Zen and the Art of Digital Disimpaction -- Episode I

I'm nearing the end of my vacation period in my third year of medical school. Along with the traveling, sleeping-in and seeing old friends that has filled this month I have also been able to dive into some fiction reading -- reading that has nothing inherently to do with medicine. Even though I have a handful of books waiting for me at home, I had this feeling that I wanted to find something completely new, as if the books that I had been looking forward to reading had already been tainted with the sweet stench of medical education. When I was in Portland earlier this month, I made made my way to Powell's book store and stood in front of the huge selection of 'staff-picks' and without reading the back of the dust jacket picked out a book. I picked out a book based on title alone -- it was this one 'Rivers' by Micheal Farris Smith which ended up being a satisfying if not an excellent read.

So it was when my wife and I were at SFO headed to the plane to bring us to Florida (where I am right now) where I decided to do the same at a small bookstore in the airport. It was here where I found 'Look At Me' by Jennifer Egan which, again I chose without reading the synopsis on the back of the book. I'm not yet finished with this, but I imagine that I'll have it wrapped up by the time my last lazy-bum pool-side afternoon wraps up on Thursday. And, even though I'm not finished it I've found it to be an excellent novel -- one that intertwines dynamic explorations of pop culture, struggles of adolescence and (even more impressively) a honest look at the dangers of philosophy and what it means to be honest with one's self. A certain character (Moose) has had me thinking about Robert Persig's 'Zen and the Art of Motorcycle Maintenance' (ZAMM) more than I have in at least fifteen years.

I must have been around sixteen when I read this book, as I distinctly remember devouring most of the book while I was waiting at bus stops while I was going to and from my after school job at Red Robin. While I cannot remember many of the details of ZAMM, I remember well the feelings it generated within me. The fact that truths of this world can, at times, be very dangerous to the human mind is a sentiment that I think I've held on to -- and as I lay baking in the Florida sun yesterday, trying to pinpoint exactly where I came up with this idea, a memory of sitting at the 82nd and Division bus stop kept popping into my mind. I remember I was listening to Frank Black's 'Teenager of the Year' album (an all time favorite, to be sure) on my discman (skateboarding with a discman in my backpack was always filled with many skips, no matter how many seconds it would buffer. The news that the iPod will no longer be manufactured only serves to reinforce just how easy the punk kids have it these days) when I reached the penultimate part of ZAMM -- at least, from this reader's point of view. Again, the details are hazy, but I had this realization, through the novel's protagonist's struggles, that in order to gain some kind of realization of truth in this world, that a sacrifice was necessary -- and that, as far as I can see, anecdotally at least, it is always a sacrifice of self.

It is easy to to go through life operating on the surface. Superficial interactions with coworkers, friends and even family are hard to break through. It is convenient to watch TV and have your beliefs and opinions sculpted by those who want not to inform, but to sell you something. It is the path of least resistance to form judgments on others based on how they appear and not what they say and do.

It is to be vulnerable when interactions with those in your life go beyond the superficial. It is hard to shut out the ever-present noise of all media and be willing to form opinions based on your own understanding of the world and not pre-approved images on the nightly news. It can be frightening to try and understand an individual who comes from a place you know nothing about -- whether it be from a far corner of the globe or who dress differently.

Okay -- hold on -- all this is great and all, but is not really what I'm trying to get at here. Furthermore, I'm struggling to try and put into words exactly what I am  trying to get at. Perhaps when I finish the novel in the next couple of days I'll have a better understanding of my own thoughts on life. And that is why I love and miss reading fiction -- I believe a good book can provide more food for thought than a thousand years of film or video can ever serve up.

If Florida is America's wang, Tampa Bay is the dirty draining infected abscess on the swampy underside of said wang.

I've been having fun planning my vacation month -- so far I've got a week in hometown Portland, including a weekend at the beach and later in the month, my wife and I will spend ten days in Florida. Four or five of them will be on the Gulf Coast just south of Tampa and the other will be in Orlando, where my wife has to attend a conference. I, on the other hand, will be learning how to golf -- a charmed life, to be sure.

Thinking about going back to the Tampa Bay area is interesting for me -- I spent over a year there in my early twenties and while I could go on and on, the gist of my experience remains that I followed a girlfriend who probably didn't want me there in the first place to Tampa, all the way from Portland , Oregon and we arrived a few days before 9/11 went down, which was a very different experience on the East Coast compared to the relatively insulated burg of Portlandia. I viewed my surroundings, relationships and experiences while I was in Florida through a thick lens of self-pity covered in a grimy layer of disillusionment that only grew darker as it baked in the Florida sun.

When I was living in Florida I had no plans of going into medicine -- in fact, I didn't even see myself going back to school at all! It was while I was in Florida I took the exam that the State of Oregon requires to be a licensed contractor (and passed) setting up the years where I owned owned a construction company before I moved to Colorado to become a snowboard-bum -- which also didn't happen. If I could sit down with the version of myself that lived in Florida, I'm not sure he would believe that I'm actually very close to becoming a doctor, or that he would or, could become a doctor. I'm not one that holds on too a lot of regrets, and the path that has brought me on this awesome adventure that is medicine is my own and one that I'm thankful for -- but there is always that twingey little part that wishes and wonders what could have been had I jumped on this a few years earlier. It would make certain choices less critical, mostly when it comes to time and wanting to be conscious of trying to limit the years of "extra" training that in turn pushes back a normal-ish family life. It matters not, though.

For most of my time in Tampa, I worked for a small "ma and pa" flooring company called "The Store of Floors." While looking for places to stay in the Tampa Bay area and then, using Google street view I tried to recreate the drive to the warehouse that I hated so much. I think they wanted me there by 5:30 in the morning, meaning I would drive in rush-hour traffic usually in the dark to a place that I didn't much like, with people that I didn't get along with. I can safely say that I was at least a small part of the problem here, though. Nevertheless, it appears that the whole operation is now out of business. I could find customer reviews as recent as 2013, but the website is down and the building is now a tow-truck company's. Bill and Kathy were the couple that owned the place, and they were no spring chickens 13 years ago -- I do hope they are off enjoying retirement somewhere nice -- where do people in Florida go to retire? Bill was a stand-up guy -- Kathy, his wife, however was not as nice and I remember trying to avoid her shrill shriek and disapproving glare just about every morning.  But with the advantage of time and a different perspective, I can see she felt like she was defending her business and life's work from, well, I'm not sure what from -- even at my worst I was still a good employee -- relatively speaking. Perception is reality.

If they were still in business, would I stop in and say hi? I don't know. What would I have to say to them? I guess, on some level I would want some validation. Of all the people in my life, they were not players who believed in me or saw some potential, etc. They took me at face value, which was some 21 year old kid who they needed for backbreaking labor. I could tell them that the experience working for them helped to form my opinion that I needed to find a career with freedom, satisfaction and monetary rewards above and beyond floor installation -- which they did, but by no means were they the catalyst that brought this notion to life. Knowing myself, I'd probably just drive by their warehouse and reminisce a little bit. However, I will do more than drive by the Cuban restaurants that I've missed all these years -- I can smell the pressed cuban sandwiches now!

“I guess what I’m tryin’ to say is…not everything comes down to how you carry it in the street. I mean, it do come down to that if you gonna be in the street. But that ain’t the only way to be.”

Eight weeks later and I’m done playing Family Medicine doctor and I’m preparing to pretend to be a surgeon, starting next week. As I’ve previously written about, the patient population in the county clinic has been, at times, challenging to work with – and indeed many days were filled with people so dysfunctional that trying to practice any medicine other than crisis mitigation was laughable. Now, a few days have gone by and the sharp image of those hostile people has blurred a little bit and I find myself reflecting on the less dramatic segment of patient population. These are people who, for whatever reason are without health insurance and income (as to get this insurance, you basically cannot have an income of any kind.) Perhaps they found themselves suddenly without a job or had an acute sickness or trauma rendering them unable to work. It could really be anyone though – I found myself connecting with people I have very little in common with constantly, and really, this is a huge part of the job description. Some people are a few degrees more displaced from living in the woods than others, but none of us are completely immune to losing everything -- including our health, at any time.

It is no secret that young men and on into middle age are a group of people that generally avoid the doctor’s office – until something fails, of course. Sometimes it is diabetes, sometimes its angina, gout or any other of the classics and it takes the men by surprise. They soon find themselves having to visit the doctor on a regular basis for management of a serious chronic disease.

There are a couple of patients in particular that I saw numerous times in the clinic who I know I was able to make comfortable and get them to open up just enough so that we could have some meaningful dialog. One in particular, who made an impression on me, was nearing 50 years old and he had been a “gang-banger” for many years, had been in and out of jail and prison multiple times. As the years advanced he started to work in construction and lead a decent life – “for his children” – he said. He had never had any health problems other than a few uncomplicated GSWs and simple knifings until last year when his leg turned gangrenous in the span of 3 days. After three missed diagnoses at three different emergency departments, he found that his leg needed to be amputated at the knee. He went from playing pick-up in the park to losing a leg in 10 short days. The transition from taking his health for granted to trying to comprehend that his days have been severely reduced unless he takes drastic proactive action to prevent further progression of his uncontrolled diabetes and propensity to DVTs (the duo that precipitated the necrosis in the first place) is one that he has been trying hard to make. And to be sure, there have many pitfalls along the way for many reasons.

This particular individual has so little in common with most of the doctors that he has encountered that he has said that he grew to dread every visit. He went as far to admit that often times he doesn’t even know what doctors are saying, as many of the medical words mean nothing to him (I would also argue that this is common, even for well educated people) but for him, stopping the doctor and asking for an explanation is not only humiliating but furthers the relationship dynamic wherein the patient feels powerless and helpless. Trying to imagine a culture where even the perception of weakness is attacked aggressively helps to understand that a patient like this needs a manner of communication drastically different. Now, I was never a gang-banger, never went to jail and never smoked crack but I do feel like I can identify with this guy on a level that not many clinicians can. The years spent as a skateboarder brought a very wide variety of characters in and out of my life –- working in restaurant kitchens and the service industry in general is a lesson in how to party hard and still manage to scrape yourself out of bed for the next day’s shift. The years I spent in construction demonstrated the awesomeness of a fellow contractor breaking parole (not that construction workers have to be criminals, but there is no doubt that its a field surpassed in criminality only by politics,) which meant I had extra work that week.

A character from the wire -- Dennis "Cutty" Wise is a character that I sort of (perhaps in a naive sort of way) found myself viewing some of these patients through. In short, for those not familiar, Cutty is a reformed gang-member and is trying to make positive changes in his life, but of course, the past doesn't always stay in the past. I tried not to fall into a role where I was making assumptions of one's past, but usually I didn't have to once I had the patients in a place where they were willing to talk. All this to say that I was thankful I was in the position to help these patients get access to care by breaking down some subtle yet insidious barriers.

The View Sure Is Nice

Working in a county health facility that functions as the lowest safety net for organized health care delivery in one of the most economically depressed and violent areas in Northern California has been a study in the human condition. It has been a little over a year since I worked with a doctor designing a study to compare levels of violence induced trauma between people in Israel vs Vallejo. The study never got off the ground, and at the time I didn't have a full understanding of exactly what kind of insights an investigation such as this could provide; now, however -- I can appreciate why the doctor I was working with had this idea in the first place.

In my small sample size of over 5 weeks seeing family medicine, women's health and chronic viral (HCV, HBV and HIV) patients, there is one element that has played a part in almost every patient encounter. That element is addiction; whether it be the patient's own current or past addiction to drugs of all kinds or food or a patient who has major life struggles associated with a loved one struggling with addiction. I've seen patients outright change from friendly, seemingly reasonable humans with whom I felt I could properly communicate with to a tortured person exuding desperation, demanding that pain med regimens be maintained or started despite clear violations of patient-doctor contracts stating that no other drugs can be present in a screen. I've seen chronic and disabling health issues and diseases wholly attributable to addiction -- again, drugs or food. I've come to decide that there may not be any coming back from 20 years of hard drug use. This seems to be that tipping point -- 20 years of shooting and smoking meth takes a person and just destroys so much that if they managed to escape HCV or HIV from needle use and endocarditis they are left with a mind ravaged and incapable of reaching any potential ceiling of function they had. This is not to say that a person can't clean themselves and have a relatively good and satisfying life afterward, but there is a price to pay and the debt load is high after 20 years.

Tangentially related and with a risk of waxing a little philosophical -- I realized that I've been recognizing and dealing with patterns of balance on large scales. Through the lens of addiction I see people who have taken advantage of tools which allow for a life to be sped up or slowed down; there is a reason why, in general, the drugs of abuse which have the most addictive power are uppers and downers. Tweakers, or abusers of methamphetamines are on a schedule so that they are actually living more of a life (or, in some non-intentional hippy kinda way, using up 'life-force' or some esoteric idea of a person's vitality with which a person can spend as they desire as if it were currency) in the span of 24 hours compared to a "normal person," or, at least a non-tweaker. Classic downers literally use up a neurotransmitter called GABA, which is the physiological inhibitor of excitatory action -- users of benzodiazapenes or barbiturates basically speed up our brain's slow down pathway, at its most rudimentary level. I even see pharmaceutical drugs in this light, in so much that a drug may be given in the hopes that a physiological process balance be altered. Sometimes it is in efforts to return to a previous balance that has been interrupted, sometimes we push the fulcrum to a non-physiological balance for the sake of other pathologies.

Again, this whole process has been a study in the human condition, but as far as our patient population is concerned, it is an investigation of imbalance -- of a type that a trendelenburg test won't usually identify. I say all of this not to disparage the patients but as more of a fleshing out the idea of exactly what opportunities I have before me. It took me 6 weeks to wake up to the idea that maximizing my education is, most of the time, simpatico with the patients needs as well. Whether it be scouring area research centers for specialists for some rare condition, calling a patient a day after the appointment with a website for cheap prescription glasses, or trying to talk down an angry patient from whatever metaphorical ledge they're threatening to leap from, it all ads up to the type of education I've been hoping for since 2006 when I decided to go back to the school in the first place.

The actual medicine is great too, of course.

passed

Word came down at the end of last week that I passed the 1st of many board exams and that I could officially pass go and collect $200, meaning that I could continue playing doctor at the local county health clinic.

It has nearly been 3 full weeks since I took that board exam, and in some ways I still feel a little traumatized by the whole thing -- not so much from the actual 8 hours of answering the questions, but more-so the run up; the anticipation, the fear, the adrenalin, the realization that one specific slice of 8 hours sitting in a testing center has significant implications and influence in what the rest of my life will be. Its not the end-all-be-all by any means, but it is a number (meaning the exam score) that will follow my name for the next 20 months, until the day in early 2016 when I find out what kind of medical residency I match into. And, when I say traumatized, I think it really boils down to not getting any time to grieve the process -- and process my body's grievance stemming from the mental and physical abuse I put myself through -- studying for 15 or so hours per day for over a month. This was the finishing touch of a couple of very taxing years. In fact, for over 2 years medical students look forward (with a mix of dread and killer instinct swirled together) to this exam -- years of anticipation! For most of us, we take the exam, and within a week or less we are jumping head first into our clinical education phase, where we have patients address as doctor and we are asked real questions in earnest from patients, in hopes we have some answers to their very real problems. To go from abstract, esoteric, molecular science and pharmaceutical mechanisms of action to dealing with patients and their problems in the span of 3 days, for me, was an exercise in integrating two very important perspectives -- patient care and protocol with best medical practices, which are based in the science behind it all. Its nothing if not supremely interesting and engaging. 

I am thankful now, more than ever for my years spent working in an Emergency Department. It gave me the ability to feel very comfortable with patients -- including when they are unhappy and difficult to deal with. It has given me a honed sense (for a newby) of when I'm being given a pile of bullshit for a story or history. That said, I'm not here to oust drug seekers, but still, despite their nefarious intentions, still provide that patient some kind of care. He or she may refuse to listen, and they may get angry with the decision to not dispense narcotics, but if we can still have a discussion about other aspects of health, and discuss the reasons why narcotics can't be given -- emphasizing the health risks and evaluating the other health dynamics at play, I can still walk out of the patient's room feeling like it wasn't a waste. The importance of giving a person the time of day and honestly inquiring as to their wellbeing does wonders for a power imbalanced relationship such as the doctor-patient one, and should not be forgotten, even in the most challenging clinical encounters. Sometimes ya just gotta call the sheriff though. 

Family medicine hasn't been at the top of my list of medicine to pursue -- and maybe this happens at every rotation, provided you're with people you like and respect (such as is my situation now), but the versatility provided through doing FM is more impressive than I previously thought. Maybe in month or two I'll be up on the DSB proclaiming my love of all things surgical and my pending future as an orthopod. We'll see.   

Psychic Dismemberment

In general, I've been well spoken throughout my life. And, as time went I found that I loved to write -- and eventually I thought I gained a master's apprentice level of proficiency concerning the English language. Now, however, I don't feel like this at all. There are times I fumble for "ordinary" words while speaking, and recently, my ability to write in a style and manner has devolved to being barely satisfactory, which is frustrating -- and, indicative of this is the few dozen blog posts I've started in the past year that have gone unfinished and unpublished simply because I can't articulate points or ideas well enough. Of course, I can spew horrible medical terminology rooted in Latin and Greek, words that I would've stumbled over only a couple of years ago. Learning medicine, at its foundation is learning a new language with which to communicate with other doctors and health professionals.

Over the Christmas break, I tried with earnest to try and complete an essay for a Global Health Organization -- it was a competition with a cash prize and subsequent publication (always good for da CV) and I thought I had a good attack strategy for the essay. I had sketched out a few outlines and was happy with the direction I was going to take it. However, when I sat down and tried to hammer out a few pages, I found that I basically was relaying facts from my trip to Israel this past summer (which was the basis for my Global Health essay) and that any ability to make my words, sentences and paragraphs more than plain and un-adorned vessels of information was met with silence -- translating to an informative piece of writing, but something that belonged in a medical record and not an interesting essay.

Cold and clinical -- this is what my writing style has become. Years of trying to find my own voice and style of writing has been destroyed with a couple of years of medical school. I'll take the trade-off -- for now, but that doesn't mean I plan on losing my voice and style completely, but instead a better integration of "cold and clinical" with my already established style is something I hope to be able to do.

This dynamic of losing parts of oneself while in this ultra-demanding graduate program that is medical school is, and should be obvious. And some aspects will be gone forever, but some will be lost but regained when we are able to normally interact with friends, family and the world in general. It was this aspect that was impressed upon me during a recent visit with friends and family, many who I hadn't seen in over ten years. Friendships forged during the formative, if not turbulent teenage years were rekindled and often, it seemed like we had not spent any time away at all. Of course, most of us have spouses and or kids who we had not met but this just adds to the joy of getting to know each other again.

If medical students do not take time away from studies and the world of medicine as a whole, parts of self will crumble and fall away at a faster rate than they may otherwise. This is one reason why I was so thankful for the ten days with a community of friends and family that, despite long standing neglect, were still warm and welcoming as if we had been hanging out on a weekly basis. As I recently heard from a residency director giving a talk just yesterday: you cannot let yourself be defined by being a doctor, but instead it must be just a part of who you are as a whole. At times this is hard to remember while in school, especially with Board Certification exams looming large, but I try to do what I can.