Thursday, February 25, 2010


Mmm. To unify the epic events of the past two infinitely-eventful-yet-blogless months: quite the daunting task. Starting this entry whilst sitting in an airport on layover awaiting a connecting flight home, part of me is sub-motivated to write at all. If I don't write, after all, I can't craft a mediocre product.

But the fact is, whatever I write not only should be "enough" - but will be. That's what the past two months have been about.

The last time I went two months without documenting the formative events of my world, both drastic and subtle, was Fall 2008 when I was dissecting cadavers and doubting my self-worth. Then, no matter how widely I opened my mouth to catch as much of the violently explosive stream of water gushing at me from the Hose of Medical Education, I couldn't learn or see or do or be enough. How on earth was I going to internalize enough information to earn the privilege of caring for a human being? To inspire trust and confidence?

Over the past 1.5 years, this theme of doing "enough" has been well borne out in my writings - and certainly in my thoughts. Am I studying enough? Am I reflecting enough? Am I balanced enough? Am I structured enough? Am I focused enough? Am I open enough? Have I earned enough? Have I re-earned and re-earned and re-earned enough? Am I confident enough? Am I self-critical enough? Am I self-forgiving enough? Do I feel enough? Am I "present" enough? Do I connect enough? Am I inspired enough?

Am I prepared enough?

Three weeks ago, I had my last day at the rural clinic where I've spent > 10 hours a week for the past year. Ironically, my last day was exactly one year from the first time I drove out to meet them (my first solo Interstate drive -- which, looking back on that post from the age of fake-driverdom, was such a big deal!). And just as that day forever changed my life, so will this one. My anniversary/departure rang of true synchronicity. Of course it would also be the day of a full staff meeting, where I got to bid adieu to everyone en mass (and receive the warmest of applauses) - where my hero would present me with a symbolic gift of the legendary William Osler's original "The Principles and Practice of Medicine" (1901), citing one of Osler's famous quotables acknowledging how much he learns from his students. Obviously, I cried in front of the whole clinic staff. Obviously. Of course we would drive through the snowy, winding hills to pay house calls -- just like on my very first day shadowing. Of course we would even see patients in clinic that I remember first seeing on that same first day. Of course I would have built-in opportunities for reflection, according to specific parameters, on how much has changed (my shift in the confidence:awkwardness ratio; my appreciation for being useful in some capacities) and how much has remained the same (how inspired I am by the energy of this place, these people; how fulfilling it is to connect with people, to understand the context of their family and community, to build on that understanding over time). Of course I took epically rewarding opportunities to thank my mentors, with great specificity, for what they have contributed to my world. I wrote to the clinic's executive director how it had been my dream to get accepted to medical school in Vermont, only to have access to meet him and see this clinic once -- let alone have the opportunity to actually train here, let alone for a whole year. I wrote to my PA mentor how invaluable it was to have someone so gifted so deeply and passionately believe in my ability to "do this" before I believed it myself. I wrote to my direct preceptor that I will spend my life working to match his balance of unfailing compassion, mindful self-reflection, and commitment to improvement of all kinds.

And when I walked out that door, I thought about what the executive director told me on my first day there: "In medical school, I always felt like an imposter... until one day, I didn't."

Beyond the hundreds of thousands of tangible and intangible things I've learned through this opportunity over the past year, beyond the influences of the energy and personalities and experiences, what made all of this all the more rewarding is that I created all of it. It didn't merely "happen." I found them, I sought them out. I decided very early that the more time I spent there, the more I would learn. Do I study books as much as other people? No. Is that bad? Maybe. But the difference is: the stuff I learned at clinic, I actually remember.

Which brings us to Influential Life Event #2. Last week, I took Step 1 of the United States Medical Licensing Exam. 6 hours of torturous convoluted questions on the basic sciences, genetics, and vague clinical correlations. Preparing for it has consumed my existence for the past two months -- particularly my "brain space" for self-reflection, self-nourishment, and self-other good things requisite for successful human functioning. I've spent most of the past month in particular glued to my kitchen table (across from my equally miserable roommate, preparing for the same exam) taking thousands of practice questions, displacing relevant and irrelevant knowledge with every extra factoid encoded, doubting my self-worth. Frustration, boredom, distraction were wicked breeding grounds for high-level procrastination. It was easier to make Spinning rides about some variant of the process than to actually engage in the process.

Did I study as much as other people? No. Did I make questionable choices of how I spent my time (i.e., packing up my apartment prematurely, snuggling with Scott, holding extra 2-hour endurance trainings for my riders, eating gluten and lactose, spending hours hanging out at clinic)? I'd argue that every one of those were good choices.

Why? I knew I didn't know everything, and would never know everything. Acknowledging that is less acceptance of mediocrity as I'd once surmised earlier in medical school; rather, it's setting reasonable, realistic, specific goals (i.e., to pass with a 20 point margin) and continue to invest in my big picture. I knew damned well that I knew a LOT. I knew a lot with great specificity. Not everything. Not even 50% of everything. But I thought that maybe, just maybe, I knew enough. And when I made that decision, suddenly my entire approach changed. I no longer feared Step 1. I no longer dreaded it. It was one big, epic "GAME ON!" -- the pursuit of success and conequest, not merely the avoidance of failure. There's a difference. And it matters.

It mattered on Game Day. Yes, there were tons of questions I didn't have the slightest clue how to answer. Yes, there were times where I muttered - literally, out loud - "are you kidding me?!" (ok, maybe I wasn't that polite/professional). But by and large, I saw a heck of a lot more opportunities to demonstrate the effectiveness of my preparation and knowledge base than obstacles to "endure." It's just how I coach people on the bike: directing one's attitude, choosing to perceive challenges as "opportunities" to demonstrate SOMETHING (strength, discipline, control, etc.) as opposed to something to suffer.

A lot of my friends told me that they "checked out" at times during the exam -- their minds wandering to skiing, to vacations, to sex. My mind wandered to snapshots, memories, of where or how I learned something. It was like Slumdog Millionaire. Sometimes it was a memory of a specific lecturer's memorable one-liner. Sometimes it was of my preceptor sharing a particular clinical pearl. But mostly, I had images of patients I'd seen at clinic. I'd read a question, admit that I either never read or never encoded this in an academic setting, sigh - and then all of a sudden, trigger a vision of someone and something I knew I'd seen. BAM. This happened over, and over and over again.

For the first time in medical school, I felt like I knew -- and was -- "enough."

I wanted to write about two subsequent life-altering experiences -- flying with my boyfriend to his hometown in rural North Carolina to meet 50+ of my future-in laws for the first time, and then reading an epically inspiring book, Every Patient Tells a Story (Lisa Sanders, M.D.). I've had so many thoughts and moments flying through my head that directly relate to the theme at hand. But I'm also supposed to be packing up my entire life into cardboard boxes and garbage bags, in efforts to move to a new state in 36 hours.

I've used this blog over the course of my training to date as a mechanism for processing important experiences, re-shaping and re-structuring them in a way that I'll want to look back on as evidence for what I've thought about and valued, documenting both the patterns that endure and evolve. When I fail to carve out time to write, I experience it as "cheating" myself out of an invaluable opportunity. But it's not like that. When I start clerkship (inpatient rotations) on Monday, I'm going to have hundreds of thousands of experiences that I'll want to "document" and reflect upon. I won't. The balance between "reflecting" and "living"/"doing" is an important one. Maintaining a sense that I am continuously evaluating "enough" is a truly high priority for me. It's just a matter of defining, and redefining, what that means.