Slightly Weightless

Having flown so frequently in the past few weeks, to Europe, to Houston, and back to Virginia, I’ve come to appreciate the sensation of being slightly weightless.  For those of you who may not partake in planes, or enjoy the thrill of roller coasters, this is the same benign gravity defiance of trampolines or bouncy houses.   While unfortunately it doesn’t make me weigh any less, it does imbue me with a strange sense of optimism.

My latest trip was to a Chief Conference, an attempt to prepare the up coming Chief Residents for their year of indentured servitude.  As with other conferences I’ve been to these past few years, it was quite motivational and energizing.  The atmosphere of camaraderie, of change and accomplishments unforetold can stir even the most stoic of hearts.  It was true after the AAFP National Conference and definitely true after this APDIM Chief Meeting.
The wisdom of Chiefs past mixing with the ideas of a congress of programs (and the constant availability of coffee) makes the blood rush to our heads and gives us notions.  The impetus for improvement, the possibilities of new power, the new responsibilities we receive are all quite intoxicating.  How can we better this or that aspect of our program, make life easier, make attendance better, help those who are falling behind?  It’s all momentarily possible, tempered by a healthy dose of realism and the briefest acknowledgement of bureaucratic red tape.  Our three year journeys are never pain free.  So many issues arise, some potentially problematic and many more merely inconvenient.
Somehow, we will strive to be hopeful and practical.  We will strive to be perfect in our own ways.  We will strive to have even tempers.  We will strive to optimize everything.  We will herd others to the light and make them the see it.  We will support them so that they can be the best they can be.  We want to develop this, to promote that, to make things interesting, to leave a lasting legacy and large foot prints.
But, I’m a born moderate.  Hopefully, this be our guiding light as the seasons change, but what we want is irrelevant.  Optimism is inherently motionless.  Starting today, it’s time to see how effective we are at maneuvering through the jungle.  Maybe by the end of the year, we truly will be swinging through the forest, slightly weightless.

Game (Musings of the not so teenage)

It occurred to me that my parents really enjoy having had their children.  Now, this may seem like a statement of the blatantly obvious.  Or if you peruse the mass of literature on the matter, clarity of the situation may be significantly obscured by mixed reviews.  However, I have recently realized that though I have certainly tried my parents in the (not so distant) past, we have reached a stage in our relationship where we no longer stress them out on a regular basis.  It seems that we have turned into somewhat of a game for them.

Ping pong: (The quintessential asian pastime)  Our brians, life experiences, various different skills are now able to positively contribute to their lives.  I’m talking relay of ideas, richer gossip and deeper friendship.  Though there is still the occasional wifi setup and phone or photo tip.

High Stakes Poker: Scoping out a significant other.  The new challenge of parents with children of marriageable age is to find someone worthy of the goose born of a golden egg.  My parents have taken to this with…vigor.  The game of poker is played well many.  Their anticipation and excitement is palpable on this subject.  Can I admit I am somewhat afraid?

Telephone:  Relaying and often mis-relaying our conversations as discussion points of fact between my brother and me.  I’m not sure they enjoy discussion or are purposefully changing tone and context to get running commentary from either of us.

Rubix Cube: The striving for perfection.  Now that all the squares are painted, how can we make them perfect through external forces?  A turn, a twist, a spin.

And to be honest, I guess I rather don’t mind.  I’m glad they find us such a source of amusement (as separate from enjoyment, love, pride, satisfaction-not-guaranteed).  In the future, when my kids are grown and well on their way to independence as newly painted rubix cubes, I hope to derive a good amount of amusement out of them as well.  I’m game if they are. (^-^)

Loopdie Loops and The Cake is a Lie!

The thing I have realized most during this residency, many others ignored in this piece, is the truly endless ratrace that medicine leads us into.  Making the transition into the third year of this confounding experience has highlighted, bolded and caps locked the unforgiving nature of the path I’ve chosen.  I realize that I love it and hate it. I struggle with this slow falling sensation while small wisps of happiness, success, and human kindness keep me suspended in animation.  This seems like a depressing start to a life long career.  The dread upon exposing this particularly necrotic appearing corner of my subconscious was particularly disappointing, silently creeping and unknown.  Would I open this and drain out the pus and be relieved or find it to continue slowly festering needing repeated debridement? Or, worst of all, would I find this spreading like wildfire, untamed and requiring more drastic measures?

What am I talking about, right?  There is a pleathora of literature, fiction and more studied accounts, of the rigors of residency.  However, this is just a passing discomfort. What I have realized is that, all the parts I love about medicine is not what I will be focusing on in future years.  There are also many anecdotes and statistics out there now that describe this in greater detail.  I’ve been flooded with journal upon journal article citing the more permanent discomfort of being a doctor in this modern age.  How many of us suffer decreased payment, sell our souls to the larger health system so we may pay off the $300,000 and mortgage we owe without risking the life and limb of our progeny or forebears?

It doesn’t even seem so bad when you read the articles.  True to form we are somewhat optimistic. It seems that many of us make life changes to follow the buck, the cheese that keeps on freaking moving. We buy into the EMR, buy the new treadmill stress test, and learn how to inject botox. We continue to roll our shit up hill so that maybe it will eventually lift us into retirement.  There’s something to be said for our willingness to undergo all this change for lack of reward. 

The paperwork we don’t have to worry about now because our licenses don’t matter, we will have to in a year or two. The current insurmountable to do lists will be replaced by an equally insurmountable task list. The more patients, the more they will need from us. Attempts at teaching us billing little prepare us for the rejections and the subsequent chase.  Even plumbers have to tolerate some late payments.  But at least they get paid their asking price.  Certainly we wouldn’t want to over charge. But it’s terrible, on even a mock productivity sheet to see that billing $10,000 for the month gets me $4500.  We may get these numbers but as of now, it’s still rare to get feedback on how to make that exchange less miserable.

Aside from the injustice of it all, residency doesn’t prepare us for what’s coming. The training, past first year is geared towards team management. Which is great, except if you become a hospitalist and you see and write orders, handle floor pages, and all the family meetings by yourself for half again the number of patients you used to carry.  Or, if you go into a practice where you have to crank out some serious RVUs.  Or, that all the home health orders come to you to sign and all the tasks and refills, and billing questions. It’s disheartening.

All I wanted was to do some primary care.  Care, primarily. I’m sure many of us did. Before I realized the bleak prospects, I still had hopes of establishing a quaint and moderately profitable small group practice.  It’s like I’ve just gotten to midmountain, only now realizing that there isn’t a downhill.  The odds looking as long as they are, I am sorely tempted to cave and go specialize something pleasant and more lucrative for less stress.  Who knows where I’ll end up these next 2 years.  Here’s to true optimism that defies logic and maybe finding a rich husband maybe….. 

Accelerated Careers in Medicine: MD By Design

I received the September 19, 2013 edition of the New England Journal of Medicine (yes, on September 17, 2013), featuring 2 perspectives on the 3 year Medical School.  NEJM typically uses this section to pit 2 well balanced opinions on popular topics against each other.  I found this one particularly eye-drawing, despite my typical treatment of my journals.

Article 1 by Dr. Abramson et al. pits the tepid endeavors many of us pursue in 4th year medical school against the disproportionate detriment of increasing debt accumulated with each additional year spent in training.  This is especially relevant as many aspiring doctors choose specialties instead of primary care because of the increased payoff promised.  The rebuttal, by Drs. Goldfarb and Morrison, cites the dissatisfaction of students and professors alike regarding the rushed nature and quality of 3 year curricula. Students would be “shortchanged,” as the title suggested, by carving off the year where they could hone clinical skills, do research, sample and relish the joys of medicine, and mature into clinicians.

What really is “enough” training?  In the US, Canada, and Australia, we have a Graduate level medical education system. Nearly everywhere else, students apply to medical school directly from high school, effectively eliminating 4 years of undergraduate study at the price of 1-2 additional years of medical school.  There are arguments that those important years contribute to the diverse foundation of well rounded physicians. That we are not all gleaned from the medical crop, and were formerly engineers, biologists, actors, or historians, makes us less bland and better as a whole.   But I believe for most students, 4th year is more about applications than education and the clinical exposure in 4th year could be furnished quickly by the first few months of any residency.
Plus, there are distinct advantages to being less than 30 years old upon reaching Attending status.  Younger physicians circulate longer in the physician pool, theoretically lessening the doctor shortage.  We have vigor and idealism enough to balance the wisdom and clout of our older colleagues both in the office and on the lawn.  And, most materially as the average age of physician retirement creeps up towards 70, our earning potential is much greater.

Yet, I don’t know if I could say my own course through medical education could support either side.   I attended a 7 year BS-MD program, 3 years BS, 4 years MD, because I never dreamed of being anything else.  In these 6 years since graduating, I have forgotten more math than I remember and programmed nothing greater than my phone.  I suspect I enjoyed college as much as the next person.  Would I have noticed its loss?  Doubt it.  In fact, most of my educational career, from elementary to residency, has been in support of article 1, waste no time, eyes on the prize.

Yet, I chose to do my residency in a 4 year Internal-Family Medicine Combined program, giving back one of the years I had shaved off my education.  Hypocrite? Looking at a variety of Family Medicine programs, I thought there was such a thing as “too short” a training, even for me.  Indeed there is a slowly growing trend towards 4 year Family Medicine residencies.  But that is talk for another day.

There’s definitely something to be said for a detail oriented educational experience, especially because of the exponentially increasing amount of knowledge that is now available for learning.  Are the products of shorter medical education inferior?  Or, can we prove that cutting an estimated 30% would still result in proficient practitioners?  The jury is definitely going to be out a while, so I guess I’ll see what this dual boarding gets me.

The Harry Potter Adversity (Teenhood Revisited – Part 5)

Harry Potter and the Sorcerer’s Stone was the first book I ever bought with my redirected lunch money. Those were the days where Scholastic book sales were the only places I could buy things without my parents looking over my shoulder. Not, mind you, that they usually had anything to say about my purchases. By the time I picked something out for keeps, my parents and I had already duked it out in my head.

This iconic novel marked the beginning of my rebellious stage.

I read it cover to cover, who knows how many times. I wanted more. I hid it from my mom by sliding it in between slats in my desk when she would peek in on me pretending to do my homework. Its spine became wearied of my insistence. Of course I had other books too, free ones from Barnes & Noble’s Summer Reading Events, cast offs from the school library or the real library.

Then several years later, I was able to purchase the UK versions of Chamber of Secrets and Prisoner of Azkaban in Hong Kong when I was visiting my grandparents. Imagine how thrilled I was It was the beginning of a collection of the SERIES! Until then, I owned The Golden Compass (courtesy again to B&N) without Subtle Knife or Amber Spyglass. I had Alana without the other songs of the lioness.

The Goblet of Fire came just as I tuned into the angsty teen channel. At this juncture, I started watching anime, hung out at school with the eclectic and nerdy characters, stealthily purchased a Gameboy Advance off my friend on the bus. But of all these major strides, The Goblet of Fire was the biggest deal. I got to buy it in hardcover before the paperback release. Unheard of.

Ultimately, the Gameboy never did get me into quite as much trouble as my temper or Harry Potter. Well, perhaps his temper and my temper. Though, to be honest, I never really did appreciate his all caps outbursts as much as I did mine. I always felt self conscious to think that what I thought of him at those moments was what my parents and other people might think of me at my angry best. (Still by all standards preferable to Bella’s moping, obsessive and singular devotion, and teen pregnancy saga.) I don’t know if there is an elegant way to be an emotional teen. He drove me to self reflection. (Seeeee~, mom, Harry taught me something!)

By the end of high school, my Tamora Pierce collection was complete and I had money from Red Envelopes that I got to keep without the required savings deposit. My SATs were 30 points below the higher level scholarship for one of the other colleges I could’ve gone to and my mom pointed straight to my Harry Potter collection. If I hadn’t been so scattered about my studying…

In following years, it was the question: Why was the Order of the Phoenix so much more interesting than MTSE that I could suffer myself to get my first C? The Half Blood Prince was like deja vu. This time, my uncle was to blame. He came over from Hong Kong just to disturb my education with the purchase of a gift (of my choosing). It must have been on purpose. Lo and behold, my MCAT score was at a level with my SAT score.

So, Harry Potter was responsible for not only the future of the wizarding world, but also for mine. Luckily for him, I secured myself a spot at St. George’s University saving him greater infamy. Who would have been blamed had I not gotten into medical school? I’ll never know, but I’m sure it could have been spread richly between Harry, myself, and my uncle with a smattering on my father, friends, and the World Wide Web.

After those fiascos, I didn’t end up purchasing the Deathly Hallows until I was nearing completion of medical school. Partially to convince myself that I had risen above the temptation and partially because Step 1 was approaching quickly. Mother could not be placated by my frequent reassurances that Potter or not, my scores would be similar (more to come reasons why). To this day, my mother believes that had Harry never been born my world would be a more academic place. You know, more “A+”.

Little did she know that Harry was accompanied in middle and high school by many Pokemon, much furtively viewed YuGiOh, the Prince(s) of Tennis, Megaman, and Gundam Wing among other culprits. College found me diving head first into the world of anime and manga. Med School marked the addition of knitting and more anime.

I’ve made the equivalent of the 10+ year journey with Naruto and Luffy animated and in stills. I’ve partaken in the seven year journey of strife and adversity with Harry Potter. But, my mom and I can agree I’ve also made it through the equivalent of 21 years of education.

For all of those who knew all my references: *high five*

What about your own blameless youth? Who was the scapegoat for your failings?

How did this turn out to be such a long ramble?

Two can keep a secret (Teenhood Revisited – part 4)

So, In a few more days I will have aged yet another year. And, as my closest friends would know, this gives me annual anxiety. I’ve had nightmares about this yearly ritual. My mother would tell you how disappointed she is that I haven’t enjoyed a birthday party since elementary school. Some people are happy to turn 16, 18, 20, or 23. But this year, as in past years, I feel the slow creep of fear feeding on my subconscious.

When I was in elementary school, I thought it was a cool subject to talk about. Do you know how old I am? I was bullied and had very few good friends. Somehow I misconceived this to be a good conversation starter. I carried on in this silly manner until middle school, when puberty hit and I was suddenly very sure of every thought and feeling. I knew exactly why I shouldn’t blabber my secrets, or as my mom says in Chinese, “to show your belly skin to the world” (no, not literally guys, though I’m certain she disapproves of that as well). Once again, she was right.

But it was too late, 1st 7th grade homeroom found me bundled with some old 5th grade classmates…proving to me that public school is a plague on my conscience. And, since puberty and rebellion stunted me as did various other things, I stayed in the expected chronology until high school. I had a shoe thrown at my head by someone, (too bad the best thing I could think of with the burning in my ears was to throw the shoe in the trash and not on the roof. Of all the missed opportunities…). I had some good friends turned into cold shoulders. All that, I attributed to, my own immaturity plus theirs, the need to be cool at the back of the bus, and the whole concept of age gradients. (mom, yes roller bookbags are convenient and you wanted me to take all my books home every day, but that was a) useless, and b) SOO uncool! c) I’m still blaming you for being the shortest in our family) Since then I’ve been told fingers could be better pointed. But, that’s how I saw it at the time.

Come college, I saw my first chance to truly start over, a new group of friends. I would be more prudent, more careful, more conservative, a different and better me. Alas, still peri-puberty, I unwisely chose a study night when we were all tired and bubbly from dry erase fumes (that stuff is considered an inhalant and the balcony door was appropriately open though clearly not all tat effective), I told my new close friends my secret under sworn secrecy. And, regretted it immediately.

Having secrets myself makes me a fair secret keeper, a quality I supposed my friend shared. I thought it was going fairly well first year and second year. Until late in third year one of my acquaintances told me she knew and would like to wish me happy birthday. Someone I saw perhaps once a week, who had minimal even peripheral interest in my life, yet she knew.

In a rush to defend themselves, my friends adamantly denied telling a living soul. Unfortunately for them, and often for me, I’m a born and bred skeptic. I felt the bitter twinge of betrayal (and still occasionally now, like when I relive it to write on it). Not that they are to blame, though older, they probably had the same self control as I did. But, that was no consolation. I still cried, for the lost theoretical opportunities, for the concept of people talking about me behind my back. What hurt the most was my pride, that I was so naive, so blind, for three years! And, boy did I hate it. Made me emo for a few month (my best friend would probably say I was touchy about this event for years…)

As in intermediate school, my untrustworthy companions and I went to medical school together. Given my visceral reaction in college, I think they tread marginally more carefully. Though, it was not without nerve wracking reminders. My boyfriend at the time found it necessary to divulge to his roommate, who told her friend who told his, who told me. And, prior to my zen moment, I neither denied nor endorsed and it definitely freaked him out that I word got back to me. He was wrong though, it wasn’t the fact that I’d heard about it so much as the broken faith that miffed me. (I had an unrealistic expectation of friendships I held dear.)

I told very very few until my 2nd year. By then, I had given myself a talking to. I was going to grit my teeth and live with the repercussions. These are medical students, my peers, at least as mature as myself, right? Teenage years behind me, I would learn to accept myself, my strengths and faults, and learn to tolerate the faults of others. (For those of you who knew me in Middle School, HS and college, I did indeed accomplish some of the aforementioned.)

For the first time in my life, after several nauseating rounds of contemplation, at the ripe old age of MS2 to tell someone how old I would be come the end of the week without mental whiplash and anxiety. It felt good, right, and free.

These days, I do have a new policy of not telling someone how old I am until at least my first birthday knowing them. I made one exception for my roommate, and look where that got me… \(>.<)/ But credit where credit is due, the friend she told stayed as true to his word as I could expect.

Still, why is this such a big deal? I'm in residency now, a responsible adult and reasonable human being in an environment of similar quality. While my program is full of fun and accepting people, do I really want to subject myself to unnecessary scrutiny? Should I put myself in the way of professional jealousies (as far from a true subject of that as I currently am)? I prefer to sit quietly and do my due diligence without seeking out stumbling blocks. In a new place, far from home, do I want to risk drawing an invisible line between myself and my peers at this early a stage?

Some may scoff, but all are risks that I've grown to learn not to take. I'm an average person, of average caliber. I've just learned how to be a careful chameleon.

Somehow, my brother has managed all these years to bypass this mental struggle entirely. More power to him. When he explained his secret, I just shook my head. How could one not fear the eyes and whispers of judgement? Then again, he was much more the philosophizer where I had my feet and eyes glued to the ground looking for my soul.

After all, the fickle minds and hearts of teens taught me to judge and be judged. Bullying ingrained in me a strong sense of caution and the reflexes to lash back (took me YEARS to grow out of this one). And, my friends taught me the truth of the proverb "Two can keep a secret…"

No, don't worry, I'm not bitter. I can bear the brunt of Happy Birthdays! Have at me.

Selective Short Term Memory Loss (Teen-hood Revisited – Part 3)

Of what I can remember, those were years of strife, petty and inflated concerns.  My adventure from preteen to teen and past-teen, over the once insurmountable mountain of  puberty, into the meandering deeper waters of adulthood was not as much chronologically challenging as confusing.  Looking back over my shoulder, I enjoy and appreciate them now probably much more than I ever did then.

The initial blogging idea came from my stint in Adolescent clinic.  My experiences there re-emphasized my fortunate circumstances and how difficult even the “typical” childhood could be.  Though my brother and I had experiences slightly deviant from what generalizes to be the “typical”, I (not so much he) went through many of the emotional ups, downs, and sideways of adolescence.

Many of these were secondary to my contrary personality clashing with my mother’s equally contrary personality. (Sorry Mom, yes, I love you.)  Me + puberty + irritant = Yelling, and lots of acne.

While I would get angry quickly, I also cooled down quickly.  And, after a good nights sleep I was ready for a new argument.  My mother? More the slow boil, thinking, and over thinking, and festering. (Still love you, Mom)

It took my mom quite some time to learn how to handle a little spitfire.  The trick was selective short term memory loss.  She would continue stand up for whatever it was that she was fighting tooth and nail for, but would temporarily forget the grief I gave her (only to bring it up repeatedly, month after month, year after year, ad nauseam….Mom, seriously, stop it.)

I knew after the hefty door slam, or re-slam if it bounced back open, followed by the good cry, that I was being stupid and that I didn’t really hate them or intend to run away (though I did sit on the curb for hours one time…or that other time…).  After all, I knew my parents best, weak points and all, just as they knew exactly where my fault lines lie.