Over time, I've come to accept that I have more genuinely life-altering "moments" than most people. There was a point that I attributed this to the mere fact that I make a big federal ordeal about experiences that others brush off; I'm over that. No. I really do lead a life of a continuous string of movie-esque moments. The characters, the screenplay, the soundtrack -- all of it perfectly scripted, the way it's "supposed" to be. The way it needs to be.
The clinic director -- the character I uprooted my life to move to Vermont to meet and see how he did what he did, in whose presence I had a panic relapse upon introducing him to give a presentation at my school -- returned from vacation. My brain was excited that he was around; my sympathetic nervous system threw a shitfit. I started stuttering, stammering, sweating, acting like a complete idiot.
Stop it, I told myself. You need to NOT do this. WTF is wrong with you?
I shared my physiological responses with two people at the clinic, who observed that other people legitimately have the same responses to this character. I found this encouraging. One of them suggested I actually medicate -- block my sympathetic nervous system with a beta blocker. Fascinating. Imagine what it would be like to go through life perfectly calm and at ease. 12 hours later, I was driving in a horrifically scary storm. It was truly petrifying -- people were pulling over on the side of the interstate left and right; nobody could see anything. But I kept going -- crawling, but fighting through it. I was hyperalert, hypervigilant, hyperfocused. My sympathetic nervous system saved the day, and I appreciated that this experience existed only to demonstrate to me why I should never block it. Check. I get it.
So this week, I've attempted to work through various strategies that are "supposed" to work for this kind of ridiculum. I breathed. I self-coached. I pulled my "adopt a character" improv trick. I instituted a reward system: "If you can get out two sentences without tripping over yourself, you get a Reese's Peanut Butter cup." No joke; this is what my life has become. Turns out, I'm motivated more by chocolate than by professional pride. Who knew?
Tonight, I targeted the ultimate reward. I told myself that if I could survive without embarassing myself until 6PM (i.e., 10 hours of work), I would reward myself by giving myself permission to take the ultimate plunge: asking this man if I could accompany him to see a patient. People do NOT tag along with him, let alone people who are relatively useless. Everyone talks about his clinical presence as being magical -- that, literally, magic happens. Patients say it; doctors say it. I wanted this experience so badly that it hurt.
But indeed, I had to earn it -- psychologically -- in order justify taking the requisite risks to structure that opportunity for myself. Today was a good day. I did 90% of a physical exam without supervision (and my findings accepted as truth... that might be a topic for another post; it was my first time experiencing that level of pressure, of confidence). Turns out, I was much better at basic exam skills with no preceptor in the room. I saw both optic discs, took blood pressure fluidly, and actually palpated a liver edge -- other exam skills are fine, but those three things thwart me ALL the time. Just like that, nailed them all. Alleviating performance pressure by replacing it with pressure to actually be correct? I spent a lot of time reading today, too. I taught myself about a ton of stuff I've been meaning to look up. I understood stuff. I integrated it into the existing framework in my brain. I was proud of my thought process, very specifically.
All of this set the context for my plunge. One more interaction, then I'd ask. Interaction: go. "The patient didn't know if he was taking X." (1 of 17 meds)
"He's taking Y."(another of 17 meds).
"Ok. But X...?"
"X is Y." (brand vs. generic)
Idiot. 9 hours and 58 minutes down without self-sabotaging. Game over.
I inhaled deeply, diaphragmatically, and exhaled loudly. I didn't even care if he heard me. I just needed to not have a panic attack. I didn't. I walkied away, dejected, appreciating that my moment had passed me.
I turned around. Stop it. Avoidance = bad. Just ask.
"Do you think that it might be possible to... go in with you?"
Pause.
Oh shit. What did I do?
"Sure."
I spent the next 3 hours with him, seeing patients and asking him questions. It was nothing short of magical.
The man listens. Time stops when you hold his attention. He is so "present." Nothing else matters but the words that come out of your mouth. Everything slows down.
He speaks with greater precision than I've ever heard. Everything is deliberate. Everything means something.
We saw a man who had a post-bypass pulmonary embolism last week-- crazy hospital crisis, crazy scare. The whole clinic staff got involved, it was pretty crazy. We listened to him talk about how fears about his body falling apart, and the compulsive monitoring and adjusting he was doing. It was magic as I watched the director listen with such purpose. It was magic as the layers of anxiety peeled away. Softened features. Softened will. Something happened in that room. It was nothing short of magical.
Afterwards, I told him so.
Sometimes when I wear my cycling coach hat, I shift into a pseudo-uncomfortable tone: of knowing what I'm talking about, and almost feeling apologetic and guilty for knowing what I'm talking about. For adopting almost a "wisdom" of whatever stylistic something-or-other I'm describing for another's benefit. I remind myself that there's no need for apology; that I actually DO this particular thing well, and that it's ok to appreciate my own niche of stylistic expertise. This guy visibly goes through this same process when he is complimented. But the more I compliment him, the less apologetic he gets -- and the more he elaborates, the more he shares and teaches. It's a really wonderful cycle, actually.
So when I acknowledged the power of his influence, he acknowledged it and shared some stories about how that sort of power can be advanced and abused. Again, every word carved deliberately with extreme precision. I locked his eyes, captivated. I knew that he knew that I was soaking every word up.
"We touch people's lives in ways we may not realize."
My eyes glowed, connecting with this thought that so deeply resonated with me. As I smiled with my eyes, I felt my breathing slow. Rhythmic, fluid. I was clear. I was present.
"Thank you. Today was one of my favorite days EVER."
I was finally myself. And that alone was magic.
Tuesday, June 30, 2009
Monday, June 22, 2009
Coming Full Circle
First day status post-first rural weekend. Catfish/collards at the local dive. Lazy afternoon shindig with a host of new characters, comparing pharyngoplasties. Casual solo 50 mile bike ride into the great beyond (find me on Facebook to see these RIDICULOUS photos...). You know, just another day in the life.
First day full-time at the clinic, really. Most of it was anti-climactic. The trouble with being supported by a grant to work on ONE project that comprises perhaps 8% of the attention of anyone with relevant input/output is that it's pretty hard to make much headway, since all of such people are out actually doing their jobs and contributing to life in a meaningful way. I was marginally useful, and selectively carved out a few experiences that I wanted. I observed a neat neuro workup of adult ADHD, and then taught myself a ton of useful things about ADHD drugs. I learned how to remove skin tags by freezing with liquid nitrogen (which is easier than scalpel/cauterizing but not as cool, and not as effective). I saw "stock" symbols of primary care -- infected fingers, irritating eczema, that sort of thing. I liked them; they made sense. But apart from those moments, I started to feel like I was in the way. I wasn't. My presence isn't actually important enough to BE in the way. I just had hoped to be more useful by now.
I suppose I was marginally useful. I got a ton of people to agree on a very complicated document that I am debuting tomorrow, doing patient interviews and medication reviews to help streamline the clinic's protocol for staying on top of current and accurate med lists, and to developing an understanding for obstacles to consistency between the treatment plan as the provider understands it and reality. The best part, really, is that I found a way to sneak in a measurement of a variable that *I* think is important -- that is, a patient's understanding of the what, why, and hows of their medications. My hypothesis is that I'm going to show a relationship between patients' LACK of understanding of certain key variables and the number of inconsistencies with a given treatment plan. It's such a small, subtle measurement folded under a larger project -- but it's the part I really care about. I don't need to be right all the time -- but this is one of the central underpinnings for my entire drive to care for patients. If I'm wrong, I'd be disappointed.
Just as I was feeling kinda lame and disappointed about the anticlimacticness of my day, my preceptor mentions that he has to take off for "the free clinic." The what? Turns out, he volunteers at a free clinic for the uninsured on a monthly basis in town 20 minutes away locally appreciated for its dreary hopelessness. I looked at him with hopeful eyes. "Wanna come?"
Obviously.
Just then, the PA who has taken me under her maternal and professional wing pokes her head in and says that she has to drain an icky infected ear. This development about accompanying my hero to a new world of significance empowered me to take action to actively create more opportunities. "Can I come?"
Obviously.
So, I learned how to irrigate ears to flush out cerumen (how did I make it through 25 years of life without knowing that earwax had a technical name?) obstruction. It was AWESOME. This giant plug of awfulness that had been plaguing this poor man's existence... just OUT, floating around in a cup. The patient started to leave the exam room -- and then, all of a sudden, the PA told him to sit back down so that I could examine his eyes.
He didn't need an eye exam. The PA remembered that I had told her over the weekend, on a random drive through the hills of my new life, that I had three important summer 'life goals':
1) I will ride my bike every day, except for when I needed recovery (like today).
2) I will take blood pressure every day.
3) I will perform an eye exam every day.
She not only remembered but went out of her way to contribute to MY life goals. "Ask and ye shall receive," I suppose. I never think to ask. I'm too concerned about being in the way. I was so touched.
I wasn't successful but it meant so much to me that another human being was committing to my commitments. I returned to my preceptor's office and told him how awesome the PA had just been -- and, in so doing, told HIM about my 'life goals.'
I hadn't told either of them of my 4th goal because it seems kind-of entitled. I really want to present a patient's case every day -- I'm so uncomfortable presenting. I've only presented a case twice in my life -- once as a 19-year old TFP intern (and I got interrupted by Former Boss' informative yet nonetheless tangential soliloquoy), the second on my first night at the clinic (and I did a terrible job). Table that.
My preceptor takes me in to see a "character" he thinks I'll like. I recognize him instantly from my first night at the clinic. The "gruff" guy that I blogged about appreciating how talented my preceptor was at playing cool, and how I wanted to make it a point to get better at adopting various characters to cope with given situational demands. I forgot about that, and obviously haven't been doing an ideal job of it. But today I was better. I rolled with his heckling and sarcasm, and was totally cool. It felt weird and un-me, but very awesome.
We head out to the free clinic. It was fascinating to observe my preceptor in a different element -- it was intriguing to tease out what qualities/behaviors were specific to a particular context, vs. specific to him. I admired him all the more.
All of a sudden -- BAM, I'm given a chart and told to go take a history and present. I did. I felt totally comfortable. I presented the case to my preceptor and was totally calm. I accomplished goal #4, without even having requested the opportunity. BAM, second patient, do it again. Another ear-flushing! Patient's at check-out -- my preceptor says, "Go back in and take his blood pressure."
He remembered! Again, so touched.
I take his pressure and screw it up. 170/80. Obviously not. My preceptor shows up in the doorway. I tell him what I found, acknowledging that I know I did something wrong. He repeats it; we're used to this drill. Except he found 170/84. I didn't screw up, and we now had the opportunity to counsel him about the dangers of his undiagnosed hypertension.
Next character. I take blood pressure again and again screw it up. 210/120. No way. I suck. The nurse had recorded the pressure as 160/80-ish. I looked at my preceptor in despair, trying to laugh it off - but obviously very distressed. He took the pressure himself again. 210/118. "I agree with you, Dr. Marotta," he said.
He takes the patient's pulse, listens to his heart.
"What's the #1 cause of cardiac arrhythmia?"
I had almost like a 'Slum Dog Millionnaire' moment. We're in his pickup truck on my first night at the clinic in early March, en route to my first house call. He asks me that question. I don't know it, because I don't know anything at that point. He tells me it's hypertension. I write it down. I later transcribe it into an Excel spreadsheet. I vow to never forget that one friggin' fact, ever in my life. It was the first time I felt like a major idiot but immediately appreciated my capacity to learn something.
I feel my eyes gloss over. I smile with a confidence I've really never felt in his presence before.
"Hypertension."
He hands me the fundoscope. He remembered.
This time, I saw something alright. A bleeding retina. Retinal hemorrhage secondary to RIDICULOUS hypertension. My understanding is that it's a huge rarity to see such a thing as a medical student.
I still didn't see an optic disc, since it was obstructed by all this commotion. But for the first time, I believed that I would -- that I could. And I believed that remarkable things really do happen if you actively carve out your own opportunities -- that it's ok to ask for what you want, that as long as you're really excited about learning something, people really do want to teach you. That if you get over worrying about feeling like an idiot and just open yourself up to being and learning and experiencing, all things really are possible.
First day full-time at the clinic, really. Most of it was anti-climactic. The trouble with being supported by a grant to work on ONE project that comprises perhaps 8% of the attention of anyone with relevant input/output is that it's pretty hard to make much headway, since all of such people are out actually doing their jobs and contributing to life in a meaningful way. I was marginally useful, and selectively carved out a few experiences that I wanted. I observed a neat neuro workup of adult ADHD, and then taught myself a ton of useful things about ADHD drugs. I learned how to remove skin tags by freezing with liquid nitrogen (which is easier than scalpel/cauterizing but not as cool, and not as effective). I saw "stock" symbols of primary care -- infected fingers, irritating eczema, that sort of thing. I liked them; they made sense. But apart from those moments, I started to feel like I was in the way. I wasn't. My presence isn't actually important enough to BE in the way. I just had hoped to be more useful by now.
I suppose I was marginally useful. I got a ton of people to agree on a very complicated document that I am debuting tomorrow, doing patient interviews and medication reviews to help streamline the clinic's protocol for staying on top of current and accurate med lists, and to developing an understanding for obstacles to consistency between the treatment plan as the provider understands it and reality. The best part, really, is that I found a way to sneak in a measurement of a variable that *I* think is important -- that is, a patient's understanding of the what, why, and hows of their medications. My hypothesis is that I'm going to show a relationship between patients' LACK of understanding of certain key variables and the number of inconsistencies with a given treatment plan. It's such a small, subtle measurement folded under a larger project -- but it's the part I really care about. I don't need to be right all the time -- but this is one of the central underpinnings for my entire drive to care for patients. If I'm wrong, I'd be disappointed.
Just as I was feeling kinda lame and disappointed about the anticlimacticness of my day, my preceptor mentions that he has to take off for "the free clinic." The what? Turns out, he volunteers at a free clinic for the uninsured on a monthly basis in town 20 minutes away locally appreciated for its dreary hopelessness. I looked at him with hopeful eyes. "Wanna come?"
Obviously.
Just then, the PA who has taken me under her maternal and professional wing pokes her head in and says that she has to drain an icky infected ear. This development about accompanying my hero to a new world of significance empowered me to take action to actively create more opportunities. "Can I come?"
Obviously.
So, I learned how to irrigate ears to flush out cerumen (how did I make it through 25 years of life without knowing that earwax had a technical name?) obstruction. It was AWESOME. This giant plug of awfulness that had been plaguing this poor man's existence... just OUT, floating around in a cup. The patient started to leave the exam room -- and then, all of a sudden, the PA told him to sit back down so that I could examine his eyes.
He didn't need an eye exam. The PA remembered that I had told her over the weekend, on a random drive through the hills of my new life, that I had three important summer 'life goals':
1) I will ride my bike every day, except for when I needed recovery (like today).
2) I will take blood pressure every day.
3) I will perform an eye exam every day.
She not only remembered but went out of her way to contribute to MY life goals. "Ask and ye shall receive," I suppose. I never think to ask. I'm too concerned about being in the way. I was so touched.
I wasn't successful but it meant so much to me that another human being was committing to my commitments. I returned to my preceptor's office and told him how awesome the PA had just been -- and, in so doing, told HIM about my 'life goals.'
I hadn't told either of them of my 4th goal because it seems kind-of entitled. I really want to present a patient's case every day -- I'm so uncomfortable presenting. I've only presented a case twice in my life -- once as a 19-year old TFP intern (and I got interrupted by Former Boss' informative yet nonetheless tangential soliloquoy), the second on my first night at the clinic (and I did a terrible job). Table that.
My preceptor takes me in to see a "character" he thinks I'll like. I recognize him instantly from my first night at the clinic. The "gruff" guy that I blogged about appreciating how talented my preceptor was at playing cool, and how I wanted to make it a point to get better at adopting various characters to cope with given situational demands. I forgot about that, and obviously haven't been doing an ideal job of it. But today I was better. I rolled with his heckling and sarcasm, and was totally cool. It felt weird and un-me, but very awesome.
We head out to the free clinic. It was fascinating to observe my preceptor in a different element -- it was intriguing to tease out what qualities/behaviors were specific to a particular context, vs. specific to him. I admired him all the more.
All of a sudden -- BAM, I'm given a chart and told to go take a history and present. I did. I felt totally comfortable. I presented the case to my preceptor and was totally calm. I accomplished goal #4, without even having requested the opportunity. BAM, second patient, do it again. Another ear-flushing! Patient's at check-out -- my preceptor says, "Go back in and take his blood pressure."
He remembered! Again, so touched.
I take his pressure and screw it up. 170/80. Obviously not. My preceptor shows up in the doorway. I tell him what I found, acknowledging that I know I did something wrong. He repeats it; we're used to this drill. Except he found 170/84. I didn't screw up, and we now had the opportunity to counsel him about the dangers of his undiagnosed hypertension.
Next character. I take blood pressure again and again screw it up. 210/120. No way. I suck. The nurse had recorded the pressure as 160/80-ish. I looked at my preceptor in despair, trying to laugh it off - but obviously very distressed. He took the pressure himself again. 210/118. "I agree with you, Dr. Marotta," he said.
He takes the patient's pulse, listens to his heart.
"What's the #1 cause of cardiac arrhythmia?"
I had almost like a 'Slum Dog Millionnaire' moment. We're in his pickup truck on my first night at the clinic in early March, en route to my first house call. He asks me that question. I don't know it, because I don't know anything at that point. He tells me it's hypertension. I write it down. I later transcribe it into an Excel spreadsheet. I vow to never forget that one friggin' fact, ever in my life. It was the first time I felt like a major idiot but immediately appreciated my capacity to learn something.
I feel my eyes gloss over. I smile with a confidence I've really never felt in his presence before.
"Hypertension."
He hands me the fundoscope. He remembered.
This time, I saw something alright. A bleeding retina. Retinal hemorrhage secondary to RIDICULOUS hypertension. My understanding is that it's a huge rarity to see such a thing as a medical student.
I still didn't see an optic disc, since it was obstructed by all this commotion. But for the first time, I believed that I would -- that I could. And I believed that remarkable things really do happen if you actively carve out your own opportunities -- that it's ok to ask for what you want, that as long as you're really excited about learning something, people really do want to teach you. That if you get over worrying about feeling like an idiot and just open yourself up to being and learning and experiencing, all things really are possible.
Friday, June 19, 2009
City Mouse's First Night in the Country
It's 10PM on a Friday night. I'm alone in an old house up a dirt road across from the clinic of my dreams. I have to carry a flashlight to get from the kitchen to my bedroom. I feel my way along the walls, fumbling for doorways and light bulb chains.
This somehow became my life.
Tonight, my preceptor showed me where to buy gluten-free food and a chill, cheap restaurant. There's kale, feta, egg whites, and lactose-free milk in the fridge. Surprisingly, I have a better Internet connection than at home. Triumph's in the shed (I drove him at 80 mph on the interstate on a bike rack for the first time -- he handled it better than I did). Across the street, a symbolic and practical representation of what I want to be and do with my life. Right here in this moment, all of my needs are met.
Except, I'm not particularly thrilled right now. I'm distracted by two unsettling events of today that I'm going to need to process before I can immerse myself in my new opportunity.
I assisted one of my favorite people today removing skin tags from a diabetic patient. I did the post-snip cauterization. What that entailed was taking a scalding hot wire and inserting it into the patient's open wound, singeing the skin and replacing blood with charcoal-esque ash. No joke.
I'd seen cauterization during a few GI surgeries I've observed -- but it NEVER occurred to me that this would be done to an awake person on the surface of their skin. Insane. But very cool.
The patient didn't have a particularly thorough sense of what was going on with this procedure, with her disease, with much of anything. But suddenly, before we began, a coherent thought rang out: "Has she ever done this before?"
Holy shit. That "she" is me. Shit. What do I say? I can't lie. I can't lie. I won't lie. Shit. Wait. She's not talking to me. I don't have to answer. Look straight ahead. Avoid eye contact. Avoid eye movement. Let the professional handle this. Breathe.
"Sure, she has."
Oh gosh. That wasn't supposed to go that way.
I felt guilty -- guilty about in any way being party to a misrepresentation, guilty about having been relieved to get a "break" from accepting responsibility for reality. I promised myself I would USE this. I had to. Otherwise I couldn't justify it. I would use this as a prompt to process how I would respond if I were asked the question myself. I'm going to be asked, repeatedly even, by multiple people. Just as I coach people on their bikes, anticipating a challenge and rehearsing a response to it is absolutely the way to go. But no responses came to mind. I made a mental 'note to self' to ask my preceptor how he handled this in medical school.
The day progresses. I saw some familiar patterns and story lines, found myself readily recognizing things that had been brand new even a few weeks ago. Made a few useful observations, asked a few useful questions. Took blood pressure and not only didn't fumble and embarrass myself, but actually obtained the same measurement as my preceptor. My confidence, my calmness, drastically changed. I felt legitimately competent.
A few hours later, I was at dinner with my preceptor to discuss our project, which now has a significantly larger health literacy assessment component (as this is my priority in life, for better or for worse). Got onto the subject of "non-compliance" -- but instead of the inspiring experience I had discussing this life approach paradigm shift that I'd had with this particular character in DC, I walked away feeling demoralized and discouraged. Maybe I really AM naive to believe most fervently that patient's understanding of what they're taking, why they're taking it, how they're taking it, etc. is the rate-limiting mediator of all other outcomes. Educating people at the onset, empowering them to play an active role in their own lives, MUST affect how regularly they take their meds. Misunderstandings are qualitatively different than "yeah, I know, I just don't take 'em all the time," for sure. But either way, it boils down to a miscommunication, a mismatch between the goals/values of the provider and the patient. "Non-compliance" is a cop-out.
I was disappointed by this conversation, in that I had built up this fantastic image of my preceptor as a champion of this cause. Again, expectations are everything. He's inspiring and amazing for other reasons, and I need to compartmentalize my frustration and discouragement and get back to learning and experiencing. This is how I see the world and, while I don't need to apologize for it, I also don't need to talk about it so much. It means something, but not everything.
And I need to be ok with that.
This somehow became my life.
Tonight, my preceptor showed me where to buy gluten-free food and a chill, cheap restaurant. There's kale, feta, egg whites, and lactose-free milk in the fridge. Surprisingly, I have a better Internet connection than at home. Triumph's in the shed (I drove him at 80 mph on the interstate on a bike rack for the first time -- he handled it better than I did). Across the street, a symbolic and practical representation of what I want to be and do with my life. Right here in this moment, all of my needs are met.
Except, I'm not particularly thrilled right now. I'm distracted by two unsettling events of today that I'm going to need to process before I can immerse myself in my new opportunity.
I assisted one of my favorite people today removing skin tags from a diabetic patient. I did the post-snip cauterization. What that entailed was taking a scalding hot wire and inserting it into the patient's open wound, singeing the skin and replacing blood with charcoal-esque ash. No joke.
I'd seen cauterization during a few GI surgeries I've observed -- but it NEVER occurred to me that this would be done to an awake person on the surface of their skin. Insane. But very cool.
The patient didn't have a particularly thorough sense of what was going on with this procedure, with her disease, with much of anything. But suddenly, before we began, a coherent thought rang out: "Has she ever done this before?"
Holy shit. That "she" is me. Shit. What do I say? I can't lie. I can't lie. I won't lie. Shit. Wait. She's not talking to me. I don't have to answer. Look straight ahead. Avoid eye contact. Avoid eye movement. Let the professional handle this. Breathe.
"Sure, she has."
Oh gosh. That wasn't supposed to go that way.
I felt guilty -- guilty about in any way being party to a misrepresentation, guilty about having been relieved to get a "break" from accepting responsibility for reality. I promised myself I would USE this. I had to. Otherwise I couldn't justify it. I would use this as a prompt to process how I would respond if I were asked the question myself. I'm going to be asked, repeatedly even, by multiple people. Just as I coach people on their bikes, anticipating a challenge and rehearsing a response to it is absolutely the way to go. But no responses came to mind. I made a mental 'note to self' to ask my preceptor how he handled this in medical school.
The day progresses. I saw some familiar patterns and story lines, found myself readily recognizing things that had been brand new even a few weeks ago. Made a few useful observations, asked a few useful questions. Took blood pressure and not only didn't fumble and embarrass myself, but actually obtained the same measurement as my preceptor. My confidence, my calmness, drastically changed. I felt legitimately competent.
A few hours later, I was at dinner with my preceptor to discuss our project, which now has a significantly larger health literacy assessment component (as this is my priority in life, for better or for worse). Got onto the subject of "non-compliance" -- but instead of the inspiring experience I had discussing this life approach paradigm shift that I'd had with this particular character in DC, I walked away feeling demoralized and discouraged. Maybe I really AM naive to believe most fervently that patient's understanding of what they're taking, why they're taking it, how they're taking it, etc. is the rate-limiting mediator of all other outcomes. Educating people at the onset, empowering them to play an active role in their own lives, MUST affect how regularly they take their meds. Misunderstandings are qualitatively different than "yeah, I know, I just don't take 'em all the time," for sure. But either way, it boils down to a miscommunication, a mismatch between the goals/values of the provider and the patient. "Non-compliance" is a cop-out.
I was disappointed by this conversation, in that I had built up this fantastic image of my preceptor as a champion of this cause. Again, expectations are everything. He's inspiring and amazing for other reasons, and I need to compartmentalize my frustration and discouragement and get back to learning and experiencing. This is how I see the world and, while I don't need to apologize for it, I also don't need to talk about it so much. It means something, but not everything.
And I need to be ok with that.
Thursday, June 18, 2009
What I Learned During My First Year of Medical School
1. Expectations are everything, and there's a difference between "low expectations" and "no expectations."
My roommate often observes that I expect things to be "the best thing ever in the whole world" and am thus ALWAYS disappointed by the anticlimactic nature of EVERYTHING. I accept this as a premise: that everything is always at least SLIGHTLY sub-"best thing ever in the whole world," and by definition falls short of my expectations. I reject the approach of expecting little, and thus being pleasantly surprised when reality exceeds those low expectations; that's guaranteed but largely non-gratifying.
When we were in DC, my preceptor suggested this concept of flaneur -- wandering through one's experiences without interpreting them. Just taking it all in. No expectations, no interpretations. Just soaking it up, processing it a bit, tucking it away for another day. I so very much identified with this concept as an adaptive way to adjust to my new life, and it absolutely works for me. While I am consistently asking myself "Is this really my life?" (i.e., the baby lamb wandering around the dinner party; the pony trotting around across the road from the clinic; the guy who cuts his leg off with a chainsaw), I'm not distracted by the surprises and inconsistencies. I don't experience them as such. They just are.
2. "To care for a person, you must BE a person." Those nut jobs in the library at 3AM aren't happy.
I don't know many first-year medical students who hold a job, read for pleasure every night, sleep 7 hours, maintain two high-traffic blogs, and train for major endurance events. But I'm proud to be one of them.
My roommate, a med student in the class above mine, epitomizes life balance. She has been a tremendous influence on me, from the onset. I adopted a P = MD mentality within the second week of medical school (many of my classmates got there eventually but I started shootin' to pass from the very start). I was awkward and uncomfortable with it at first, guilty -- how could I NOT feel compelled to master everything that could ever possibly help me help someone whose life depended on it? Turns out, even if I tried, I still couldn't. A very wise classmate of my roommate observed to me during the second week of school (at the gym, symbol of life balance): "You're never going to be 'caught up.' If you wait to be caught up before you make time for you, you will never ever make time.' He was totally right. School is out for the summer and I'm STILL not caught up. But I'm happy. And I learned how to organize my thoughts, the things I encode and retrieve -- and how to look up things when I need them. I'll be re-learning those processes for the rest of my life.
3. Tapping into "pet" themes and concepts that empower and inspire me are important coping mechanisms.
Over the past 10 months, I've had several of such themes/concepts arise. Self-efficacy, of course. The patient/physician "partnership" construct (and its resultant rejection of the term "compliance" and related mindless paternalisms). "Inhabiting a person's existence." Those have been my Big 3 for the year. I think about them all the time, read what other people are publishing on them, plot how to weave them into my present and future daily existence, dream of how to understand and do and be better.
4. People actually don't expect you NOT to suck.
Who knew?
5. Processing the subtleties of your experiences while they're fresh gives them so much more "staying power."
This blog and my other are my #1 coping mechanism for navigating the challenges of my world. When I'm distressed, if I don't write about it, I distract myself to no end. I haven't written in a while, for example, and have been imbalanced, chaotic, and unproductive. If I process something meaningful, however, I learn from it and take it with me. It works.
6. My life is shaped by the characters I meet, and the words I choose to hear, process, and speak. I am in complete control over how much of that I attend to.
Last night, I heard a story from a wonderful woman whose teenage daughter had difficulty finding peers with whom to connect, finding her place in the world, until she haphazardly met traveling Eastern European musicians who enlightened her to a whole new culture -- and she's now traveling the world performing and studying and learning and growing and.... wow. All because of these completely random characters she happened to encounter. Great story, right?
I've been so fortunate to have so many formative "life characters" of my own, each of them playing a very specific role at a specific point in time. Sometimes I appreciate that in the moment, sometimes I appreciate it far later. But I'm always mindful of it, always curiously observing how that influence is going to evolve.
Last week, I went to a talk given by a Chicago surgeon who graduated from UVM 45 years ago. He offered some advice that, while not life-altering or paradigm-shifting by and large, seemed consistent with how I see the world. So after the talk, I approached him to ask him a question that had been on my mind and distracting me (about which I'd NOT been blogging -- see: #5).
I told him that, while I've been fortunate to meet many positive/enlightened influences, I am SO contemptuous and discouraged by anyone who speaks in patient-uncentered terms (i.e., "non-compliance") and that I wondered his thoughts on coping with exposure to that sort of negative energy. His reply? "Tell yourself it doesn't matter. They're not ready to see the world a different way. But you are. Go with it."
7. "Pursuit of Success" is qualitatively different than "Avoidance of Failure."
When I enter into an intimidating academic or clinical situation, I find myself thinking: 'Don't screw up.' That's absolutely NOT helpful. Even "It's ok. You won't screw this up.' isn't helpful.
'You will rock this,' 'You will do this,' 'You will be awesome at this' is really where that self-talk needs to be. But of course, see #4.
8. Even though I still know NOTHING in the big scheme of things, I know a RIDICULOUS amount of stuff. It's INSANE how much I know. (But I still know nothing.)
'Nough said.
9. Finding an equal/opposite force to balance the profound feeling of uselessness/incompetency with usefulness/mastery is absolutely key.
My coaching/cycling-blogging life affords me the opportunity to feel like a knowledgeable resource EVERY day. That balance is BEYOND important to me. It's why I invest so much time in that part of my life. As a first-year medical student, the ratio of 'things you know' to 'things you've never even heard of before' is BEYOND miniscule. It's a hard reference point: being 0% of an expert in "this thing" you've decided to do with the rest of your life. So tapping into the notion that spending hours-I-don't-really-have is essential to my view of myself in the world, that was pretty key.
10. For all my struggles to balance my "coaching" life with my "physician-in-training" life, they're the same damned thing. There's nothing to balance.
* Empowering people to identify their own values and goals
* Empowering people to make their own choices consistent with those values/goals
* Offering expertise and guidance towards the pursuit of preventive wellness and improvements to challenges
I've actually started planning training sessions that are based entirely on this concept. I'll write more about it on Spintastic soon. But I believe most firmly that what I'm doing in the Spinning studio is a direct reflection of how I'm going to try my darnedest to be with my patients.
If a Spinner stayed in the saddle when I coached my class to stand, would I call that person "non-compliant?" Obviously not; that would be ridiculous. (This argument spontaneously came to me, and it's the best one I've ever heard. I plan to make it repeatedly). Would I expect a Spinner to train at certain heart rates and buy expensive shoes/clothing... if I didn't take the time to educate him or her as to why I was recommending such a thing, and to provide that education in the context of his or her specific goals and values? Again, obviously not.
So why on earth would I approach medicine any differently?
I wouldn't.
There's a reason I've started cross-linking this blog with Spintastic. The themes that arise in both realms in my life are really mostly the same. Because I designed it that way.
If nothing else, this year has been about THAT. Carving out a very specific fusion of the way things should and should not be, just because I said so.
And with that, thus concludes my first year of medical school.
My roommate often observes that I expect things to be "the best thing ever in the whole world" and am thus ALWAYS disappointed by the anticlimactic nature of EVERYTHING. I accept this as a premise: that everything is always at least SLIGHTLY sub-"best thing ever in the whole world," and by definition falls short of my expectations. I reject the approach of expecting little, and thus being pleasantly surprised when reality exceeds those low expectations; that's guaranteed but largely non-gratifying.
When we were in DC, my preceptor suggested this concept of flaneur -- wandering through one's experiences without interpreting them. Just taking it all in. No expectations, no interpretations. Just soaking it up, processing it a bit, tucking it away for another day. I so very much identified with this concept as an adaptive way to adjust to my new life, and it absolutely works for me. While I am consistently asking myself "Is this really my life?" (i.e., the baby lamb wandering around the dinner party; the pony trotting around across the road from the clinic; the guy who cuts his leg off with a chainsaw), I'm not distracted by the surprises and inconsistencies. I don't experience them as such. They just are.
2. "To care for a person, you must BE a person." Those nut jobs in the library at 3AM aren't happy.
I don't know many first-year medical students who hold a job, read for pleasure every night, sleep 7 hours, maintain two high-traffic blogs, and train for major endurance events. But I'm proud to be one of them.
My roommate, a med student in the class above mine, epitomizes life balance. She has been a tremendous influence on me, from the onset. I adopted a P = MD mentality within the second week of medical school (many of my classmates got there eventually but I started shootin' to pass from the very start). I was awkward and uncomfortable with it at first, guilty -- how could I NOT feel compelled to master everything that could ever possibly help me help someone whose life depended on it? Turns out, even if I tried, I still couldn't. A very wise classmate of my roommate observed to me during the second week of school (at the gym, symbol of life balance): "You're never going to be 'caught up.' If you wait to be caught up before you make time for you, you will never ever make time.' He was totally right. School is out for the summer and I'm STILL not caught up. But I'm happy. And I learned how to organize my thoughts, the things I encode and retrieve -- and how to look up things when I need them. I'll be re-learning those processes for the rest of my life.
3. Tapping into "pet" themes and concepts that empower and inspire me are important coping mechanisms.
Over the past 10 months, I've had several of such themes/concepts arise. Self-efficacy, of course. The patient/physician "partnership" construct (and its resultant rejection of the term "compliance" and related mindless paternalisms). "Inhabiting a person's existence." Those have been my Big 3 for the year. I think about them all the time, read what other people are publishing on them, plot how to weave them into my present and future daily existence, dream of how to understand and do and be better.
4. People actually don't expect you NOT to suck.
Who knew?
5. Processing the subtleties of your experiences while they're fresh gives them so much more "staying power."
This blog and my other are my #1 coping mechanism for navigating the challenges of my world. When I'm distressed, if I don't write about it, I distract myself to no end. I haven't written in a while, for example, and have been imbalanced, chaotic, and unproductive. If I process something meaningful, however, I learn from it and take it with me. It works.
6. My life is shaped by the characters I meet, and the words I choose to hear, process, and speak. I am in complete control over how much of that I attend to.
Last night, I heard a story from a wonderful woman whose teenage daughter had difficulty finding peers with whom to connect, finding her place in the world, until she haphazardly met traveling Eastern European musicians who enlightened her to a whole new culture -- and she's now traveling the world performing and studying and learning and growing and.... wow. All because of these completely random characters she happened to encounter. Great story, right?
I've been so fortunate to have so many formative "life characters" of my own, each of them playing a very specific role at a specific point in time. Sometimes I appreciate that in the moment, sometimes I appreciate it far later. But I'm always mindful of it, always curiously observing how that influence is going to evolve.
Last week, I went to a talk given by a Chicago surgeon who graduated from UVM 45 years ago. He offered some advice that, while not life-altering or paradigm-shifting by and large, seemed consistent with how I see the world. So after the talk, I approached him to ask him a question that had been on my mind and distracting me (about which I'd NOT been blogging -- see: #5).
I told him that, while I've been fortunate to meet many positive/enlightened influences, I am SO contemptuous and discouraged by anyone who speaks in patient-uncentered terms (i.e., "non-compliance") and that I wondered his thoughts on coping with exposure to that sort of negative energy. His reply? "Tell yourself it doesn't matter. They're not ready to see the world a different way. But you are. Go with it."
7. "Pursuit of Success" is qualitatively different than "Avoidance of Failure."
When I enter into an intimidating academic or clinical situation, I find myself thinking: 'Don't screw up.' That's absolutely NOT helpful. Even "It's ok. You won't screw this up.' isn't helpful.
'You will rock this,' 'You will do this,' 'You will be awesome at this' is really where that self-talk needs to be. But of course, see #4.
8. Even though I still know NOTHING in the big scheme of things, I know a RIDICULOUS amount of stuff. It's INSANE how much I know. (But I still know nothing.)
'Nough said.
9. Finding an equal/opposite force to balance the profound feeling of uselessness/incompetency with usefulness/mastery is absolutely key.
My coaching/cycling-blogging life affords me the opportunity to feel like a knowledgeable resource EVERY day. That balance is BEYOND important to me. It's why I invest so much time in that part of my life. As a first-year medical student, the ratio of 'things you know' to 'things you've never even heard of before' is BEYOND miniscule. It's a hard reference point: being 0% of an expert in "this thing" you've decided to do with the rest of your life. So tapping into the notion that spending hours-I-don't-really-have is essential to my view of myself in the world, that was pretty key.
10. For all my struggles to balance my "coaching" life with my "physician-in-training" life, they're the same damned thing. There's nothing to balance.
* Empowering people to identify their own values and goals
* Empowering people to make their own choices consistent with those values/goals
* Offering expertise and guidance towards the pursuit of preventive wellness and improvements to challenges
I've actually started planning training sessions that are based entirely on this concept. I'll write more about it on Spintastic soon. But I believe most firmly that what I'm doing in the Spinning studio is a direct reflection of how I'm going to try my darnedest to be with my patients.
If a Spinner stayed in the saddle when I coached my class to stand, would I call that person "non-compliant?" Obviously not; that would be ridiculous. (This argument spontaneously came to me, and it's the best one I've ever heard. I plan to make it repeatedly). Would I expect a Spinner to train at certain heart rates and buy expensive shoes/clothing... if I didn't take the time to educate him or her as to why I was recommending such a thing, and to provide that education in the context of his or her specific goals and values? Again, obviously not.
So why on earth would I approach medicine any differently?
I wouldn't.
There's a reason I've started cross-linking this blog with Spintastic. The themes that arise in both realms in my life are really mostly the same. Because I designed it that way.
If nothing else, this year has been about THAT. Carving out a very specific fusion of the way things should and should not be, just because I said so.
And with that, thus concludes my first year of medical school.
Effective Self-efficacy.
I coached a ride for my mindfulness/cycling fusion class Tuesday night called "Triumph Over Adversity." The idea was to inhabit a moment in the near or distant past in which one truly felt accomplished, after completing SOMETHING that meant something to them. After identifying that moment, I coached my riders to re-experience the reasons they were even undertaking that particular challenge and to channel, through each of their senses, a connection with what it felt like to pull it off. What they learned. How they changed. What they now felt uniquely qualified to do.
I was to present this ride the night after my final exam of my first year of medical school. Yet when I was preparing for it, the "moment" I selected to 'process' myself was NOT what one would expect me to have chosen. Why not? Because I hadn't accomplished it. Deep down, without the confirmation of a grade, I believed that I hadn't pulled it off. I rehearsed coping mechanisms for how to respond to being presented with the news that I'd failed. I expected to fail. In my next entry on what I learned this year, I'll talk about the appreciation that expectation is everything. And my expectation was completely inconsistent with the pursuit of success; my entire mindset was that of avoidance vs. failure to avoid failure.
So today, I got that grade on which my determination of "completion" was to be based. I not only passed, but I rocked it. And when I saw that confirmation, that validation of some of the toughest, most discouraging 8 weeks of my life -- to culminate 10 months of the intellectual and emotional roller coaster that is the first year of medical school, I cried.
But as I sat there crying for 20 minutes, I DIDN'T think: "Holy shit, I didn't fail."
I thought, "Holy shit, I did it." Because I did.
It's been a pretty maladaptive, dysfunctional few months marked by more self-pity and poor coping mechanisms than I'd like to admit. After a month of subtly waning motivation and not-so-subtly growing frustration (partially attributed to micronutrient deficiency, partially attributed to pure distaste for most of the brain), I had the sub-ideal experience of incurring a concussion. So on top of my vague physiological/cognitive deficits, I stopped being able to read/articulate sentences longer than a few sentences (before I'd forget how they began). My 23-day headache was also sub-ideal. 'Really?' I kept asking myself. 'No. Really?'
My self-pity ran deeper than my pulled trapezius. I didn't want to DO anything, be anywhere, learn anything. I just wanted to wallow and sleep and eat and think about all the things I was supposed to be but was absolutely not. I stopped riding my bike, distracted by my anticipatory anxiety, and got quite proficient at rationalizing my avoidance. Nice way to engage one's favorite hobby.
I met with my course director after BOMBING an exam. She crunched the numbers for me and identified what sort of grades I'd need to pull on the last exam in order to pull this off. Somehow the sheer act of inspiring HOPE -- it made the difference. The haze cleared, the contexts settled. I believed it was within the scope of my control that I WOULD 'do' this.
This was an exercise in learning the difference between living a life of self-efficacy and living a life without it. As much as I talk and think and write about this construct within my physician-in-training and coaching lives, while I've absolutely appreciated and been grateful for the fact that I possess it, I don't think I really processed it deeply enough. In forensics, we speak of context being everything. Competency is task-specific (i.e., one can be competent to draft a will but not competent to stand trial) -- turns out, so is self-efficacy. I absolutely 100% believe that I will excel at many things: I can write, I can coach, I can listen, I can interpret, I can carry a decent conversation. But I do NOT believe that I can do the perfect eye or lung exam, master neuro physiology, create the perfect patient education program. I really don't. And that's why I become a clumsy, blubbering idiot when I'm doing ANY physical exam, taking an anatomy practical, and all of the other things I absolutely suck at.
Is there even such a THING as global self-efficacy -- that thing I was supposed to study next, after I wrap up my first-round HRM study next month? Now I'm not so sure.
What I did learn, however, is that I don't think it matters. If I want to be good at something, I really just need to do it enough times to believe that I can do it. I can suck at it over and over and over and over and over again -- and then, eventually, I won't suck at it. Not "I might not suck at it." I won't suck at it. EVERY beginning starts like that. I don't know why I ever expected this to be differently.
Last week, I had to introduce the director of the clinic to speak before my class -- a talk I'd organized, about which I was INCREDIBLY anxious. I wrote a beautiful introduction. Got up there, deep breaths, all the stuff I talk about ad nauseum... and then I blanked. Words just didn't come out. I felt my heart rate rising faster than my breath could control, the sweat dripping, my chest tightening -- it felt so familiar, as though I hadn't NOT had a panic attack in TWO YEARS. 'Really?' I asked myself. 'No. Really?'
I managed out a few words and sat down to properly complete my panic attack. Really.
I was beyond discouraged. I do NOT have a problem with public speaking. I addressed my college graduating class and their families at graduation with no problem --thousands of people. I espoused the cheesiest, most emotionally gushy stuff imaginable before over a hundred people just three months ago. I speak before 25-40 people almost every day. But my goal wasn't to speak, in that moment. My goal was to impress this guy who has inspired me so much, and I did NOT possess self-efficacy to do it. I did not believe that, deep down no matter what, that this guy would like me. Validation as a deficient pre-requisite for 'self-efficacy to impress?' A fascinating construct. It's NOT ok -- but it's a fascinating mechanism to explain a phenomenon that strikes me far too often. So I'm rollin' with it.
This summer, I am investing in context-specific self-efficacy development:
1) Self-efficacy to perform two basic physical exam skills that make me anxious and really need to not make me anxious: blood pressure and fundoscopy
2) Self-efficacy to ride my bike without hitting my head on concrete
3) Self-efficacy to control my physiological response to perceived self-inefficacy.
This entry wasn't supposed to go like this. It was awkward to write, awkward to re-read. I almost just deleted it all. But this blog isn't supposed to be about cheerful rainbows and sunflowers and whatever. It's supposed to be about the important subtleties of what I appreciate during my training. The appreciation that one can recognize when one absolutely sucks at something and can formulate a plan to address it -- I'll take that over a rainbow any day.
I was to present this ride the night after my final exam of my first year of medical school. Yet when I was preparing for it, the "moment" I selected to 'process' myself was NOT what one would expect me to have chosen. Why not? Because I hadn't accomplished it. Deep down, without the confirmation of a grade, I believed that I hadn't pulled it off. I rehearsed coping mechanisms for how to respond to being presented with the news that I'd failed. I expected to fail. In my next entry on what I learned this year, I'll talk about the appreciation that expectation is everything. And my expectation was completely inconsistent with the pursuit of success; my entire mindset was that of avoidance vs. failure to avoid failure.
So today, I got that grade on which my determination of "completion" was to be based. I not only passed, but I rocked it. And when I saw that confirmation, that validation of some of the toughest, most discouraging 8 weeks of my life -- to culminate 10 months of the intellectual and emotional roller coaster that is the first year of medical school, I cried.
But as I sat there crying for 20 minutes, I DIDN'T think: "Holy shit, I didn't fail."
I thought, "Holy shit, I did it." Because I did.
It's been a pretty maladaptive, dysfunctional few months marked by more self-pity and poor coping mechanisms than I'd like to admit. After a month of subtly waning motivation and not-so-subtly growing frustration (partially attributed to micronutrient deficiency, partially attributed to pure distaste for most of the brain), I had the sub-ideal experience of incurring a concussion. So on top of my vague physiological/cognitive deficits, I stopped being able to read/articulate sentences longer than a few sentences (before I'd forget how they began). My 23-day headache was also sub-ideal. 'Really?' I kept asking myself. 'No. Really?'
My self-pity ran deeper than my pulled trapezius. I didn't want to DO anything, be anywhere, learn anything. I just wanted to wallow and sleep and eat and think about all the things I was supposed to be but was absolutely not. I stopped riding my bike, distracted by my anticipatory anxiety, and got quite proficient at rationalizing my avoidance. Nice way to engage one's favorite hobby.
I met with my course director after BOMBING an exam. She crunched the numbers for me and identified what sort of grades I'd need to pull on the last exam in order to pull this off. Somehow the sheer act of inspiring HOPE -- it made the difference. The haze cleared, the contexts settled. I believed it was within the scope of my control that I WOULD 'do' this.
This was an exercise in learning the difference between living a life of self-efficacy and living a life without it. As much as I talk and think and write about this construct within my physician-in-training and coaching lives, while I've absolutely appreciated and been grateful for the fact that I possess it, I don't think I really processed it deeply enough. In forensics, we speak of context being everything. Competency is task-specific (i.e., one can be competent to draft a will but not competent to stand trial) -- turns out, so is self-efficacy. I absolutely 100% believe that I will excel at many things: I can write, I can coach, I can listen, I can interpret, I can carry a decent conversation. But I do NOT believe that I can do the perfect eye or lung exam, master neuro physiology, create the perfect patient education program. I really don't. And that's why I become a clumsy, blubbering idiot when I'm doing ANY physical exam, taking an anatomy practical, and all of the other things I absolutely suck at.
Is there even such a THING as global self-efficacy -- that thing I was supposed to study next, after I wrap up my first-round HRM study next month? Now I'm not so sure.
What I did learn, however, is that I don't think it matters. If I want to be good at something, I really just need to do it enough times to believe that I can do it. I can suck at it over and over and over and over and over again -- and then, eventually, I won't suck at it. Not "I might not suck at it." I won't suck at it. EVERY beginning starts like that. I don't know why I ever expected this to be differently.
Last week, I had to introduce the director of the clinic to speak before my class -- a talk I'd organized, about which I was INCREDIBLY anxious. I wrote a beautiful introduction. Got up there, deep breaths, all the stuff I talk about ad nauseum... and then I blanked. Words just didn't come out. I felt my heart rate rising faster than my breath could control, the sweat dripping, my chest tightening -- it felt so familiar, as though I hadn't NOT had a panic attack in TWO YEARS. 'Really?' I asked myself. 'No. Really?'
I managed out a few words and sat down to properly complete my panic attack. Really.
I was beyond discouraged. I do NOT have a problem with public speaking. I addressed my college graduating class and their families at graduation with no problem --thousands of people. I espoused the cheesiest, most emotionally gushy stuff imaginable before over a hundred people just three months ago. I speak before 25-40 people almost every day. But my goal wasn't to speak, in that moment. My goal was to impress this guy who has inspired me so much, and I did NOT possess self-efficacy to do it. I did not believe that, deep down no matter what, that this guy would like me. Validation as a deficient pre-requisite for 'self-efficacy to impress?' A fascinating construct. It's NOT ok -- but it's a fascinating mechanism to explain a phenomenon that strikes me far too often. So I'm rollin' with it.
This summer, I am investing in context-specific self-efficacy development:
1) Self-efficacy to perform two basic physical exam skills that make me anxious and really need to not make me anxious: blood pressure and fundoscopy
2) Self-efficacy to ride my bike without hitting my head on concrete
3) Self-efficacy to control my physiological response to perceived self-inefficacy.
This entry wasn't supposed to go like this. It was awkward to write, awkward to re-read. I almost just deleted it all. But this blog isn't supposed to be about cheerful rainbows and sunflowers and whatever. It's supposed to be about the important subtleties of what I appreciate during my training. The appreciation that one can recognize when one absolutely sucks at something and can formulate a plan to address it -- I'll take that over a rainbow any day.
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