A Resident Should Get Student Discounts, Right?

A lot of emphasis is put on the team aspects of modern medicine and in some circles, this is viewed as a negative aspect, or more precisely, an encroachment on the (often) paternal and blanket authoritarian rule of law. Different environments have varying degrees of teamwork and each individual physician, in any given clinical scenario has a sizeable impact on the "temperature" of the room. Over time, with relationships built, and with a trust between people, people who work well with people will enjoy a healthy workplace community, in general.

As a medical student, there is not enough time to let time naturally build relationships and trust, and the astute and emotionally competent ones set out to get to know the people they will rely on to do their 'job' which is being a physician-in-training. Of course, by the time the support staff knows your name, it is time to go to the next rotation.

In politics, and popular culture at large one often hears about 'the movement of the goal posts,' which in this slickly packaged reference to our now non-intentional post-modern society of fluid truth and it  stands as the short-sighted idol to the evil of a progressive and self-critical society. In reference to the life of a medical student in their clinical years, it is much simpler with, usually, a more myopic gestalt, at least in day to day operation. Each physician I've worked with over the years has certain things they uniquely incorporate into their daily practice -- which stems from the interpretation and utilization of the collective experience, this is how training works. Sometimes it may be just a different way of questioning, or perhaps idiosyncrasies in bedside manner and communication, and of course all this when incorporated with the art of clinical practice it can be summarized as the exclusive approach to the art of medicine. Each hospital has their own culture, and within that setting the residents, attendings and of course, each Graduate Medical Education office has their own requirements and needs, too.

Medical students are often seeing things that we've seen many times over, for the first time. Knowledge is compartmentalized and a big-picture perspective is yet to grow. However, the third year students, who are all fresh off of taking the first round of board exams, have the largest working knowledge of esoteric and abstract facts and mechanisms. Stuff that I used to obsess over while studying for step/level I now seems like a fuzzy memory. It is good to remember the foundations of pathophysiology and I appreciate the students for this.

If life has taught me anything, and as a dedicated life-long learner, I enjoy trying to soak up lessons and experiences that are, at times, uncomfortable -- I can boil it down to two maxims, which are generally true some of the time, it is this:

1.  NO GOOD DEED GOES UNPUNISHED When doing the right thing, or when doing something nice or considerate for others, expect to pay a price. You can make a clear choice when acknowledging this as general law of the Universe

1. BETTER TO REMAIN SILENT AND THOUGHT A FOOL, THAN TO SPEAK UP AND REMOVE ALL DOUBT This is definitely true in medicine. In front of patients, support staff and colleagues, it is imperative that one chooses their words carefully and thoughtfully. In some ways it could be described as 'defensive speaking,' akin to 'defensive driving.'

Obviously I did not come up with these well-used cliches, but I do recognize their utility. And, as far as being a med student is concerned, the second one should rule one's conduct throughout the clinical training years. Knowing when to ask questions and perhaps, more importantly, the difference between asking a question versus having a question and making a note to look something up, or asking later is a skill that can make or break a rotation. 

I've not been in the military and nor do I have a lot of first, or even second hand knowledge of what being in the armed forces is like. However, medicine has a defined hierarchy and properly navigating the power structure demands adaptive behavior. Of course, when you are moving from one distinct environment to another on a regular basis just as med students do, it can take a toll on those who cannot adapt and who are not adept at "reading the room." Like all professional relationships, success doesn't necessarily come with all parties understanding the expectations of their role but I assure you that if even one party has an issue with understanding or failing to live up to the expectations set forth, failure is forthcoming. And that is the key -- expectations set forth. Often the most important expectations of a role are the ones that go unsaid. How unfair! Not only are the goal posts in motion, but you can't even see the goal posts! Once again, when humans are involved, communication is key.

So, as the interview season heats up for residency and the match process, I tip my hat to those catching the red-eye that they booked on their other credit card, the one that's not maxed out, just to get back to their rotation and catch hell for taking a couple of days off. Just know that you won't be wearing the Ice Cream Man coat forever.

The Laws of Nature Abides No California Stops

A patient the other day asked me at the end of her visit what I liked best about being a doctor. The question caught me off guard, mostly because we were talking about mother-in-law dynamics and how she was glad to have a good relationship with her daughter's husband. I said something about a mandate for life-long learning and building relationships, whatever. Yeah, that is all true. But I've been slowly grinding on that question for a few days and on a day off may have identified, specifically what I like best.

Last week I went to a drug rep dinner (maybe the best one I've been to, with a charismatic speaker and valuable information no less) but, no, while as a resident these dinners are appreciated, they are not my favorite aspect of being a doctor.

The trust that people have in me, is something that I never take lightly and while I couldn't be a physician without this dynamic I couldn't do that as well without the doing this -- Active Self-Criticism.

I'm not criticising myself to make myself feel bad (sometimes it feels bad) but to change my behavior and grow my "toolbox" in order to be a better physician -- with increasing ability to develop my judgement and efficiency in managing interventions, medications, evaluations, and communication with patients -- with an emphasis on effective two way communication.

This is a difficult thing to do, it is tiring. In medicine we are taught, in class and ultimately by taking care of patients, that "anchoring" is dangerou and needs to be actively guarded against. Very simply, anchoring is latching onto an initial diagnosis or impression despite new or changing data that indicates otherwise. On a complete side-note, I go back and forth on my feelings of using italics, or (God forbid) all caps to emphasize any point I try to make. I rarely send text messages with more than one exclamation point or question mark in a row -- if more equates to stronger sentiments, where does it end?

Just as Bobby Digital, amongst many other luminaries are fond of saying, I try to adhere to the "word is bond, yo" philosophy, and as such, why should an italicized word mean more than the letters of increased verticality? But, then I must contemplate and meditate on the fact that my speech is not of all the same quality and that by the mere way I say words can add to, if not completely supplant the words and the meanings they traditionally hold. A life of conscious duality isn't too bad.

Back to anchoring -- this isn't unique to medicine, this is obvious. The essence of anchoring is choosing the path of least resistance even if the path is a dead end. It is lazy and mandates instant gratification or satisfaction over truth and ultimately, experiencing the best outcome of any given setting, situation or problem. We do this in our lives in so many ways; perhaps our self-image hasn't kept up with the actual shape our bodies are in. Maybe a relationship that has been neglected is still viewed through the lens of years ago. See, we hold on to old data because it helps us build a reality that is emotionally pampering versus the truth, that reality will not allow for what would have been the best outcome.

I saw the clip of Rush Limbaugh saying that Irma, and hurricanes in general were welcomed and capitalized upon by the liberal democrats who desired to advance an agenda based on climate change and the repercussions thereof. But, no -- wait, he did not say the 'repercussions thereof' -- he just left it at "agenda of climate change." This of course is so completely disingenuous -- and I hope all of you can see this. BUT, why not extend this fallacy to see how it holds up. What if climate change is a hoax? An evil agenda to -- to, uh, reduce the power of the oil industry which is nearly indistinguishable from the industrial-military complex? An evil agenda to decrease risk to a fundamental vulnerability to live, produce or defend ourselves in the setting of even a minor production wane? An evil agenda to transfer jobs from coal mines, which destroy lives and mountains to jobs manufacturing windmills and solar power products? An evil agenda to clean up the air and reduce particulate pollution in the city so my wife can breath without an inhaler? An evil agenda to have roofs made of solar panels that can store energy in batteries in the garage and sell power to the grid when the need is high. The people who want these things, these hippy, libtard, overeducated, safespace-needing, common-sense lacking cucks are taking us to a dark world indeed. Anyway, Rush ended up evacuating after all.

While Mr Limbaugh may not necessarily actually believe the things he says, especially knowing that drama and controversy brings listeners. But on some level he is being dishonest with himself. If he does believe the things he says, he definitely is lacking in active self-criticism. If he does not, he is using deception to advance a political agenda and this is profitable for him. It is one or the other. He has the luxury of sitting back and not being held accountable for lies, or misinformation that may harm individuals or the country as a whole. He is immune in that capacity, legally speaking,  however if you believe in a God or higher power, or whatever, this kind of individual is asking for trouble when it comes to accounting for their actions and life's work. But most of us, to some degree or another, do not have this luxury. That is, we are held accountable for what we say and do at work and in our lives, in general. A shitty carpet installer won't have a job for long. A careless doctor may find themselves in deep doodoo. A doctor that intentionally deceives people may go to prison.

This dynamic of professional development can, if one desires, spill over into other aspects of life. Especially as doctors advance in their profession and the fundamental foundation of competently managing their patient population, we can obsess over other professional endeavors and, of course, hobbies can become all consuming, as well. I write all this at the risk of sounding like a self-righteous self-help peddler of propaganda. But this lesson is something that can be applied in every one of our lives. Whatever you are doing during the day, endeavor to do it well. Maybe all you are going to do is lay in bed and watch Rick and Morty, old Simpsons seasons and maybe a Ken Burns documentary with the most active aspect of the day being doing laundry. Do the laundry well. Get. Those. Stains. Out. Make sure the dryer vent isn't clogged. Remember to check the lint filter.

And it is this component -- that I must always evaluate my performance and prepare to improve forever and ever amen, that I most like about being a doctor.

Why Yo-La-Tengo Should Be Your Favorite Band

I've written about this before, how music has played a large part in my life (not a unique scenario, to be sure) and how I've always been on the receiving end of a speaker's offerings; always the listener and appreciator never the strummer, key tickler, axe-man or skin-beater. Teenage years, when individuals are trying to be as individual as possible by assimilating to a subsect of culture they wish to identify with, is often when a particular genre of music becomes a part of their persona, too. Thankfully, I've spent time with many different sub-cultures -- as is often the case with skateboarding there exists an umbrella under which all types of people are welcomed and through a shared love of wooden toys with wheels, new aspects of a hitherto unknown culture is known. And as I've grown older, pieces from various times, activities, friendships and workplaces, I keep the music from those times, almost as a vehicle for revisiting and getting in touch with old friends. Some of the music I take for myself, making it less of a nostalgic piece, and instead it transcends, building upon the foundation of which I first heard it and becoming something that means much more than a reminder of good times with (good, or sometimes, not so good) people. I don't really listen to much Skinny Puppy these days, but oh boy, when I do, I think of that one guy when I was fifteen, who listened to Skinny Puppy and Ministry, only, as a strict rule. And I love this aspect of music, it's ability to transport us in time, to re-introduce us to old friends.

Yo La Tengo is a band formed in 1984 in Hoboken, New Jersey. They have been making music for a long time. Ira Kaplan and Georgia Hubley have been the two mainstay members, with various bass players and producers over the years. I was introduced to their music in a tumultuous time in my early twenties and, at first, it was because of who and how I was introduced to them, that I became infatuated with the band. As the years have gone by this band has transcended way beyond anything that has to do with the initial impetus that drew me close to Yo La Tengo.

But first, let us take a step back and look more at the fascinating world of creating sounds, especially in a world before computers. What first got me thinking of writing about all of this, is an article about 'gated reverb' that I came across the other day which is quite informative (especially for those of us who have never spent a minute in the audio engineer's seat) concerning one of the most recognizable sounds that is often associated with music from the 1980's, and now, music that sounds like it is from the 1980's. Gated Reverb, in this instance was a way to change how the drum sound was recorded, and, subsequently heard on the recording. Phil Collins and Prince made much use of this sound and once you hear it, it is something you will always be able to pick out.

Another interesting article about various sounds that came to be associated with famous songs (Pixies, Beatles and Joy Division songs are discussed if that means anything to you) which, as the article notes, the sounds are often sampled due to their unique but recognizable nature. I'm surprised the article didn't tackle the most famous (that I know of) sound from modern music: John Bonham's drum intro from "When the Levee Breaks:"

While I'm sure "Rhymin and Stealin" by the Beastie Boys wasn't the first place I heard this drum sequence, I can safely speak for myself, as a child of the 80's that this is where this was seared into my brain as an iconic musical moment. Kind of a shame, but -- in the controversial (used to be) world of samples, if nothing else, hip-hop music and the ubiquitous sampling has opened my eyes to music of yesteryear that is worth paying attention to. A quick Google search of "john bonham's drum sounds" brings up many articles and videos of people trying to replicate how he initially gained his impressive sounds.

Getting back to Yo La Tengo. Below is one of my favorite songs from them. It is from 2013, so relatively new compared to most of their library but it harkens back to the Shoegazing sounds that initially had me fall in love with them.

This sound, on exhibition in the above song, so exquisitely embodies what first drew me towards Yo La Tengo. The noise. The feedback. The harmony that springs out of seething chaos. A song that sounds urgent in its character but tells us to sit down, and just enjoy the process, exposing the competing and disparate ideologies and needs of the band members is exactly what I love. A female vocalist. A male vocalist. Acoustic. Electric. Keyboards. Orchestral accompaniments. Feedback. Distortion. I'm

Yo La Tengo is nothing if not versatile and unafraid to explore new aspects of music. This one, which may be on the other side of the YLT spectrum is one that really got me hooked way back in 2000 when it was released. Tears Are In Your Eyes:

YLT is also known for their covers of a wide variety of music. While I do enjoy most of their covers, it is their original music that brings me back over and over again. I don't really know much about the members of the band -- I don't spend time reading about them in gossip columns (probably doesn't exist, anyway) or following them on tour as if I were a 'dead-head' version for YLT but songwriting that spans the decades, as theirs does, allows us to grow up with the band. Songs from the early 90's that express the heartache and pain of heroin addiction and powderkeg breakups that are most often found in the early, formative years are prevalent. So often, a band's mojo dissipates after life becomes more stable -- inspiration formed in the pits of despair that mar the landscape of a twenty-something often wanes when marriage, then a family, then the morose mid-life crisis force us to look backwards, often leading us to grasp at the last vestiges of youth with a sickening desperation.

I trust that when (assuming I haven't already!) I look into the gaping maw of mid-life-ness and see the road fade into the distance that is known (death, yes, I'm talking about dying) I will not lean on exterior facets to secure my fleeting youth, but instead put on some headphones and sink into my really nice lounge chair (the one I got instead of the sports car) and travel back in time to when I listened to Skinny Puppy, and all the other bands that function as placeholders in my life. Yo La Tengo hasn't been there the whole time, but I'm thankful for them and what they have done for me.

Time keeps on slipping, slipping, slipping, into the future

Getting old isn't for the young.

When I was a youngster, I remember thinking that "old people" must not feel pain in the same way that a young'n would. Perhaps all the talk about a loving and benevolent creator led to this line of thinking. Then again, plenty of discussion concerning original sin and the closely held notion that our bodies are bad and must be punished (sex bad, food good) should have balanced out my feeling on the feelers of old folk.

Of course, there is no mercy, even at the end of life, when it comes to pain.

I also remember thinking, when I was young, that I would not forget what it is like to be young.

Much of childhood is like this. Major advancements on a short schedule. Growing larger, taller. Hair here, other things there. And school, with their precise stratification, serves to magnify this making each year's milestones demarcating lines between all the children.

It is difficult to remember what being a teenager was all about. While some of my best times, but also some of my worst times were during my teenage years. Just a whole lot of bad decisions and at times, superbly turbulent emotions and an inability to process everything. Being an adult, compared to a teenager, at least for me, adulthood has been smooth sailing, with spotty thunderstorms. The teenage years were like one 100 year storm after another. And after being out of and removed from the world of megastorms and we become increasingly prone to forgetting what a real storm is like, and how scary it can be to try to sail those seas.

But getting older has some benefits, at least, before 'getting older' turns into simply being old.

I was born at the tail end of the 'Gen-X' era, which, according to Wikipedia, ended in 1981. Supposedly, the 'Millennial' generation started in 1982.

Is it already old hat to discuss all the ways that older generations "hate" on millennials? I still see articles written about how this generation is painted with a broad generic brush of negativity. I hear older coworkers and other professional people lament the attitudes and presumption that this younger generation comes pre-installed with. And that is the key -- similar to how a computer often comes with malware preinstalled (mostly PC's of various ilks) so does a child with it's upbringing. Of course, this analogy can only be taken so far, but it does fit. 

Imagine a VP at Dell, or something, buying a computer and then being angry with all the bullshit that comes with the computer. Programs that are bulky, annoying and sometimes downright malicious. It was his/her company that did this!

So it is with the 45 year old doctor who now complains about millennials and their bullshit. He or she raised that generation, or one aspect of it. They were part of the culture at large that produced the next generation. 

I think of it like this: the older generations know that they slipped, that they have taken more than their fair share -- greed, corruption, and all the other human experiences have coalesced in this country, specifically, to leave less for those who are coming after them. The actions, even the healthy ones, demonstrated by millennials, are reflections of and direct responses to the choices and behaviours of the baby boomers, and even the older gen-x'ers. 

Pick a dying industry, or one that has been "disrupted." Taxi-cab service is a good one. Millennials destroyed taxis. Well, it is fairly obvious that if the taxi industry had been just a little more flexible and willing to change with customer desires, it could have easily been ahead of the Ubers and the Lyfts. A cab company that offered the ease and convenience and relative safety of the ride-share programs could have taken over the industry. I'm old enough to remember calling a cab at the end of a night, at a restaurant and waiting, with uncertainty if a cab would ever come pick us up.

Millennials are killing cable TV. Well, thank goodness. Somebody put them out of their misery already! Put us out of our misery! Now, if only the millennials could band together and stop the FCC from handing over the reigns of net neutrality to those very companies who aim to replace the lost revenue from "cord-cutting" with paid internet streaming services and options, we would be getting somewhere. 

This is kind of a unfocused blog post. It is kind of how I feel, caught between pre-defined generations. When I was a child, I spent a lot of time with older kids, teenagers even. Mostly because my parents were in charge of the youth group at the church we grew up in. As a small child, I was listening to Boston, Journey and (yes) some actual good classic 70's album rock. Many of my contemporaries were listening to whatever pop slop pumped out of the FM stereo speakers -- and that is okay, it is just I've straddled the generation gap since the beginning, and at times, I feel it. 

And this is all stuff that other people have made up. Babies are born with no predilection as to what generation they should be a part of. The parents don't care, most of them are just happy to have gotten laid -- they're not purposefully designing the next generation, however -- I argue, that is exactly what they are doing, and just like Crosby, Stills and Nash, of the baby boomer set had to say...

You who are on the road

Must have a code that you can live by

And so become yourself

Because the past is just a good-bye.

Teach your children well,

Their father's hell did slowly go by,

And feed them on your dreams

The one they picks, the one you'll know by.

Don't you ever ask them why, if they told you, you will cry,

So just look at them and sigh

And know they love you.

And you, of tender years,

Can't know the fears that your elders grew by,

And so please help them with your youth,

They seek the truth before they can die.

Teach your parents well,

Their children's hell will slowly go by,

And feed them on your dreams

The one they picks, the one you'll know by.

Don't you ever ask them why, if they told you, you will cry,

So just look at them and sigh and know they love you.

Songwriters: Graham Nash

Death Panels

During medical school, I had a preceptor who worked at a county clinic serving the least fortunate in Vallejo, California. He once said that the experience working at the clinic "is how Republicans are born." This, coming from him was, of course, tongue in cheek. But, he has a point. The front lines of medical care in this country bring to light the vast and substantial inadequacies in the health of the people, in this country.

I could go on, and on about the policies and political decisions that have brought us to this point -- I have no shortage of opinions in this area. I feel compelled to express and assert what is tantamount "end-user experience expertise," leading to a greater insight than most -- yes, it comes from simply being a doctor and working where I work, but also from the many jobs I've worked over the years. I've spent time as a business consultant in health care. There have been large swaths of time spent un- and under-insured.  My opinions are formed from a perspective imbued through the seasoned lens of wanting better health -- for all of us. I have no concern for the shareholders of private insurance companies, hospital systems and pharmaceutical companies. It has been shown that capitalized medicine only works for those with capital.

And, while I happen to believe that access to health care is a right, it is a discussion that should be had in the public arena. I believe it is, undeniably the right thing to do. It is also the best thing for this country, to ensure a future with citizens that can contribute to the greater good, where preventable diseases and unexpected traumas don't ruin a life -- physically, and financially. It is paramount for national security -- we are a nation that depends on our brain trust,  we need healthy brains.

There is another side, a darker side -- one fraught with sirens that call out to all first responders, true public servants, hospital clinicians and especially physicians, it is a desirable chorus that we must fight against, must resist. It stems from a rampant lack of individuals taking personal responsibility for their actions compounded by the desperate situations that come from a lifelong pattern of this. While all of our lives have aspects of uncertainty woven into them, there exist decision tree patterns in this world which, to a (un)certain degree lead to predictable outcomes. One may fall into many different careers in their life, but one does not just fall into being a physician. This is a decision tree with relatively predictable outcomes. The schooling, training and the sheer length and intensity of it all offer many off ramps and outs along the way (mixing metaphors feels sloppy, but I'll allow it this time.) I paused at a number of off ramps along the way, I've even explored some side streets here and there, only to get right back on. Neglect of the body --.> disease. Some of us just ignore an insidious disease like diabetes mellitus. They keep on going despite the pancreas all but giving up its endocrine function, walking around with blood sugars in the triple digits for years straight, all the while the little tiny blood vessels and tiny little nerves in their eyes, feet and kidneys are being fried with acid, killed over time with an absoluteness that makes this one decision tree even more assured in its outcomes. They will lose their eyes, toes and kidneys if their diabetes remains uncontrolled.

There are other algorithms that people follow, such as allowing oneself to be consumed with anger and deflect all responsibility outwards -- this person often uses more resources and is more "trouble" and time consuming than ten other patients combined. Sometimes this person comes in as a drug seeker, with manipulative means that have been honed to put the doctor in a corner, forced to fight against improper opioid administration. A patient with no fear of respiratory arrest, but "all body pain" rated 10/10 can be a 45 minute, desperately fought discussion teetering on straight argument, depending on the patient. It is hard to have compassion for this patient. They take time away from other patients that need attention. Infuriating situation, at times. Other times, a patient isn't fighting to further their addiction, but simply to have a warm bed and food. There are keywords which mandate a relatively expensive workup, and at times can land a stay longer than six hours in the ED to a few nights up on the floor. While these misallocation of precious and fleeting resources are disturbing, it is more understandable than the patient who has a dilaudid deficiency.

I mentioned the sirens earlier. These sirens feed on these types of patients, lurking behind us during rounds and whisper things in our ears that are evil -- judgemental, unempathetic, shortsighted thoughts that can entice people to broader plains of falsely founded bias and even bigotry. I actively fight this siren's call.

It is easy to focus and imagine the patients above, and how they waste such a disproportionate amount of our resources. But let me be absolutely clear, the ratio of these patients vs those who find themselves in the hospital fallen from historically tried and true decision trees, is actually very low. I see people, on a daily basis who, even in the eyes of a capitalist, hardcore, Reagan worshiping and Grover Norquist adhering Republican -- are valuable contributors to society who don't have access to reasonable preventative, much less affordable acute, emergent care. These people aren't the squeaky wheel, unlike the patients that remain in my mind, the ones that the sirens keep bringing up, reminding me of their greedy and incautious ways.  Just like the image of the "welfare queen" buying steak at the grocery store invalidates welfare programs, regardless of how many real, needy people, people who chose to climb a decision tree that shouldn't leave them destitute, outnumber the "welfare queens."

Listen, it is not as if I think an installation of government run, one-payer, "socialized" health care is the panacea to this problem -- but, I personally think that it would be, in general, an improvement. I could care less about political allegiances. I just want decision based not on short term, privatized profits, as they are now.

This is a national security vulnerability.

Sometimes I think that if the poor state of this country's people were framed in a way that would hurt the military-industrial complex, the Pentagon may actually advocate for a better system. I suppose that outsourcing our military to a population from overseas would be their preferred plan of action. Afterall, it seems that the political powers that be are preoccupied with ensuring that we have less access to care, in the name of political infighting, real life consequences be damned. If they're buying shares of private health insurance companies, maybe I should too, after all my student loan payment plans are next on the chopping block.

Fifty Things To Do Before I Die

My parents moved when I was seventeen years old, the summer after I graduated from High School. I moved out a few days after I turned eighteen. There was a window of about thirteen months when I could have written the above list. Most of that time I was working two full time jobs -- with my Uncle installing roofs and then at night and weekends I worked in the kitchen in the Clackamas Red Robin restaurant. I wrote this list, and, then promptly forgot about it, until my Mother found it some years later when she was cleaning out the room. Perhaps it was when the carpeting was replaced, but it must have been ten years or so after I wrote the list. She gave it to me and then, I promptly stowed it away in some shoebox where I have stashed nostalgic stuff from the past. Recently, I moved to Long Beach and going through the unpacking process, I stumbled upon this list I entitled Fifty Things to Do Before I die. 

An examination of the list shows how ridiculous some of the aspirations of me at age seventeen were, but they are not in the majority. Most of them are attainable and worthwhile -- some of them I've even accomplished, or are on the way to accomplish. Four of the entries are blocked out due to involving specific people who I don't want to identify -- nothing terrible regarding them, I simply don't want to involve them -- it is not fair to them. I thought I'd take the self-indulgent, cathartic time to evaluate just how I'm doing regarding the goals set for myself. I haven't died yet, and twenty or so years have gone by -- I should have gotten somewhere by now, you'd think!

1. Publish A Novel I'm closer to this goal now, than I've ever been in my life. Between when I wrote this list and now, writing as an endeavor has only existed in the second half. Roughly ten years ago I started my undergraduate studies, which included a degree in creative writing. At this time I'm nearing completion of my first draft of a novel I hope to have published in the near future. 
2. Publish A Collection of Poems Hmm. During my recent unpacking I did come across a binder full of poems I wrote during my teenage and early twenty years. Most of them are cringe-worthy, angsty things that may as well  be the lyrics to some shitty Nine-Inch Nails song, or some emo, eyeliner-wearing whiner who prides himself on being "deep." If I ever publish a collection of poems, it will either be an easy money-grab because I am famous for something else, or a posthumous money grab by my estate, because I was famous for something else. Either way, it will be worth the embarrassment.  
3. Learn to Play The Piano I still want to learn. This one is getting kicked down the road, unfortunately. 
4. Earn a Phd In Quantum Physics I'm a doctor, and that is as close as I'll ever get to this. Well, one time I did see the Schrodinger equation written on a chalkboard in the science building on campus, that's probably as close to as I'll ever get. 
5. Not Watch TV For One Month Straight While this hasn't happened recently, I've gone large chunks of my life with having no television involved. Granted, I did just buy a new sixty five inch television (great deal at Costco) so I'm not sure this will happen in the near future. Residency doesn't exactly lend itself to laying around all day and watching TV so, I'm not too worried. 
6. Run Five Miles A Day Again, for a period in my life I was an avid runner. I love running, but arthritis makes it a tough go, especially when carrying around a couple (few) extra pounds. I wish to save the remaining cartilage in my knees for things more enjoyable. 
7. Live In Canada For One Year Well, considering the politics in this country...
8. Do 360 Kickflips Consistently There was a time where I could be seen throwing some threes around Creston, or the Waterfront, but I never did have them on lock. In the grand scheme of things, I always thought my switch threes looked much better, not that I ever had those on lock, either. 
9. Travel Europe A couple of years ago I had the pleasure of wandering around Europe for nearly a month. London. Amsterdam. Paris. Barcelona. Can't wait to go back. 
10. Visit East Coast Relatives I never have done this. As time has gone, and my connection with the ACC has dimmed, it seems less and less likely. Perhaps, in the future, I can make it happen, I would like to see where my grandparents came from. 
11. Learn To Pray Daily This one is still a struggle. 
12. Walk For One Month When embroiled in the struggle that is practicing medicine, this becomes more of a desirable experience than I might have imagined. I've always held a romantic notion of 'wandering' and I while taking off on foot may never happen, I desire more wandering to be in my life. 
13. Learn To Watch My Mouth In general, this hasn't been a huuuuuuge problem in my life. There have been times where I shoulda just shut up, no doubt. I grew up hearing 'sticks and stones can break my bones but words can never hurt me' but it isn't true, no matter how convenient it would be, if it were. 
14. Become Proficient In German I don't foresee any major undertakings to learn how to speak German in the near future. I mean, I would like to do so, but realistically, this one is dead.  
15. Become Proficient In Spanish My medical Spanish needs a boost, that is for sure. 
16. Become Proficient In Latin Just not gonna happen. 
17. Call The Art Bell Talk Show Coast to Coast AM, the name of the Art Bell show, which Art Bell hasn't been a part of for years, as far as I know, seems to have turned into an alt-right mouthpiece. I remember hearing Alex Jones as a guest many years ago and I think that says it all. No thank you. 
18. Address Congress And Give Them A Piece Of My Mind I mean, I would have many different things to say now than I did 20ish years ago, but my point still stands. Disgusting. 
19. See BB King Live BB King died May 14, 2015. I never did get a chance to see him perform. 
20. Bench Press 400 Lbs That is a lot of weight! I believe the most I've ever bench pressed is 250lbs, and that was not a one time max effort, but during a time where I was doing sets. Maybe, at my peak, I would have been able to push up 275 lbs, maybe? Besides, I doubt I need to add the extra mass needed to get to that state. I'm fine with my 225 BP at highest set now. 
21. Learn To Speak My Mind (Selectively) Another item where growing older takes care of things automatically, or, at least a mix of effort and time. 
22. Spend One Month In Solitude In The Wilderness There things like this on the list. I'm not sure I'm in a place where I'm as excited to spend a whole month by myself in the woods, maybe I'd do one of those television shows where we spend a few weeks in the wilderness. I wouldn't be afraid to do it naked. 
23. Publish A Research Paper On The Philadelphia Project This could easily be the most ridiculous thing on the list, and the thing that betrays my age at the time of writing. So silly. 
24. Travel To Israel Between my preclinical and clinical years of medical school I took on an acute care internship at a small hospital in Netanya, Israel. Initially it was going to be five or six of us going, but they all fell out and I decided to go by myself. I rented an apartment for myself, on my own dime and walked to the hospital everyday for a whole month, well, on the weekends I walked to the beach and swam in the accommodating waters of the Eastern Mediterranean. I learned a lot, I fell in love with the land and the people and cannot wait to go back. Tel Aviv is one of the most enjoyable, dynamic, vibrant and friendly large cities I've ever been to. 
25. Thank Grandma Pamer And Tell Her I Love Her Grandpa Pamer died only three-ish years before this and Grandma was, I think, still living on her own. It must have been either my senior or sophomore year and I was required to do a project for my German class. I roped my Grandma Pamer into showing me how to make some German meals. She was a good sport and she walked me through how to make cabbage rolls, and I don't remember what else. She included some stories from her childhood and how she learned to cook for a large family on a short budget. I wish I still had that VHS tape -- who knows where it went. In the following years she was overtaken with Alzheimer's Disease. It was tough watching the descent into dementia but I'm thankful for the time we had. 
26. Learn To SCUBA Dive Oh yeah. It is a shame that I haven't gotten around to this. Maybe I make this a goal while I'm in Southern California for the (at least) next few years. 
27. Go Skydiving Sure. I think the thing that I least look forward to concerning jumping out of a perfectly good airplane is having to do it tandem. 
28. Have Children We'll see. We were close last year. 
29. Read War And Peace This one perplexes me. Maybe I should just read it? If I knew this was a goal of mine, I would have just read it already. I guess now I know, or know again, more specifically. 
30. Spend A Night In Jail Haha! Of all the things I'm glad haven't come to fruition, this one could really screw up my life. Stupid responsibilities and professional considerations. Sheesh. 
31. Snowboard In Alaska Haven't done this, but I did get a few great years of riding in Colorado that I never put on this list. Maybe I'll get some big mountain riding in before I'm pushing up daisies. 
32. Meet Jeremy Wray And Eric Koston I stood next to Jeremy Wray at a Tampa Pro contest in, it must have been, 2002. He is tall for a skateboarder. Much respect for tall skateboarders -- we have further to fall! Now fat and tall skateboarders, woowee! 
33. Meet The Woman I Love And Marry Her Nearly 11 years to the day. 
34. ***
35. Travel To Papua New Guinea The desire to do this has diminished greatly as I've grown older. When I was very young my Mother traveled to see her sister and her family, who were in PNG, and I've known many others who worked there. I used to spend many hours imagining what it was like to live there, among the native people, in their villages. I don't spend many hours these days thinking about that. 
36. Listen To Others More It has become abundantly clear that my greatest strength in the capacity of being a physician is my ability to connect, relate to and build rapport and relationships with patients. And for that matter, other health care workers too. Around the country a new and young generation of physicians have taken the the valid criticisms of the previous' generations of doctors and their bedside manner and just, general way they conducted themselves to heart. Perhaps it is partially due to the physician not being the end-all-be-all in clinical decisions (in general this is not good for patient care, but I will not digress at this time...) as we were in the past that has led to the greater harmony concerning team-based patient care, perhaps its just the natural evolution of people recognizing shortcomings of the past (if only this was applicable to more areas of society) and the movement to remake us doc's in the likeness of humanity. 
37. Be Willing To Help Others More As discussed directly above, I think my journey towards and in medicine has functioned to more than accomplish this goal. I don't think that I ever was severely lacking in this area, but admittedly, all of us should aspire to this goal on daily basis. Unless you're driving slow in the left lane of the freeway, I'll be there for you! 
38. Hitch Hike Across The Nation This one seems very similar to the one below, that has me walking for a whole month. Forrest Gump was fresh in everybody's mind back in these days -- and I really did love that part of the movie. 
39. Bungee Jump As I get older, I feel less inclined to do these kind of things. I would probably still do it, but I don't actively seek out these types of adventures. 
40. Kickflip/Shuvit The PSU Gap I never did either of these and the parking lot is gone. Off of 4th street, on the SW side of the Portland State University campus was a parking lot. This parking lot had a smooth run up to what amounted to a little lip (think very small jump ramp) and then maybe five or six feet of dirt and then the sidewalk. The run-up was perfect, as was the landing. Although, before the parking lot was gotten rid of, MAX tracks (or StreetCar tracks, I don't remember) were put in, making the roll away after the sidewalk more difficult. Zak Danielson 360 flipped this gap in 411VM issue #4, which can be seen below. I ollied and frontside 180'd it and I'd like to think that kickflipping, heelflipping or a shuvit over it could have been accomplished given the opportunity. 411VM #3 Zak Danielson at the PSU parking lot  
41. Own A House I've had a few now. Will have more. 
42. Get An Enjoyable Job I think becoming a doctor fits this bill. It certainly isn't always enjoyable but I think it is more fulfilling than I could have imagined. It is worthwhile to note that none of these items on the list have anything to do with medicine, much less becoming a doctor. 
43. Get Tattoos Don't have one yet. For a few years, I actively avoided getting tattoos as I saw them as more conformist than not having one. I love good, tasteful ink. Terrible, tattoos just look so trashy. I guess you could say I was trying to out hipster the hipsters by not having ink. I have some things in mind. Maybe I'll get one this week. 
44. Own My Own Company This one may be the one item I completed closer to the time of creation of the list, in relation to all the others. At the ripe ol' age of twenty two I started a small construction contracting business. I didn't engage in that business for very long, nearly two years but it gave me a taste and even now I have an LLC (not actively conducting business right now) and foresee myself as a small business owner (active) in the near future. This time, I won't be installing cheap carpet in section 8 housing, thankfully. 
45. Study Philosophy I took a community college class in introduction to philosophy at Mt Hood Community College once. I didn't finish the class. 
46. ***
47. ***
48. Always Go For It Thinking back to my self, and what was going on in those days, this pertains, most likely, to two different and specific endeavors: skateboarding and girls. I like to think that, in general, in the grand scheme of life, that I have, indeed, 'gone for it.'
49. ***
50. Always Be Honest, No Matter What Still striving, and always will be striving for this. 

19/46. Some of the softer goals are subjective in nature. I'm giving them to myself. Please, if you dispute, feel free to call me out. 

Righting the Writing

I'm still trying to write a novel. The outline and overall plot has evolved into a simplified version of what I have previously described on this blog. I still have more than one timeline involved, but I have taken my first scenario, involving the earthquake and subsequent landslide in the Columbia River Gorge and the Native American family caught in it and added a modern day timeline. Gone are the two subsequent sections -- the 'shanghai'd sailor' and the Netanya bombing character. I'm roughly 25% done, concerning word count alone, but feel like I'm missing some key elements that will propel me to the next phase of the story.

In the modern day timeline, I have a 29 year old male who is built from elements stemming from my experiences and a few key friends of mine. For the past three weeks I've been working in a hospital in Wisconsin, consulting physicians and some support staff with a new computer set up. I've had plenty of downtime, and I've tried to write but have found it hard, and have struggled to produce anything I want to keep. However, I've been able to comb through my hard copy of what I already have written and copy edit and identify sections that require re-writing. In general, such intense scrutiny before the overall work is completed, is something I try to avoid. That said, I've never attempted a writing project of this magnitude before. My gut tells me that I should back off of the hard copy scrutiny, as it has served to discourage me. I believe in the story, but through intense inspection I've been focused on a small grove of trees and lost sight of the forest.

In fact, even writing about writing and the inherent struggles should serve to weaken whatever block I've been working through. Working in a hospital for fourteen hours a day, in a three week straight blitz has not served to allow abundant inspiration to flow -- I recognize this, but time is growing short and I must manufacture a breakthrough.

As much as I think my intense editing and rewriting has been detrimental for my ability to continue writing this novel, I do think I learned something about my intentions concerning the core elements of the story -- of what I want to say and what I want the reader to understand. I've gotten lost, as I have subconsciously brought themes into the story, which serve to confuse and distract the reader -- hell, they distracted me! These disorganized, tangential elements are self-indulgent. My biggest obstacle lies in finding a compromise between telling the story I want to and avoiding overwhelming hedonistic digressions.

What kind of things have seeped into the story that I need to address before moving on? Let's see. In no particular order:

• Stubbornness and harboring of bitterness and anger and what it means for family dynamics
• Generational differences in worldview, especially concerning economics in the U.S. 
• Hypocrisy that can occur with blind adherence to religious dogma -- especially the dichotomy that modern American Christians have allowed to prosper
• Anti-science proclivities and the ridiculous, insidious nature from which it springs
• Human-ness and its transcendence through time and cultures, no matter how disparate  

All but the last one I identified after re-reading and editing my initial work. The last one, concerning human nature and how very much alike we all are, in fundamental ways, is exactly what I am hoping comes off the paper when the reader goes back and forth from the two timelines. I include it in this list only because I do see it bubbling up in ways I had not specifically intended -- this pleases me, and is indicative of being on the right track, at least as this is concerned. 

Do I continue to build on the other elements I've built into the story? I think I need to, in some fashion with, perhaps, varying intensities. Thankfully, public reception of a novel, written by yours truly, will have little bearing on my career or ability to feed my family. And, moreover, I'm simply writing this for myself -- and in that lies the need to seek balance. I do want people to enjoy it, but that is not the supreme, guiding goal of this project. I have to be comfortable that the only person I really want to love it, is me -- and that is much harder to come to terms with than I would have thought. 

What we've got here is a failure to communicate -- About Failure

Failure is painful. Pain, in general, we avoid. However, like all things we can override our primal drive to avoid pain if we recognize its utility in a cost-benefit ratio analysis. In other words, no pain -- no gain.

Recently I was reading about a high-school teacher's experience concerning the differences between students in 1997, 2007 and now, in 2017. She had numerous things to say, but what stuck with me and, what was the primary driving force of her analysis, was that students today are overwhelmingly lacking self-confidence. She tied this to a fear of failure. They are unwilling to try anything challenging or new without a significant amount of one-on-one guidance and encouragement. Of course, in a classroom of more than thirty students it is impossible to give this type of attention.

While pondering this perspective I became overwhelmed with situations and dynamics that I have experienced and witnessed. Education, ideally, in my mind is a time where failure is a path to learning and growing in ways that initial success -- whether it be by accident or competence, disallows. I started my undergraduate pre-medical studies in my late twenties and because I had that goal of becoming a physician, I felt the pressure to not fail. There were individual tests I failed (not too many, thankfully) but the prerequisite classes for medical school matriculation were very important and a failure would be painful (and while it would be a growing experience I'm glad I didn't have to "grow" in that fashion.) Because of these classes and the rigors involved I came to appreciate my English, literature and writing classes very much. I had one writing instructor for many of my writing classes and after I got to know him I had a discussion concerning my paranoia about my GPA and what it was going to take to get into medical school, and despite my enjoying his classes very much I needed to know what criteria he would use for grading his students. I remember telling him I was concerned that if I tried to branch out, to take risks and write in styles, fashions and themes that I was not already comfortable with, that it would affect my grade. How sad is this? I love writing. I loved his classes and I became a better writer because of them. He was a Ph.D teaching at a University -- he knows how things work and what grades mean for advancement. Obviously, I don't know what he was thinking but I'd like to think that he would recognize the fallacy I'm trying to get into here: that failure is beneficial, provided lessons are learned. I did achieve high marks in all of his classes -- and I think I deserved them, if only because I put forth tremendous effort, which was easy -- after all, it was like a respite from all the chemistry and biology classes -- a chance to exercise the other, starving part of my mind.

I finished highschool in the 1990's. In many ways, in those days, I had a solid, if not misguided, sense self confidence. And while I didn't aspire to further my education at that time, in a rudimentary, incubatory fashion I learned how I wanted to live my life and who I wanted to be through many trial and error type experiences. Many of those experiences, at the time, felt like less like searching for truth than just having fun. And that, precisely is the elixir of youth.

I can easily point to many aspects of modern life that can work to subdue a young person (or, if we're honest with ourselves, all of us regardless of age -- us old fogies simply have the benefit of growing up in a social-media-less environment, among all the other things I'll point out.) However, taking a step back and examining what I think is an important aspect of the human experience will allow a proper framing of what these larger societal shifts and their impact on our emotional life.

Satisfaction and happiness are both dependent functions of an individual's expectations, in any given situation.

I buy a bottle of wine for $10 and I really enjoy it. My expectations were low. The situation was pleasurable. I am satisfied and happy with the purchase and libations.

I buy a $100 bottle of wine. It's okay -- I didn't spit it out. My expectations were high. The situation, while acceptable, lacked in pleasure, relatively. I am less satisfied and happy with the expensive bottle of wine.

And here is the key -- in a vacuum, with mitigating factors such as price, which lead to varying expectations, my enjoyment of the expensive bottle of wine, compared to the $10 bottle, may actually be superior. But it is the function of expectation which dictates which scenario I will prefer.

A child who views the lives of their peers through the filtered lense of social media is comparing their "low-lights" against other's "highlights." Growing from child, to teenager and into adulthood is difficult. It is an emotionally charged out of control train which can leave the tracks.

Pathways to successful careers less plentiful now compared to twenty years ago. Many students are paralyzed by what they see as impossible standards for success. Beauty. Brains. Money. Innate coolness. We see these projections of partial reality and our expectations function to decrease the satisfaction and happiness in our own lives.

We also have a President who refuses to acknowledge any deficiency regardless of how obvious. That man is not the only guilty party -- many people in positions of leadership, at all levels see their grip on power depending on their perceived infallibility. Allowing humanness to shine through, to acknowledge the struggle we all share is tantamount to failure. And, with this perspective, people beholden to such beliefs see failure as a finality of defeat. Temporary setbacks and learning experiences are indicative of incompetence. I see this larger trend in society only serving to exacerbate the spiritual flogging of our society.

The Scientific Method.

To explore our world and search for answers of mechanics and etiology, and of course, the ever juicy -- what if?

Experiments that do not work as expected, even failing to prove a hypothesis are valuable. A student who fails a test can take it as a sign he or she is just not good enough to earn a good grade. Or, they can learn, adapt and grow.

Just as science has been demonized and vilified due to its insistence to recognize facts, our young people have had their psyche and sense of self-worth beaten down with weaponized untruths.

People who do not believe in themselves don't believe they need to be treated well. They will not fight for themselves. Politically, they will prefer finger-pointing and blame-shifting rather than objective determinations, leading to leadership which uses these prods to stay in power. A tried and true technique.

But back to the high school students of 2017. Trite admonishments such as 'it is not how many times you fall down, it is how many times you get back up,' while containing wisdom are lost in the flood of inspirational posters and other catchphrases. And these students are not putting themselves in a place to fall down in the first place -- and this is the key dynamic that I believe the teacher was referring to. And I get it. I remember when I was a pre-teenager who wanted to get into skateboarding, being around the older kids and being scared to try things such as drop-in on a ramp for fear of failing. So I found places where no one else could witness my failings and I kept at it until I felt comfortable in my abilities around others.

Social anxiety has become the new 'nerd' in that it is acceptable to blame, or indulge in what is an honest feeling that I would guess (eschewing my solipsism belief tendencies) all of us have, to some degree or another. And like many other things, pushing through and, even when failing multiple times, persisting leads to self-confidence. This is important, as it is a genuine self-confidence, a manner of existing that doesn't necessarily require the bravado of arrogance or rotting pridefulness. Perhaps my upbringing, where I was endowed with a sense of self-worth, leading to a base foundation of self-confidence as a human being, independent of performance, allowed me to grow in a healthier (subjective analysis, to be sure) fashion than some others. Is that what younger people are missing -- is this what happens when life becomes so measured, metered, quantified, judged and evaluated that we come to feel that our self-worth is based on performance alone?

I don't know.

It seems possible. My ramblings and spontaneous musings while trying to write this are insufficient to fully explore this sweeping generalization encompassing a whole generation. In fact, sometimes when I take a step back, I truly think that us humans, through time are surprisingly steady. A small percentage of us fight for and achieve power. Most of us just want to have fulfilling lives, enjoying our family and a modicum of freedom which money can provide. Often I think that indeed, 'the kids are alright.' But, in order to not completely invalidate my musings I will assert that the innate and supreme fundamental human craving to communicate and ultimately feel understood is being fucked with through our means of mass, personalized communication. Loneliness and forced apathy abounds. I feel it too.

Still Searching For That Clinical 'Banger' For The Ending

In no way can I blame my parents for not forcing me to learn to play a musical instrument as a child. However, there are many times where I wish I did know how to play an instrument or at least read music. Many of my friends do indeed pursue music as a passion and even a career. I've often found myself wondering, in awe, how the fingers of a piano player or a guitar strummer can so effortlessly find their place with such precision movement. The closest thing I have experienced involves skateboarding; repetitive movements -- muscle memory that becomes subconscious in that a conscious decision to execute a larger "trick," or in the case of music, a "tune" or "song," is comprised of a symphony of learned behavior. It becomes automatic.

Skateboarding has also been responsible for much of the music I've loved. I grew up in an era which had 411 Video Magazine's monthly VHS offering was eagerly consumed. Each video started with this iconic tune:

The alarm on my phone plays this song. Something subtle in the meaning of the song, buried deep inside my mind, irrevocably lodged in there when I was a teenager gets me amped up -- the perfect alarm song. 

Of course, the songs during video parts are even more influential for me than the 411 theme. One of the first skate videos I remember watching was The New Deal's "Children of the Sun." Besides the 411 videos, it was the first video which I watched, and rewatched hundreds of times over. Dave Duren's part had a song from the Smashing Pumpkin's album "Gish" from 1991. Of note, this is before "Siamese Dream" took the alternative music scene by storm in the mid-nineties. 

The very nature of skateboarding, in sharp contrast to institutional team sports, has a propensity for it's participants to pursue artistic endeavors. Painting, music, graffiti, writing -- some of my favorites have roots in skateboarding. Shooting a basketball is an individual endeavor, but winning a basketball game is a group effort. Skateboarding has no team, it has no winners or losers! One may point to the many skateboarding competitions in contrarian efforts -- well, sure, a "winner" is crowned but these are judged on a subjective style interpretation. I would even argue that the staunchest competition skaters only do it for the money. And in this lies the most beautiful aspect of skateboarding -- it is an artistic expression of the skater. This is not expressly unique -- gymnasts, skiers, divers, and many others conduct themselves, at the base maneuver level, the same way. However, I propose that the culture and the manner in which skateboarding has evolved -- using urban architecture and utilitarian infrastructure in novel ways, sets it apart. The rallying cry for the past forty years of, "Skateboarding is not a crime" arose from the pushback (and in many cases, understandably so) of using the urban landscape in a manner that is a delight to my eyes. Inspiration is fertilized by tribulation. 

Bad Religion, Black Flag, Minor Threat, Tribe Called Quest, Wu Tang Clan, Buffalo Tom, Motorhead, Souls of Mischief, Nitzer Ebb, Sebadoh, EPMD, Bad Brains, Del Tha Funkee Homosapien, Pennywise, Ned's Atomic Dustbin, Stereolab, Fugazi, Superchunk, Seaweed, Tortoise, Slayer and my love of so many more are all rooted in skateboard videos. 

I used to always ponder what song I would want for my own video part. When I think about it now, I imagine myself with a highlight reel of clinical moments -- diagnosing that rare condition, calming the anxiety ridden patient and not mistaking the PE for pneumonia. And if I had to now have a song, I would still want to use that age-old trick where I get to choose two songs (think "Yeah Right" by Girl, who had most of their riders get a "B-side" with a different song) and they would be:

and 

The goal is to have more than one video part, of course. Too much good music out there.