Sunday, September 27, 2009

Acceptance & Loneliness... or Accepting Loneliness.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Saturday, September 12, 2009

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

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

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

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

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

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

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

Say something. Anything.

"I'm sorry you're in so much pain..." I started.
She moaned.
"Please help me.... please help me.... can't someone help m..." she trailed off.

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

"We're going to do everything we can to get to the bottom of what's causing your pain."
"Please help me.... please....."
"We're going to try to figure out what's causing this, and help you get better..."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thursday, September 3, 2009

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

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

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

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

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

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

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

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

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

Then I remembered Operation: Acceptance.

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

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

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

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

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

And in that moment, reality was ok.