisms and side effects and niche pharmacokinetic properties and dose-limiting factors that they're all the friggin' same in the end. You see a symptom -- is it related to a drug? Sure, why not? Every drug causes everything, when it's all mixed up in your brain. The key is just having the awareness to look up a symptom and check on its possible relation to a given drug. What distinguishes my preceptor is that he knows a SHITLOAD of things and recalls them on the drop of a dime, even before he looks it up (he looks up a lot, all day long -- he's inspiring that way, too -- I'm just talking about the insane amount of info he has in RAM at his disposal).

I've spent so much damned time actively training my brain to get things OUT of RAM -- to free it up to be thoughtful and creative. The lists, the structure, the notepads. It has taken three years (inspired by my first read of Edward Hallowell's "CrazyBusy" when I left The Forensic Panel) but I can honestly say that I have gotten SO good at keeping my RAM free. I naturally select the specific environmental stimuli to which I attend. I don't read billboards. I don't hear car horns. I don't see dangerous cracks in my glass plates before I eat off of them. But you know what? I also don't hear ceftriaxone and think gallstones. And I need to.

Yesterday I emailed my preceptor about this muscle tox and statins question -- that I thought I remembered taking a mental photograph of her meds list and thought I'd seen a statin, was that true? And if it was, does muscle toxicity actually present like this kind of burning?

He just wrote back. Turns out, he'd thought of that, too. He's going to stop the meds for a while and see what happens. If the burning subsides, he will reintroduce the drug to see if it returns.

On the drop of a dime, I thought: Coates' Postulate. A random detail that I'd heard someone mention in passing this week, that describes this common medical approach to identifying the cause of a side effect. Maybe my brain can do this, after all.

It thrilled me that I had a useful medical thought, supported by someone I already really respect. I literally glowed, starting bouncing around the room. I can glow all the time if I just stop reading and thinking and "being aware" -- and start DOING. If I honor my promise and commitment to myself, that reflection of the very fibers of my integrity. If I make choices that are consistent with my principles and values in the pursuit of feeling this way all the time. If I discipline myself to remember that I want to feel this way all the time, want to feel things that are more empowering and intense than even this.

Sure. I can do that.

Thursday, March 19, 2009

Something = Useful

One might think about the road to medical school as carrying the status of "in training... for training." That's really what it was -- which means that medical school (i.e., "training") actually feels like a legit destination, even though it's clearly a transition towards an even greater one. The difference -- that is, the most surreal quality of this sensation -- is feeling adequate. As a medical student, with all the privileges and responsibilities that confers, I'm treated as "something" and often legitimately feel like I am "something" -- as opposed to "one day, going to be something."

It's almost a spiritual appreciation: one's self-concept and schema for how one fits into the world -- what role one plays, what impact one makes, the experience once crafts for themselves. It's different when you're "something," as opposed to "one day, going to be something" -- even while acknowledging that this "something" changes every single day. The key point is feeling like, no matter what changes happen, whatever that "something" turns out to be at any given point in time is, by and large, enough. There's somehow less anxiety, less awaiting. Enjoying being in the moment, this "training" -- because it's more than just a means to an end; it's awesome in its own right.

Yesterday, I was especially mindful of this. I had my second day at the clinic. I was there for 9 hours again; and, again, I had the time of my life. It was like an epic field trip -- except it's my life. I am on a field trip to LIFE. It's mine. It's here. And it's awesome.

I was a lot more comfortable yesterday -- with myself, that is. I asked bolder questions of my preceptor (whom I officially adore; he really is the coolest human being in the entire universe, and I am pretty darned close to declaring hero status). When I felt like an idiot, I told him I felt like an idiot. He's very empowering: he admits to his own faults and weaknesses, praises me for small doses of sub-idiocy, and never ever ever makes me feel inadequate.

He taught me, directly, to take blood pressure -- the kind of "menial" task often delegated to perceived subordinates (yet is actually a REALLY hard thing to do correctly). He takes all of his patients' pressure himself. Nobody'd ever sat me down with such a "basic" thing before; that's not how it's taught in medical school. We had our standardized patients, given a tool, and were told to "do it." Uh, yeah, sure, I heard something.

I felt moderately useful, too. I feel like, slowly but surely, I am integrating the basic "life concepts" that I know about and how they might fit into a given patient's situation. I find myself having thoughts that my preceptor later posed as his clinical reasoning. I get excited when that happens; it pseudo-reflects that I think usefully. I ask about diet and exercise all the time, when given opportunity to ask questions. My preceptor started asking patients about some of the GI concepts I tell him I care a lot about. Again, I feel useful.

There's something so gratifying about soaking up the subtleties of one's experiences, synthesizing them in a meaningful way, and finding a way to usefully apply them... already. Even while just being "in training." It's something.

And, boy, were there subtleties to soak up yesterday. Note to self: Never allow this much time (24 hours!) to pass between clinic and blogging. I've lost so much already...

* 18 year old kid, wealthy parents sent him here from out-of-state for private drug rehab. Well-mannered and polite, well-groomed. His caseworker was in the exam room with us. He was there for a new patient visit, though requested an STD test. My preceptor asked him if he had any concerns about an experience with a partner; he did, and cited that there had been unprotected contact. My preceptor did not inquire further -- not about the type of contact, whether it had been with a male, female or both, not about any of that. He did ask if the kid wanted everyone else in the room to step out; he declined. I later asked my preceptor if he intended to get into "touchier" subjects at his next visit (in a few weeks) without the case manager being around. Yes. But I didn't ask about what level of detail he was going to pursue. I'd want to have a complete understanding of this person's lifestyle practices, the risks and conditions to which he will be exposed. It's all relevant. It's so tricky to balance when/how one asks about those things -- when is rapport strong enough to be set up for success?

* I did ask a somewhat ballsy question of my preceptor at the end of the night. I noted that several patients we saw throughout the day were overweight, self-acknowledged it, and responded to my questions about diet and exercise with pretty discouraging responses -- and that I wondered under what circumstances did he take the time to intervene? I recognized that I was potentially inspiring awkwardness. Having a student around watching you, analyzing your moves and strategies, must be awkward. He was good about it. He told me that he intends to intervene every single time -- that, over the years, he has these conversations with these specific characters that go nowhere and that he gets discouraged and "gives up." I told him that I doubted that he was really giving up -- it's just that, under time pressures, he was prioritizing what would be most effective in the moment. I think he appreciated my attempt to make him feel better; and I think, also, he was actively reckoning with the dilemma as we sat there. He was trying to set a good example but explicitly acknowledged where he thought he had not delivered. I respected him so much for this. I can't wait to see how he really DOES carry out an intervention. I like this guy so much.

* One thing I particularly dig about this guy is the specific style with which he conveys information. When he mentions a particular detail about a symptom or a drug or anything else, he says: "You remember that..." or "You know that...." -- when, really, I do not know or remember any such thing. It's new. 99% of everything is brand new. I scribble it down, clinging to every detail, lest I never see it again until someone's life depends on it. I later transcribe it into my Excel spreadsheet, and look up whatever I can to fill in the details. Wikipedia is often more helpful about pathophysiological mechanisms than legit books or databases, which surprises me. It's hard to organize everything in a meaningful way, as I encode these random details. But I'm motivated to try, as opposed to feeling discouraged or daunted -- and so much of that has to do with the way this guy teaches.

* While my preceptor left the room to get something for his patient who was partially blind in one eye, I stayed in the exam room and asked him to describe to me what it was like to see both with and without his corrective lens. I wanted to practice inhabiting his existence. It was a really nice conversation, and I could tell that he enjoyed the opportunity to just tell his story. I heard all the nitty gritty crazy details of the past 5 years of his medical woes and, in response to my prompting, how they impacted the other realms of his life. It was rewarding to practice, specifically, the kind of narrative history-taking I've been thinking and writing about so much in recent months.

Fast-forward to today. Had a lunchtime speaker on eating disorders --a Q&A session for my classmates, who by and large are super-sheltered from the whole issue. This shocks and appalls me, mostly. We had an eating disorder theme during MSLG last week, and I was literally APPALLED at how poorly most of my classmates misunderstood any of the salient concepts. I've been brooding about it quite a bit all week. One day I'll write more about the specifics. Earlier this week, I had a Spinning student come talk with me about a friend of hers. I felt like I delivered in the support department; I felt good about it. Today's speaker was coincidentally from the outpatient program to which I referred my student. I conceptualize my role in most tricky areas in which I happen to have a lot of thoughts and insights to be to at least bring to the forefront of my colleagues' minds the kinds of thoughts that they should at least ENTERTAIN down the road. So I asked a lot of questions during this panel, designed to do just that. I was happy with how it went. But I'm still disappointed in how poorly the people around me a) think about relating to people struggling with psychosocial challenges; they get so awkward and b) embrace notions of self-awareness and perspective-informing. I was also underwhelmed by how there are no transitional support services to bridge inpatient and outpatient eating disorder treatment in the Burlington area. This surprised me. A classmate and I were talking, later, about starting up a program.

I think that this is a project I'd find really rewarding to create. More, eventually. Again relating to the point I raised earlier: my self-concept of where I fit into the world, what I'm suited to meaningfully contribute. I forgot how meaningful this issue was to me until the MSLG class pissed the hell out of me. Now that I remembered, I need to do SOMETHING with this appreciation.

Something useful.

Thursday, March 12, 2009

Stepping into the Role

My sense is that medical training is a continuum between "impostor" and "legit." The entire continuum carries its special responsibilities and privileges -- all of them up for the taking -- but the process of training, beyond developing a legit knowledge base and skills, is about developing into one's self and developing the confidence accept more and more of those responsibilities and privileges.

I've written before about how even gaining entry to this continuum on the "impostor" end affords you completely ridiculous opportunities. By virtue of my status as "medical student," I get to say, see, hear, touch, and smell things that the general population does not -- things carved out into the most intimate spheres' of human beings' existences. I've also written about how profoundly "wrong" this occasionally strikes me, despite my gratitude for the cultural infrastructures in place to allow me to learn. A few weeks ago, when I donned my white coat and anxiously tip-toed into a patient's room with an assignment "just to talk," I felt completely ridiculous. Who was I to seek out my own learning opportunity while not being able to contribute even 0.005% to this person's state of affairs?

When I reflected on this here and to some people in my life, a friend of mine told me a story about being hospitalized for her ulcerative colitis -- and how, what she remembers most from those difficult times, was the third-year medical student who spent time with her just talking, following up on details, holding her hand. Just being present with her. I sort-of accepted that this was true all along -- that listening, being around, was an important role that I felt that I'd be good at filling. But hearing this directly was tremendously empowering -- feeling that, just maybe, I would be able to do similar good for someone's life... just by "being there." Not an impostor, per se, just being good at ONE part of my role.

Yesterday, I had my first chance to explore this. It was my first day of shadowing at interdisciplinary rural clinic about which I have previously ranted and raved. And it was one of the best days of my life.

The day started with a monthly staff meeting, at which the clinic's executive director introduced me to the 60 people who worked there. Everyone was so welcoming and I could feel myself just GLOWING to be around them, soaking up their energy for just "being there." From there, I attended a separate meeting of the medical staff holding a Q&A session with a local urologist to educate them, as family medicine practitioners, as to parts of their patients' urological care that they could properly manage themselves. I was surprised at how much I could follow -- I didn't think I knew ANYTHING about urology. Turns out, a little bit of exposure to histological changes, ion transport, blood tests, and some informal knowledge acquired about procedures via my old boyfriend, went a hugely long way. I was "right there," following everything -- scribbling notes to myself about things I'd later go look up to fill in the details for my knowledge base.

It was then time to accompany my preceptor, the practice's medical director and quite possibly one of the coolest human beings on earth, on his patient visits. It was 3PM when we started, and I knew that his clinic day would end at 9PM. I was determined to stay the whole time, a) because I'd spend two hours driving to/fro... I may as well make it count; b) I wanted to spend as much time with this guy as possible, given his status as my new favorite human being; and c) I wanted to make up for my lack of knowledge with enthusiasm and dedication. I stayed til 10:30.

Just like in my Forensic Panel world where some of my coolest opportunities happened after sane people would go home, so it happened here. I got to make a HOUSE CALL around dinner time (whereas "dinner" = rice cake with peanut butter, which afforded the opportunity to be a resource about Celiac disease to this super-smart, accomplished guy. I liked that, too.) We drove out through the winding roads of rural Vermont in my preceptor's truck, and made a legit, bona fide house call -- right out of the movies. An elderly woman, bedridden with infected sores (colonized by a bacteria I actually knew about, pseudomonas aeruginosa -- identified through a distinctive smell) that were potentially a complication of her rheumatoid arthritis (which also happens in Crohn's disease, which I knew about: pyoderma gangrenosa). On the way back to the clinic, I was able to engage in a legit conversation about antibiotics' use and contraindications... RIGHT out the course I'd just finished. I'd retained way more than I thought I did.

In the car ride back to the clinic, we talked about stuff I knew nothing about and stuff I knew a lot about. I felt like an idiot for not knowing common things (#1 cause of cardiac arrhythmia = hypertension) but felt pretty good about knowing not-so-common things (where you see PG). It's a task of balance -- impression management, knowledge seeking, confidence building, empowerment maintenance.

I shouldn't have let 11 hours pass between leaving the clinic and writing this, as already the intensity of the experience has waned a bit. I saw SO much stuff yesterday. Maybe I'll transition into somewhat of a highlight-recording mode:

* Salty, crusty Vermonter -- crude, gruff, good-natured. I learned the importance of selecting sub-roles to play -- I had to up my confidence level, to roll with this patient's inappropriate jokes and not let on any embarassment or intimidation. My preceptor, who is 500000x cooler than anyone else on earth, even got cooler in this environment. "Adopting a character" is an art I've been working on for years; it's how I survived at TFP. I listened to his lungs and heard nothing. I suck at lung exams, and it embarasses me. I confided this in my preceptor and he assured me that we'd keep practicing.

* Elderly woman -- 81, double knee replacement, still super-active. A skiier, even. Had bursitis of her hip (like I did) and physical therapy wasn't helping. My preceptor asked her if she wanted a hydrocortisone injection (i.e., what I *JUST* learned about that morning). I watched him prepare the solution and identify the most tender spot on the woman's bare hip. She grimaced. He guided the syringe needle directly into the bone, retracted just a bit to be in the hollow sac of the bursa -- which I visualized from the "wet models" of my gross anatomy lab, trying to apply where that was... and how AWFUL that might feel in a living human being to have a piece of metal inside my bone). She started to wimper. Instinctively, I put my hand on her back. And she wimpered louder, I applied more pressure. She stopped. I felt, for the first time in medical school, that I actually contributed at a stage of my role that I felt confident and competent to fulfill.

* Kid with psychiatric condition, heavily medicated, with symptoms reflective of bad untreated allergies... or gastroesophageal reflux disease. My first pediatric exposure. Decided that I absolutely want nothing to do with treating kids. How awkward to not be able to communicate directly with your patient, to base ALL of what you do on an unknown third party's description of what your patient is experiencing. No way. Not for me. I tried a lung exam again. Maybe heard breathing; doubtful.

* Similar experience on the flip side, with an elderly patient suffering from dementia. She didn't know what state we were in, but did know that it was 2009 and that Obama was president. It was neat to see a mini mental status exam performed (I knew those are the kinds of things one asks, but had never seen it done). Everything was based on her daughter's account -- and everything in the patient's life was dictated by the daughter's intentions and efforts. Including a shitload of raw vegetables, beans, and milk. The woman's chief complaint was gas. My preceptor, for some crazy reason, actually lets me participate in these visits I observe -- and, turns out, I had some decent thoughts: increasing soluble vs. insoluble fiber, tricks for reducing gas, perhaps a dietitian consult. It felt fantastic to know something useful.

* Young woman suffering from IBS with some sort of urinary tract/bladder infection. My preceptor asked how I'd feel about going in to take a focused history by myself. It didn't help that I didn't know the "pertinent positives" or "pertinent negatives" of a UTI -- but I learned them without sounding too much like an idiot, and now I know them. I was surprised by two things through this experience: a) how much easier it was to connect with a patient when I was by myself, less nervous about performing -- was just able to be myself, and I was mindful of how well I was connecting with even this most awkward of a character (note to self: serving as a forum for people to talk about their GI woes is my absolute favorite rapport-establishing mechanism; I'm pretty good at it). I got awkward when I started asking about sexual history -- probably not legitimately awkward, but I felt awkward. Next time, I'll be less awkward. But I started to get nervous and distracted, so I forgot to ask her a few important things that I absolutely knew enough to ask (my preceptor didn't ask, later, either -- but I would have). It was very much like when I get nervous during clinical skills exams -- I don't breathe, and I don't focus. I blank out. I need to pay more attention to that -- to go through the structured protocols that I really do know back and forth.

This encounter gets a second paragraph, as it was one of the more meaningful parts of my day.
Pelvic pain, weight gain, missed period, hormonal changes. Think: pregnancy. I wasn't a huge fan of how my preceptor broached this issue with her. She was maybe 20. Unmarried, not in a relationship, swore up and down that she'd had no sexual activitity for 9 months. My preceptor was matter-of-fact and forthright, which struck me in the moment as a bit cold (even though he is the polar opposite of "cold"). I wondered how I might have probed the same issue differently. He asked her about hygiene risk factors for recurrent, persistent infections also in a manner I would have handled differently. I noted that I felt confident in silently rejecting vs. adopting stylistic things -- confident in filtering implicit knowledge, selectively integrating themes and concepts into my world. When my preceptor said goodbye and left her to give another urine sample, I had an idea. I asked her about "streaking" in her panties -- which many people with GI woes have, in that a "whoosh" of gas actually occasionally takes with it, uncontrolledly, remnants of stool in the rectum from a prior incomplete evacuation. Nobody talks about it, as it's super-awkward. It's the kind of thing that people don't even want to tell their doctors about -- even people who otherwise have no qualms about discussing their GI tract. So I asked her. I saw the relief pass over her eyes. "Yes, that happens all the time." I also explained to her that we do pregnancy tests all the time, that she's probably completely not pregnant, and that if she wanted to - she could wait around for the results. "I'd like that," she said. She wasn't pregnant. I told my preceptor about the staining; he hadn't realized that this is fairly common in IBS patients. We then had a whole chat about IBS; he asked my opinion about treatments and was genuinely interested in what I had to say. I felt so comfortable, right there, being a resource about something I knew so much about. I was really proud.

* Waiting in the hallway to present this patient's case to my preceptor, the clinic's director wanders by. Says hello, makes small-talk. I got anxious. I'm always anxious when I don't know if someone important likes me or not; it's one of my major character flaws. So I decide that I should practice "adopting a character role" and pretending to be confident enough to practice being myself around this guy.

"I just took my very first official patient history!" I tell him, proudly.
He looks up from his paperwork and smiles. "Really? Tell me about it."
I tend to acquire far greater insights FROM people than using them as a sounding board for my self-insights. It's an art of prioritizing how you use your resources, and I'm getting decent at it over time. So I made that happen. So right there, in the hallway, this guy started telling me about his own medical school experience -- how he hated it, how he felt like such an impostor, how he felt so awful all the time... until the one day that he didn't. Until the day that he felt like he truly, naturally came into his role. It was so refreshing to hear that this important guy who has done so much in the world for other people -- starting this clinic from scratch, on a pipe dream that he could meet the needs of this community, becoming a federally qualified health center, expanding into mobile programs to meet the far-reaching stretches of rural Vermont -- went through the same things I am.

* 20-year old boy recently started psychotherapy for depression, referred by cognitive-behavioral therapist for pharmacotherapy. Nice kid. Bad habits. Watching him come into his own, acknowledging certain realities and challenges, was really inspiring. My preceptor counseled him on the natural antidepressant properties of exercise -- I'd never seen a doctor actually talk about the specifics of exercise, other than "you should do it." I was really excited by this. Another thing I felt like I'd be able to do confidently.

The last time I wrote about my trip to the clinic, I wrote about my interstate-driving epiphany on the way home that symbolized my experience of empowerment. So clearly, my car would HAVE to provide me with another opportunity to appreciate my experience in a different context. By falling apart and stranding me, throwing me into the fire with nothing but my wits and breathing techniques.

At 10:30PM, I went out to my car, started it and heard a strange scraping noise as I backed out of my parking space. Pulled forward. It got worse. Got out of the car. My still-detached bumper was a bit more out of alignment, but not enough to explain that noise. Drove forward, noise got worse. This was NOT ok. Climbed under the car, saw a piece of plastic beneath tbe bumper at somehow become detached, shredded, caught in the wheels, and scraping against the concrete. Also NOT ok. I didn't have the after-hours phone # at the clinic or my preceptor's pager # -- and he didn't hear the main doorbell (everything was locked, and his office was nowhere near the exit). I called my roommate to ask her to look up his pager # on my desk. Cell was off. Not ok. I tried to stuff the piece of plastic back out of the way -- but, honestly, it's a friggin car. You can't just push "pieces of car" out of the way. I took deep breaths. Avoided tears, avoided panic. I'd be able to handle this. It'd be fine. I drove out of the parking lot -- noise was worse. Came back to the parking lot. Tried again to ring the bell. I toyed with the idea of towing my car back to Burlington but decided that being alone in the pitch-black dark in an empty unlit parking lot to await such a thing was worse than dragging part of my car 50 miles on the interstate. Every mile I drove, I could feel my wallet draining -- how much more this would cost to fix, the more damage I did. Because of the way this dangling piece was blocking/re-directing air (like the underside of an airplane's wings), the wind was blowing me all over the place on the interstate. It was very much NOT ok. Still, I took nice deep breaths - dropped my shoulder and my elbows, focused my gaze on "where I want to go" (just like when I get scared on a bike, feeling like I'm not in control of my motion speeding down a steep hill), and it was fine. Over time, I reached a new, functional steady state of anxiety -- it felt like something I could manage, something at which I wasn't necessarily super-good at, but to which I was good at controlling my responses. Making technical adjustments, fine-tuning as I went, responding to what worked and did not work.

I made it home just fine.