Tuesday, December 22, 2015

wrest rest from the grisly grizzly that is the daze of these days in order to write right

I've always fancied the idea of writing a novel. Many readers, at one time or another, get this tickle -- just as watching a movie lends itself to wanting to be an actor. What kind of novel shall I write? That is a great question -- and prompts this primordial type of hopeful feeling in me; of potential being manifested and worlds yet unimagined being born.

I like interesting. And while my life is enhanced by finding interest in just about everything I come across, it means my threshold for holding my interest is low, which means needing to work to ensure optimizing just how interesting I can make it. Subjective as it is, the best part of "interesting" is that seeing as how I'm in the middle of becoming an physician, I have relatively little pressure to move expediently nor is there any reason to write a novel other than for the pleasure in the pursuit of creating something that I can take pride in. Simple as that.

On an ongoing basis, I plan on developing the novel here on this blog. The goal today is to develop a summary sentence describing the novel. From there, the sentence is expanded to a paragraph, and from there the characters and story line will be fleshed out. Using design principles to build a story makes sense. Even with short stories, I've written myself into corners that were difficult to escape, and often unnecessary had proper planning been managed from the start. 

So here we go:

_______________  is the first offering from JLP, and is a thought provoking and moving novel that proves that ties to ones past can be more difficult to escape than it might seem; it is set in various times and settings, including the wild west as it played out in the "Shanghai Tunnesl" of Portland, Oregon and in the Coastal Native Americans who find themselves in the middle of the biggest natural disaster in the Pacific NorthWest in the  post-ice age  and in the old folks home in the city of Netanya, Israel that suffers through a suicide bombing  in the early 21st century and the hospital staff who treat the bomber who survived.

A theme I wish to explore will be made obvious by having this verse as an opening epigraph:

Keeping mercy for thousands, forgiving iniquity and transgression and sin, and that will by no means clear [the guilty]; visiting the iniquity of the fathers upon the children, and upon the children's children, unto the third and to the fourth [generation].
Ezekiel 34:7

Assuming I use these 3 settings, which I will already find superbly intriguing and dripping with mystique and potential, the furthest behind in history will be the Coastal Native Americans who are making their way up the Colombia River when the earthquake which triggered the "Bridge of the Gods" in the Bonneville Slide, which occurred between 1060 and 1280, and actually damned the river for a unknown period of time. The next setting will be in the rough days of early Portland Oregon, when shipping from the Far East prompted a horrible term known as being "shanghai'd,"  meaning that a young man who, perhaps had too much drink, or perhaps too much opium, or was beat up -- ends up on a trading ship to China as an unwitting member of the crew. There were (are) some tunnels beneath the streets that dead end into the western shore of the Willamette River as it passes by Portland to join with the mighty Columbia as it marches to the Pacific. One of my favorite bars in Portland (circa 2001) was actually called the Shanghai Tunnel, and was in one of these spaces under the street and building. The next time would be March 27th, 2002, in what is referred to as the Passover Bombing in Netanya, Israel, a pleasant seaside town 20 kilometers or so north of Tel Aviv. I am inclined to make the main character a young American physician from Oregon who is training and in residency and during a global health medical training trip ends up treating the "suicide" bomber who was not wholly successful with the suicide part, and all the ensuing hilarity that can be had from such a pleasant position.

What do I want to say through writing this? Hmm. I do harbor this opinion that all created pieces of writing exist as propaganda serving the worldview of the author. I like my worldview, and I like to think that my personal creed is built to serve others as much as it serves myself -- and at times, more-so. I want to communicate this. And as much as I have principles that I stand on to live my life, I want this novel to be in large part a worthwhile piece of art that performs well as entertainment.

All of this literature stuff especially the subtle connections that English students (I did get a minor in English with my Bachelor of Science degree, and while I enjoyed the writing classes immensely, at times the literature classes were worth some chuckles when realizing the thread-bare arguments students, instructors and textbooks would make when arguing for exactly what a particular author was meaning to say or express. I'm reminded of Ray Bradbury (who I spent a semester researching and crafting a dissertation on what his writing meant not only to the world of literature but in shaping public opinion concerning technology and the dynamics between progressive and luddite perspectives. He once walked out on a lecture where his work Fahrenheit 451 demanded to be seen through a lense not about the effect of mass media on the populace but about censorship. As alluded to earlier, writing a novel is like giving birth to a creation, and just like human babies, they grow up and take on a life of their own -- and in light of this, I could argue that Mr. Bradbury had birthed this seminal work of fiction and had become something beyond what even he could hope for his creation's future. kind of like having a kid whom the dad wants to be a baseball player and the kid goes on not only to dislike baseball but to eschew team sports altogether and becomes a successful skateboarder.) On another parenthetical note, I just took some time to look for the Bradbury paper I wrote in the last year of undergrad and I couldn't find it. I think a lot of that stuff I wrote from then is gone forever as I had pulled the hard drive from the laptop that I used but eventually crashed in hopes of pulling data off of it, but I probably don't have it anymore. Kind of a bummer.) such as myself come up with is just the brains desperate attempt to recognize patterns, as it seems wont to do.

Oh to have such problems as having a novel being discussed in university classrooms.

Since this is doubling as a blog post and my first effort to bring a novel to life, I'm going to paste helpful links to each timeline so I can start the actual research of how to construct each world.

The oldest timeline will probably be set on the Colombia River where a big landslide occurs and damns the river for easily decades. I was also thinking of pushing the timeline further back in history and using a certain event that I remember learning about in a geology class. At the end of the last ice-age, there remained a humongous lake in the western part of what is now the U.S. When this lake drained westward it was what we call the Missoula Flood. There is a great PBS show about how this was discovered and the weird ground formations that spurred research into just what went down when the flooding happened. One of these events I'll use, but, as I'm also contemplating using Oregon as a geographical tie in and as one of the connections between these people spread apart by thousands of years.

https://www.youtube.com/watch?v=a7iC1fBREPI (pans the bridge from the Oregon side, short)

https://www.youtube.com/watch?v=arQ0RY-jwVI (kite-boarding contest which clearly shows the remnants of the landslide from the Washington side)

http://www.historylink.org/index.cfm?DisplayPage=output.cfm&file_id=8018 (Detailed story of Indian lore surrounding the events of the bridge's formation, destruction and Mt. St. Helens as the birth of the youngest mountain)

https://www.youtube.com/watch?v=2mIszJv_Qow (Brief Oregon geology Hx video)

https://www.youtube.com/watch?v=zzxtb4bJObA (Video showing the rapids that used to be on the river before the damns)

http://www.oregonpioneers.com/tribe.htm (Blurb on Coastal Tribes)

http://www.pbs.org/wgbh/nova/earth/megafloods-of-the-ice-age.html (Worth watching for general edification no matter who you are or what you're interested in)

http://hugefloods.com/LakeMissoula.html (Well done website, if not a little outdated, about the Missoula floods)

http://www.shanghaitunnels.info/ (Tours of modern day Shanghai Tunnels)

http://www.legendsofamerica.com/or-shanghai.html (Blurb about Shanghai Tunnels)

https://www.youtube.com/watch?v=THJNPIGT6xc (Shanghai tunnel video -- 20min)

http://lostoregon.org/category/portland-history/ (Less about Shanghai but awesome blog about PDX Hx)

https://en.wikipedia.org/wiki/Passover_massacre (Suicide bombing in Netanya by Hamas in 2002)

https://www.youtube.com/watch?v=Gkib03PpARA (Video from first responder POV in Passover Massacre)

Monday, October 19, 2015

44°50'29.0"N 124°02'57.8"W

The board exam season of this summer is long gone, and the past couple of months have had me engaged in the activity of what will most likely be my final form as a physician. For the very first time, I've actually been directly functioning -- albeit in a truncated, supervised fashion -- in the capacity I've been working towards for nearly the past 10 years. Exciting Shtuff, to be sure. 

Spending so many hours in the hospital provides for the opportunity to get to know many patients, some over a day, some over weeks. I've also been training in Oregon, the place where I grew up and in many ways, consider home even though I officially live in California, these days, and haven't officially had a residence in Oregon for 10 years. There is something very easy about being around and getting to know people who call the same place home. One particular patient from a few weeks ago who was in the hospital for a condition which was considerably more serious than he wanted to believe, at least, at first. He really wanted to leave, and he had good, solid reasons to desire this and many providers tried to speak with him and convince him of the severity of his particular condition. I spent less time doing this, but more time just talking with him -- of course, the fact that he was very interesting and engaging made it a natural thing to do. Among many interesting stories and tidbits from history and his life, he shared with me a special part of his family history. 

He, like my family, loved to go to Fogarty Creek State Park, on the Central Oregon Coast. He told me a story about when his grandkids were young children and how this one afternoon spawned an annual tradition that lives even to this day. But -- we'll get to this part later. I told this patient that after my gig in Corvallis was over I was headed to Lincoln City to work in the small hospital nestled between the big breakers of the Pacific and the lapping of the little waves of Devil's Lake. He, in a way inspired me to take a nostalgic walk through the wonders that Fogarty Creek State Park have to offer. I spent many days as a child here, often with big outings filled with dozens to hundreds of family and friends and there are many memories that come flooding back when here. 

Working as a bona fide hospitalist often provides a humane schedule of 7 days on and 7 days off, with 12 hour days, or less, usually. Training as a hospitalist is brutal, usually consisting of 6 days a week with 12 hour minimum days. So has my schedule been for a couple of months, and so shall it continue to be. On one of these days off, I went to Fogarty Creek State Park, as I promised the patient in Corvallis, to not only honor his family and their tradition, but to tie a small piece of myself and my families tradition to his in a quiet way. 

The excitement of parking and then finally walking along the path along the creek and underneath Highway 101 and then finally catching the first glimpse of the ocean in the distance is etched upon my mind. Often, my parents were early for many events and I was sent ahead to see what side of the creek the festivities would be. I've built many damns on this creek and while none of them have survived the test of time, the tradition continues and having driftwood laying around helps. I was in no shape to build a damn this day but what looked like the last vestiges of a previous effort was waiting for me -- allowing me to cross the creek without soaking my shoes and socks, hopefully.   

Assessing best way to cross the mighty Fogarty. 

I think I've got it. 

And I've made it. Shoes and socks no worse for the wear. 

The volcanic rocks which are the focus of the beach component of the park are perfectly situated so that only in the highest tides during the year are they inaccessible for climbing. Interestingly enough, it was a year ago where I came here with a handful of good friends and the tide was exceptionally high. I made my way to the rocks and as I did so, the surf began to converge from either side of the rock formation so that I had to find refuge on a smaller rock a few feet about the sand and wait to escape. My shoes got wet that day. As we were leaving a group of kids spilled out of a few vans in the parking lot and headed for the beach. We went down to Depoe Bay where we watched the Spouting Horn drench a few of our party and many strangers. The spray was so high it was soaking the entire highway and even wetting the opposite sidewalk -- for those of you who know the area, the impressive nature of this surf is known. Returning north, we saw a Coast Guard helicopter hovering above the highway with multiple emergency vehicles parked on the side of the highway. The few of the kids from the vans we saw earlier had gotten themselves stranded on the rocks and more than a couple were injured trying to either escape or save the others. While I was there near high tide this day, it was no were near that day a year ago. I was able to climb to the top easily, just as I did so many times as a kid. 

High tide on this day, which was less than an hour away was not going to have the breakers converge around the rocks, to provide some perspective. 

The rocks on the right are separated a little bit from the larger formation on the left. On low tide one can explore what is basically a pool inside the rock, full of starfish, sea anemones and other crazy critters. I wasn't able to make it over there -- maybe all the starfish have died, as they have had a rough time lately on the Pacific coast, as they have been plague with "sea star associated densovirus.

The water was getting higher, I had no time to waste. 

Just out of frame to the right is a nearly perfect "chute" in the rock allowing for easy scaling -- and, more importantly, an easy way back down. 

And I'm up. It couldn't be easier if a steps were built into the rock face. 

From this perspective you can see the pool I was referring to earlier. The surf was high enough that I had no access. Looking north, you can see Cascade Head in the distance which lies at the north end of Lincoln City.

The highest point of the rock formation; perfectly flat on top. If I had time I might have taken a nap up here. 

I find it interesting that dirt is still present on top of the rocks. It is mostly clay, seems like, and not easily washed away -- nevertheless, waves crash over the rocks in no infrequent manner and while I my memory is not infallible, it looks the same to me as it did 30 years ago while climbing the rocks and pretending to push my friends off the precipice into the boiling angry waters below. 

Looking south at the bluff overlooking the more secluded portion of the beach. 

Water is getting higher. 

While idealistically it would be preferable to not have hotels lining the bluff of the northern aspect of the park, I've had enough good memories there to allow it. Also, the blue sign of the "Surfrider Hotel" adds a nice blue glow at night. The restaurant has some of the best views anywhere, if only the food matched the magnificent view; that said, I think I won a few hundred dollars with the video poker machine in the bar last year. I try to only gamble on holiday -- its as if the machines know whether you're playing with real money or vacation money, and reward or punish accordingly. 

Time to head back down. Hopefully I can keep my shoes dry. 

I've identified where I will cross back over the creek to the other side of the beach. Time to explore the other, more subtle joys of Fogarty Creek State Park. 

Like so many things from childhood, these cliffs used to be so much bigger. I remember the first time I saw one of my friends up on the top of the cliff -- I was flabbergasted! I may have been 11 or 12 when we found a trail leading up to the top. Exploring woods is such a pleasurable activity. 

This side of the beach was where we would wade into the ocean, as the waves came in much straighter and rip tides were less dangerous compared to the other side of the rock formation. 

The cliff really starts to gain elevation here. Continuing to the right, towards the ocean is the big rock slide, which still, even now looks relatively new. A certain father of a certain friend of mine told a story which had a big cave that used to go into the wall of the cliff and that a girl and a boy were in the cave when the opening collapsed, leaving the haphazard boulders as they sit now. I tried to find something online concerning the rock slide but there is nothing. While quite difficult to believe,  I always imagined there being a secret cavern that was left open and that the kids survived to, well, I guess die of dehydration or starvation, or eaten by a bear or something. 

These boulders are larger than they appear. The cliff is maybe 80 feet up or so. 

Playing with whips. 

There not a lot of absolutely clear days on the Oregon Coast. 

Two thirds of the way back to the highway, around the bed in the bluff is a break in the dense underbrush you would be forgiven for looking past. 

Like a little hobbit path through the thicket with large looming alders, sitka spruce and western hemlock trees. Plenty of spider webs. 

The first view when breaking out of the hobbit path. 

The afternoon my friends and I found this path we explored for a bit -- and then, we decided to cut down a tree. We didn't pick the largest tree -- I've always been ambitious, in some respect. A little more bothersome, in retrospect, is the fact that this tree was tall -- easily 100 feet tall -- and right below the precipice was our family and friends, moms and dads, grandma and grandpa hanging out on their blankets and in their beach chairs. 

See the bird at the top of the rock formation's high point? My kinda bird. Not that far from here is a hotel where I stayed as a child -- and seagulls would land on the railing of the balcony. I fed it a cracker or too and it kept coming back. I loaded a cracker up with hot sauce and fed the poor creature a table spoon of hot sauce. It came back after a short while soaking wet. Dripping wet. Kinda funny. I never fed a seagull an alka selzter though -- that is not funny. 

As you go further south along the bluff and towards the high part above the dead children in the cave are little paths of to the cliff's edge providing quite spectacular views. 

At the point where the rock face turns to the ocean and the beach ends below is a little clearing that I wish these pictures could convey with a little more effect. The trees here arch over and intertwine with each other; and with the slight depression with the surrounding hills this is a protected quiet little shelter. It can be quite windy and this is a calm area. The ground is springy from all the needles and leaves that carpet the ground. Some rolls of old carpet pads are rotting in the distance in the photo above. I didn't do it, I promise. 

Trees are covered in glowing green moss.

 I always thought that if I had to be on the run, or hide or something, I would come here. Now that I'm telling you that, I'm going to have to find another good hiding spot. 

The path southward continues along the cliff's edge and out and around for a mile or two all the way to the finger of tidal pools and rocks that are easily overtaken with waves and disappeared below the surface for half of the day. It really is an amazing hike and if you're up for some adventure, it is something I cannot recommend enough. Go with another person though. I turned around and headed back down the path towards the beach, though. 

Shadows are long.

Back underneath the 101 and into the other portion of the park are many picnic tables, and even picnic table ruins, which, for some reason much more intriguing than they sound. Now I was on the hunt for a piece of the story that the patient told me about. He told me that when his grandchildren are young, they went running away, and and when they came back the youngest granddaughter was breathless and could barely contain her excitement over the tree they had "found" and that they had to go and check it out. He described the area of the park it was in, and I wanted to see it, just like he wanted me to. While I think some of the trees are magnificent here, this tree was merely a trunk that came out of the ground at a low angle with a big trunk coming off about 6 feet up allowing for you to walk up and sit on the branch. They took pictures of all the kids sitting in the tree, and for the most part, had kept that tradition, now with the great grandkids -- taking pictures in the tree for a whole generation. This guy, whom I had just met was realizing that this tradition might already be over for him -- that he the pictures he took during the summer that had just ended might be the the last. The finer points of life, the subtle yet all powerful realizations are the moments that impact us. 

I systematically started my sweep of the south side of the park. I had enjoyed many barbecues among these picnic tables. 

A mossy concrete sidewalk winds around the underbrush away from the other picnic table clusters and I wondered if this is where the tree stood. It seemed so easy -- to just follow the path into the deep wet woods. It was just picnic table ruins, though. Interestingly enough it was obvious that the underbrush had been maintained to not overtake the little path or the concrete blocks. 

I kept moving. I moved into the next cluster of tables, a few hundred yards further from the ocean. I came around a bend and in the distance I saw it. The tree coming out of the ground at a 45 degree angle. 

And there it was, just being a tree like only it knows how. Did it remember the kids that have grown into middle age and came to sit on its branches every year when the days were the longest? Did it mourn for the man who held this tree to be above all other trees? 

Probably not; its just a tree.  

Fogarty Creek is named for John Fogarty, who came to Oregon in 1875 and settled in Yaquina Bay in 1884. He served as city councilman, county commissioner and judge. The sand stone cliffs on the eastern border of the beach continue to erode and are slowly creeping back away from the ocean. This is accelerated on the north side under the various hotels and condominiums. Action to save the structures will be needed in the decades to come.   

The drive up and out of the park. 

Monday, August 24, 2015

Beta Amyloid Blues

I've heard of other people describe this kind of experience. A memory that has persisted and serves to mark when the internal dialog began. I was three years old, and I remember going out the back door of the church I grew up in, standing on the concrete pad and looking at the huge oak tree and thinking to myself, 'I'm three." It was just something that resonated with me, the fact that I was a person who recognized that I recognized my own existence. I'm sure thats not what I thought, explicitly, at the time, but it is the essence of the experience. I would venture to guess that just about all of us, all of humanity has experiences like this, whether or not they persist as memory landmarks, is hard to say.

Memory and the ability (or, inability) to memorize is such an intriguing aspect of life. Just about every other day I take the dog for walks at the nearby park, and have, on and off for the past few years and usually, we park at one particular lot and go for a hike. The last few times I parked down the big hill, which means passing the other lot on our hike as we head back down the hill. Every time she has tried to get me to go to the other lot. She doesn't remember that the car is down the hill. I take it for granted that I'll remember where I parked, but even this isn't guaranteed.

Alzheimers Disease (AD) has among its signs and symptoms, a specific manner in which patients have a consistent pattern of regression and experience and reliving of old memories. Recently I was reading about a study that examined just what kind of memories persist as the disease process progresses. A man in his eighties who was a Toronto taxi driver for over fifty of his years was diagnosed with AD, and until his death many years later, when he was no longer oriented to person, place or time and could not independently execute any of the standard activities of daily living he could still demonstrate that he knew his way around Toronto. Streets, directions, addresses -- it was still there and accessible. Many other examples, while not as dramatic, exist. And what they have in common is simply a matter of redundancy. A working memory, such as driving around Toronto, that is used on a daily basis for a majority of a person's life is so deeply ingrained and has, at a structural level, so many neurons devoted to this memory construct that it simply lasts the longest. Secondarily, memories that are impactful also last long. Childhood experiences are often relived by AD patients, and while the article I was reading didn't specifically address the difference, on an anatomical level in the brain between the two types of memories, but I couldn't help but wonder. Curious that, seven or eight decades after an impactful experience in childhood, even if it has not been something thought of frequently in adulthood, it still persists. The neural network that maps Toronto persists due to brute strength derived from numbers alone. If I (in a far of distant future, but one that hopefully doesn't exist, as there will be major advances in AD prevention and treatment by then) ever have to suffer through AD myself, I could imagine that my memory of stepping out into the early afternoon sunshine in Portland, looking up at a mighty oak tree and having that all too human experience of self realization, would be one that I relive even when I can not function independently at a foundational level.

I may go years without thinking back to that morning. Inevitably something will spark the memory and I'll hold on to it and savor it for a moment, giving it a nod of respect and thankfulness that its still there. Then I put it away. If I had to put a number on how many times I have done this, I would say anywhere between twenty five and thirty five times. Obviously, its persistence is not a function of redundancy. What allows it to be accessed all these years later? The details have faded over time. Of course I can fill them in, as I know the yard very well and spent years playing and running around in it. The garage, the shed,  the grapes that grew over the fence from the neighbors yard that were perfect for throwing but horrible for eating -- all this I can picture well. Those things that live in my mind are there from repetition, and I can pick out a couple of individual experiences that come to mind, but nothing like that early one when I was three years old. That memory, I contend, must derive its sturdiness from organization and configuration, not sheer power of abundance.

Geometry of structure, and the applicable physics of the tangible universe rule the macro and micro worlds (of course, exploration into worlds of scale that seem to ignore Newtonian physics and have allowed for fantastic advances in science and technology but humans proprioceptive interactions with the world are solidly physical and ruled by how the apple drops). In some ways I see my first memory that I consciously recognize as my most efficient memory. It is simple. I have no idea what happened that morning, what kind of songs were sung, or who I was playing with, or where we went for lunch, or anything like that. None of that matters because of what the memory represents, which is the beginning of me as I have always known me to be. It functions as a key to what it means to be me, and unlike most other keys in my life, I've never lost this one.

Medical school, especially the first two years is really "memory school" as there is no time to understand all of the processes, or etiologies of nomenclature. Seeing things in person and experiencing pathologies in person as if they leapt right off the page, allows the formation of 'keys' to distinct pathologies. Having a patient with Addisons Disease, which while not super complicated, is an endocrinological process with many secondary, tertiary and quaternary actions that must be recognized and managed. Learning about all these things from reading, discussion, practice questions and board review material is necessary, and with enough work and effort put in lays the foundation for truly understanding the pathology, diagnosis, management and treatment which can only be had by having a real, living human being who needs your help.

The difference between reading about something because you will be tested on it versus having a patient on the fourth floor in danger is substantial. Of course, the idea is that all those tests are preparing us to help the patient, and they do, as much as they can. Taking that knowledge and forming it into a permanent "vault" makes me think of what it must be like to give life to an inanimate objet. I build a boy out of wood, call it Addisons Disease, paint it, and lovingly put the finishing touches on what is just a static structure. Spoiler alert: the wooden boy comes to life. By trying to see the disease through the patient's eyes, the wooden boy becomes animated. Each time I see this process in a patient the boy grows and takes on a life of his own, and becomes a construct in my own mind which will teach me about this disease.

So that is kind of a weird metaphor. I'll allow it, though.

Tuesday, June 2, 2015

"You always make each day a special day. You know how: By just your being yourself. There's only one person in the whole world that's like you, and that's you. And people can like you just/exactly the way you are."

It was late Sunday evening, after a day filled with reading and practice questions, that I was browsing Amazon Prime (through the Roku, on the television) as I was looking for something to watch while I did busywork that I found "Mr. Roger's Neighborhood" was available -- the entire catalog. I watched a few episodes and I got to thinking that many people -- no matter the age, would benefit from watching this show. 

Just like reviewing the fundamental science behind medicine -- albeit, at a relative superficial level, is imperative to understanding physiologic and pathologic processes and the treatment decisions that stem from this understanding, so is hearing Mr. Roger's positive reinforcement aimed at children who are growing and trying to find their way in this world. 

I think my favorite part when I was a child was the make-believe portion where the trolley would come out from the hole in the wall and then go back into the wall, where the king, queen and lady Elaine lived. With revisiting the shows, I found myself forwarding through those portions. What a shame. 

So, to sum up: Mr. Roger's Neighborhood is to adults as Pathoma is to physicians. 

Saturday, May 9, 2015

Never Bored but Always Preparing for the Board

Being a medical student is such an interesting place to be. We are in interesting places literally, metaphorically, philosophically, emotionally and of course financially. There is a lot written, and a there continues to be much written about the med student experience. It is definitively a formative experience and I can't help but write about the experience.

A few spurious thoughts on the process:

Today, one of the Obstetricians I was with asked me what other rotations I had done this year -- something that I've been asked at every rotation this year. This time I, with a brief but glorious pause, told him that I had already done all of my cores -- and had also served at a free clinic and spent time with an interventional cardiologist. Of course I knew that this was going to be the last gig of 3rd year -- but that was the first time I had articulated that point and it was pleasant. We then chatted how crazy it was that this was the chunk of time that I was to know exactly what I would dedicate my life to. At the school I attend, the 4th year schedule is completely up to me to organize and arrange. This is of course incredibly time consuming, depending on what approach one takes, and of course the next 4 or 5 months we will have submitted our interview requests. In these interviews, our academic record, including grades, evaluations, board scores, crazy extracurriculars, clinical record and elective choices will be reviewed, all of which play a huge part in being able to actually match at any given program in whatever specialty. I think I know what I want to do. I would like some more time to figure it out, though.

Another large aspect of going into medicine is the constant, rigorous selection process at every stage for every opportunity. Some of them are objective metrics, others are harder to deal with -- like programs who decline an application for an elective or audition rotation, and of course those who aren't interested in interviews. This is less an issue of a program necessarily shunning a candidate and more a "real world" dynamic and habits inclined to do business with previous relationships that have proven successful. This is how most of the world works. However, making the transition from academia (purely) to a training program where we are employees with contracts is a strange one. Granted, we still may be in "academia" by name, and we will conduct research and be involved with teaching -- but make no mistake, it is a business arrangement. It is a very complicated dynamic, and one that I don't fully understand, but doctors can still help people while being in a business environment. I think that all physicians should review their personal statements that they penned to get into medical school in the first place, where some variety of "I want to be a doctor to help people" theme was on display. I also think that realizing this early -- especially for student-doctors who have not had to be in the "real world" business environment is imperative to ward off burn out -- which often stems from disillusionment of how things work, and not feeling like they are able to make a difference in the system, and of course, in people's lives.

Many doctors, even if they are not a teacher in the full time sense, will bring on students if asked. They know that their experience is important to pass on -- and as a student in the process of contacting physicians and asking them to add even more inconvenience to their already jam-packed schedules to show me the ropes is a strange process. One major theme that has impressed me is that whether you are on a core (required) rotation, or an elective -- whether you really dislike, or really love whatever given field you are spending time in, it is imperative to demonstrate interest, invest time in reading up on major elements in that field, and of course, be pleasant! The coffee shop/roaster I worked at for many years in Denver was (still is) involved with a lot of wholesale business to other coffee shops, and employees of the shops we would sell coffee to would send their employees to us for training. We would teach them to make a proper latte, cappuccino and how to pull a proper espresso shot. We would teach them about the coffee beans, and show them how we roasted them, all in the hopes they would be good, knowledgeable stewards of our coffee and of course, be successful in the relationship with our business partners. There were times that a teenager, or young person would show up for training and obviously have no interest in learning anything. We would teach these people the bare minimum, and often send them off with skills that were inadequate to make a steamed milk espresso drink for anyone -- not for lack of effort. The same principle applies to medical students. A little enthusiasm goes a long way. The rotation I'm on right now has what some of the other students have described as "strong personalities," which, being medicine, this should come as no surprise. I've found, through chatting with the MAs that there have been students who have spent time there who have, at worst, outright told the doctors that they didn't care about learning about OBGYN, or that they hated what they were doing and really didn't care about much other than passing the exam. After a couple of days on the rotation, and after getting to know the MAs, they told me that they thought I was doing a great job, and that the doctors liked me. This was very nice to hear (as it always is) especially as I really felt lost. Admittedly, I was not looking forward to this as much as other gigs, and I really have very little interest in OBGYN as a career. Furthermore, one reason I've chosen IM over FM is that I don't have to take care of children (I love children, just don't want to treat them) and IM has very little women's health training. And because of all of that, I knew that this might be the best opportunity to learn about OBGYN and I should make the most of it. Apparently having this attitude has paid off in that the doctors are actually interested in teaching me -- if I could give one piece of advice to medical students entering this stage of training, it would be this -- act like you want to be there, even if you don't at first, and you may just enjoy your time more than you thought possible.

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