Mile 3288: Shortie - Nature & Nurture

Above: Jason Alexander as 2nd most popular motivational speaker in the USA, from the short-lived ABC series Bob Patterson in 2001.

"MOST OF US ARE
FAR FROM OUR POTENTIAL."
Dr. Angela Duckworth at the University of Pennsylvania

Folks, its been a busy week at the new clinic I'm at. So here's a quick shortie, and you'll get a full update on what's going on very soon.

The sacrifices that we make to go to medical school are large (both for U.S. and Caribbean students). For many of us, the sacrifices include a long time in school and being piled in debt that is miles high. For others, the sacrifices are greater, either from the demands of moving from place to place, and even trying to support a family during the demanding time schedule of school. Some of us have been more successful at balancing the plates than others.

One thing I've always wondered in such a demanding & competitive environment is whether or not there really is an advantage of background when going through medical school? Is the person who comes from a lineage of doctors going to be more successful from the student who comes from a farm-based community in Iowa who wanted to become a doctor to exit the world of agriculture? I know of many successful doctors who have come from families where mom, dad, or more relatives came from the medical field.

What truly determines our success, the drive or where we come from? One of my Facebook friends, Frank, posted a link to a New York Times article saying that motivation actually outweighs nature and nurture (background) in the long run. It's been a debate that has been going on for centuries. Some scientists are saying that genetics are not related to how well someone does in their own field. Others say that challenging environments make people better at their field by generating motivation. And finally, we still have people out there saying that families of people good in a field will foster future generations also good in that field.

After going through my Leadership Certificate training at the Illinois Leadership Center at the University of Illinois, I still believe it is truly up to the person to make themselves the "cream of the crop." And it is for this I want to somehow become involved in teaching, because I have always wanted to empower others to reach their potential; many people at the U of I have motivated me to make it this far, even as I'm not from a family of doctors. From my experiences, I think its a good combination of the right environment and self-motivation that can make someone the best that they can be. Talent isn't necessarily inherited.

I encourage you to read the cited article below to learn more.

Source: The New York Times

Mile 3187: Stand Up

Above: April 2010. Our wonderful crew & one of our attendings for the last two weeks.

GET UP... STAND UP...
STAND UP FOR YOUR RIGHT.
Bob Marley

I have something to admit. I'm a frequent second guesser. I know. It's a bad habit. I gotta quit... I'm working on it.

I'm coming up on the last day of these past two weeks. From my last entry you've seen I've had many firsts at the clinic we're working at. Our past Wednesday was one of the busiest we've seen, and at the end of the day we found ourselves sitting on those big fluffy couches, simply tired. Our attending (different from last time), comes in, pulls up a roller chair and starts to talk to us.

His words were quite simple, but they were encouraging. He said to us that our team (the one pictured above) pulled in quite a huge amount of patients for such a short time period, much more than previous teams he had worked with. We had worked efficiently and hard to accomplish a lot. Then he told us some good advice, advising us to start defending our decisions. I forgot his exact words, but from what I remember, it made lots of sense: the only way that us students will learn is if we take our own positions and defend them as well as we possibly can.

It comes down to a concept that I've been trying to work on all along: making medicine my own. There's a lot of data, opinions, and options out there in the medical field. But in order to learn, I need to interpret and make sure I can be competent in taking whatever is best and applying it to the decisions I make for my patients. Each patient that I'm put in charge of is my responsibility... if someone tells me or tries to do something that stands in the way of my approach to the patient, I need to be secure about my decisions. Otherwise, something might go wrong, just when the ability to control the situation slips out of my own hands.

So I need to stop second guessing. The physician's assistant (PA) that was working with us told me that she saw no reason for me to overthink, and to pick up that confidence to make solid decisions. With 2 more weeks in the rotation to go, I'll give that my best shot, with some motivation from her encouragement.

So, to Eric, Faith, Vanessa, Melissa, Veronica, and Shannon, thanks for being a great team. To our attendings at the clinic, Dr. S., Dr. G., and Dr. M., thanks for all your support to us. Finally, to the people at the shelter we serve, thanks for all your trust.

Mile 3166: Firsts

Above: May 2009. First time I ever popped an umbrella with Mary Poppins. I hope there'll be a second time.

THERE'S ALWAYS A FIRST
FOR EVERYTHING.

Last week was filled with a bunch of firsts. Here's five.

1. FIRST BLOOD DRAW.
Blood drawing can be intimidating for all the parties involved. On the patient end, seeing needles and blood is not exactly a pleasant sight. On the doctor end, it can be scary to not find a vein or take a wrong approach to inserting the needle, as both may cause discomfort to the patient. Adding both can lead to a stressful situation, but with the help of the patients in the chair, it made my experience much more inviting.

"If I can be the guinea pig and can handle being drawn blood from all of these sites, you can do it," one of the patients told me. I came out clean and was honest about telling the patient this was my first time. Tourniquet on. Search for vein. Spotted. Alcohol swab. Swished it around. Insert needle. Tube in. A flash of crimson blood entered the tube and it began to fill. I thank the patient in the chair for making my first try successful. I guess the first time isn't so bad with the right support.

2. FIRST FETAL OCCULT BLOOD TEST.
Okay, I'll skip the details, but we had to analyze for blood in a patient's stool to eliminate the possibility of any GI conditions. When our attending requested someone to do it, the hand that always gets me in trouble went up in the air. I soon was in to get the sample. This first showed to me that after the first time, its easy to get into the rhythm of things. Sometimes, exposure to the extreme is just what one needs to cross barriers.

3. FIRST PAP SMEAR ASSISTING.
I wanted to say "actual pap smear," but this was simply an assist. Getting a pap smear is intimidating for a male-doctor-in-training, for obvious reasons. But with the help of four other female doctors & nurses in the room, I was able to get through it. A complex process if done by self, but hopefully I'll be able to be in the hot seat with my awesome support team finally this week to try one.

4. FIRST TIME IN COUNSELING MODE.
I won't get too much into the story here, partially because of HIPAA and second because most of the situation occurred in Spanish (a lot more than Señor Fixity-Fix-It below). But I learned today that there are times that it is okay to step across the professional barrier, and not call someone by last name and to be honest about what's going on.

A lot did go over my head during the patient interaction, with some translated by an accompanying PA in the room. However, with even the little I knew, I went ahead, was honest, and told the patient, "No hablo mucho español, pero cree que eres un hombre/mujer fuerte. Puedes hacer todo,"* the reply of "Gracias" and a smile made me know that I connected with the patient when I needed to. I'm a sucker for emotional moments, but they're one of the most beautiful things about life.

*Translation: "I can't speak much Spanish, but I think that you are a strong man/woman. You can do everything."

5. FIRST BERRY & OREO ICE CREAM COMBO AT COLDSTONE CREAMERY.
One word: simply amazing. Okay, that's two, but that's how good it was... especially after enjoying the new movie release Kick-Ass.

And with all these firsts, I hope there will be seconds.

Mile 3106: Pimped

Above: With a careful eye, this overexposed picture outside my apartment shows a traditional occurrence in Florida weather, the sunny rainstorm.

I'LL TAKE THE
PHYSICAL CHALLENGE.
The best way to play the 1980s Nickelodeon game show, Double Dare.

MONDAY, 9:03 AM. Six medical students, and one physician assistant in training are all wearing white coats and sitting on huge beige pillowy leather sofas right outside of the doctors office. Some are waiting patiently, with their legs crossed and eyes toward the wall, while others seemingly less patient, get into the rhythm of tapping, some with their pens and others with their feet. Being this the first day, we do engage in some small talk as we wait patiently to begin our day.

A creak at the door awakens all the students out of their trances.

A doctor comes into the room, sits down on a sleekly designed roller chair and rolls around to each of us to welcome us to the clinic. After he finishes his round, he gasps, and rolls over to one of the students sitting two seats to my left, leans over and asks him:

What do YOU think you're strongest on?

OH SNAP. Usually the following concept is great: Say something you're strong at when someone asks you for your weakness. However, the opposite would be bad... Especially here, since the doctor then started popping questions out of his head one by one by one. He soon came up to me and asked me the question. It was my turn to engage in "the game." The word that involuntarily came out of my mouth was "Endocrinology." And soon I felt I was playing one of those shooting games as he was firing the questions out at me like a mad man.

Hit. Miss. Hit. Hit. Miss.

The final question he asked me had to be what he thought was the toughest one, because as he leaned over in his rolling chair to ask me it, his right eyebrow upturned, and he started to massage his chin with his right hand. He stared at me like he was focused on his target and soon started to ask me about what nuclei produce the hormones released in the posterior pituitary.

It took quite an amount of effort for me to say the words "Supraoptic" and "Paraventricular," partially because this is Step 1 information that I have not looked at since my exam. I thought I'd follow the general piece of advice to go with my "gut." The words came out of my mouth one sy-lla-ble at a ti-me.

A half-smile grew soon on my face rather nervously after I said those words. A moment of silence began.

"You are an expert," he suddenly said, as he extended his hand, smiled with a gentle chuckle, and shook my hand. My simple reply was a rather nervous, "I guess I am." (To this day, I still think, "I guess I got the question right.") After seeing some patients that day, I walked out the door feeling like I had been just slapped with the stamp on my forehead that said:

"PIMPED."

---

I believe in challenges. Provided that the one giving them does them for the right reason, not being able to meet all of them shouldn't be discouraging: Mistakes give me motivation to become better. And this is the first time I've undergone the medical school teaching concept called pimping. From my understanding, pimping is getting asked a series of challenging questions on the spot revolving around a concept when in groups during clinical rotations.

I like it, it forces me to think on my toes, and because someone actually wants me to be responsible for the information, I get myself to learn it. Getting feedback and evaluation on what you know and don't know is very useful in medical education. This philosophy continues on in residency and when I become a real doctor, because it isn't the teacher who will drive me to learn; my patients are going to expect me to be responsible to have the right information so I can treat them correctly.

For more on the effectiveness of medical school pimping, check out this New York Times article from 2006.

(And just to make sure it's on the record, this week was filled with firsts, including my first Digital Rectal Examination and my first blood draw on real patients. More on this later.)

Mile 3079: Back to Basics

Above: "Hole in the walls" are some of the best places to eat. May I recommend the Oasis Cafe if you're ever on Key Biscayne, with its sophisticated year-round Christmas lights. But their Tilapia Filet & Rice is absolutely amazing.

ARE YOU THIRTY? - One of my patients.
Me: Ha, not yet!

I remember having a talk with one of my professors in Dominica about why med schools do two years of basic sciences. At that point in time, I thought that basic sciences education wasn't really worth my time. My naive self then was thinking, "How is the pathway of glycolysis going to really be used in a clinical setting? I'm not going to tell my patients about it."

Now looking back at things, without basic sciences, to me, learning the clinical sciences would be like learning things blind.

Basic science education has its hits and misses. It kinda sucks that with basic sciences information, practicality in real situations doesn't really come by until put together with clinical experiences. After Step 1, I probably could tell you a lot about what tests to run with a patient who comes in with concerns about breast cancer, but knowing that the the genes BRCA-1 and BRCA-2 are linked to that cancer won't tell me when to start yearly mammograms, what questions to ask from my patient to assess the situation, and how to reassure them.

Practicality can come in the form of algorithms (flowcharts which guide clinical thought). These are great when trying to organize one's thoughts take a proper, succinct history. Although for common conditions, they work well, but what if someone doesn't have a "textbook" case or condition? Here I see the benefits of basic science education, as the foundations of medicine can help clinicians to adapt to "new-found" cases. Because the processes within the human body are linked together, there has to be a way to explain non-textbook cases through the mechanisms learned in the basic sciences.

But that's not the only benefit... the human mind is one to learn more by links & context (I think I might have blogged about this before). So by knowing the mechanism as to how drugs work, how diseases appear, and the molecular background behind the human body can one make the puzzle pieces of medicine fit together a lot better. Integrating the basic & clinical sciences can contribute to better skills in diagnosis & treatment for our patients.

Although I still think of it as frustrating, taking time to memorize the glycolytic pathway in first semester is now something I am more appreciative of.

---

Today ended my 2 weeks at my current site in my family medicine rotation. On my last day, one family came in, displaced from another clinic that was closing down. One of the kids in the family was afraid of shots, so I offered some of my "insider tips" for surviving them, which made the patient smile. I could tell by the kid's expression that he/she was ready for immunizations when I left the room. When the family left, they all said, "We'll see you next time." And I said to myself, Damn, I won't be here next week. Here, I was about to start a strong foundation for a good relationship with this family. On the outside, I laughed, saying "I won't be here next week, but you'll see another student just like me." But on the inside, I had one of my first feelings of settling down; I started to feel how much I valued relationship bonding in medicine. I didn't want to move on.

Starting next week, I'll be moving on to a clinic run by a local homeless support group here in Miami. Four more weeks, and then the adventure will take me to what I think is the most critical rotation in my education...

Mile 2916: Señor Fixity-Fix-It

Above: Miami traffic to Key Biscayne was a pain this weekend due to the Sony Ericsson Tennis Open.

On the way down, somewhere in the swampy regions of southern Georgia along southbound Interstate 75, I was driving while bopping along to the groovy tunes of Spyro Gyra when....

SSSNNAAPPPP!

... as I looked around the car to see if anything went wrong, I noticed a white streak from the passenger-side pillar of the windshield beginning to crawl across until it gradually came to a stop, forming a discrete line across my windshield. Now, noticing that the line was 1) horizontal, 2) not moving toward the roof of my car as my car was moving at highway speeds, and 3) not disappearing with the truckloads of windshield wiper fluid I poured on it, I figured it was a crack caused by some random piece of debris on the road. Since it didn't grow initially, I drove down to Miami thinking nothing would happen, but by the third day in town, the crack grew up the pillar of my car and towards the center of the glass.

Fortunately, my insurance covers windshield replacements, so I had it fixed just in case it'd get worse.

They sent a repairman over to my apartment in Miami to fix the glass. I met him in the parking lot outside my garage. The man was middle age, but built, clearly a working blue-collar man. He had drips of sweat coming down as he spent the moments outside preparing his tools while waiting for me to come out in the Miami sun that was gradually intensifying. As I looked inside his van, a picture of his kin and a glimmering cross was hanging from the rearview mirror of his van.

I walked up to him and said, Are you here to repair my glass?

The first thing he said to me was, I can't speak mucho English.

I replied to him with a rather nervous smile: Puedo hablar un poco español. He smiled back at me, with a slight chuckle, and he got to work. As the work went on, here we were, both of us trying to speak each one's first language, and using different hand motions, synonyms (oh, my spanglish was on a roll!), and broken english/spanish, yet we were getting what each other's message. I'll have to say that the man had mad repair skills: the windshield repair didn't appear to be fácil (easy), but he was able to pay attention to the details to get the work done, and yet focus on our conversation quite well.

As the work came to completion, he said to me, grateful for our ability to communicate, Puedes hablar como mi en ingles (You can talk just like me in English), and I replied back to him, Solomente con practica. With a smile, we wished each other a good day, I gave him a small tip for his buen trabajo (good work), and were off on our separate ways.

---

This is the thing. After meeting the repairman, I thought about the term language barrier. But is language really a barrier if both parties try to understand one another? It's only a barrier if the two parties don't try hard enough to understand each other. I thought it was really cool how we figured our way around where possible misunderstandings could occur. I'm going to encounter people either in the hospital or in my practice that aren't going to speak my language, and I see how creativity in communication can go a long way to understanding where another person is coming from.

I've said before, I'm an optimist. Although, I can see how people still see this situation as a language barrier, I still prefer to look at it as a language opportunity.

Mile 2896: Experience the Difference

Above: Nope, I'm not driving in Britain. The Florida Turnpike (right) and I-95 (left) run side-by-side for many miles in South Florida.

CAN YOU WRITE
A LITTLE BIT BIGGER, PLEASE?
My preceptor at my Family Medicine Rotation

(Relax: It might be April 1st, but no pranks here. But this might help.)

I'll admit to you that I was thrown into culture shock as I got settled down in my apartment here in Miami. My apartment isn't exactly in the best of areas (although the accommodations are pretty nice and I'm staying with a friend from high school), and some of the neighborhoods where I'll be driving through were quite sketchy (I wouldn't walk outside here at night). At a point, I started feeling like I wasn't admitting things to myself. I had to finally admit to myself:

I'm a suburban kid who might be afraid of the "big city" concept other than in my hometown of Chicago.

I was scared because of the rumors that I've heard about the horrible drivers, the high crime rates, and the not exactly country-friendly people in Miami. And my doubts about Miami were further hastened when I was assigned for my first two weeks to a private clinic in an area that didn't exactly get "smiles" when I mentioned the place to anybody local. I did a test drive to find my site there, and the environment was different from anything I was used to: numerous black bars were on the windows, people talked through plexiglass at the surrounding gas stations, police cars were patrolling the area left and right, and sketchy-looking trailer homes with poorly-maintained landscaping were prominent. And the kicker: I was the only one assigned there for the first two weeks. On the first night, I took some time that night to remove the CD's, bags, and anything valuable out of the interior of my car.

However, as discouraging as all that sounds, I'll say the first week turned out to be the best mind-opening experience I had to date. What made the difference?

First, time. With each day, I found myself getting used to the area. I found out that driving in Miami takes patience, predicting, and communication. I also found appreciation in the lack of big stores along my route (I could probably call it the Pawn Shop Parade) in creating a community-driven economy. And not to mention, now experiencing an area first-hand that originally I would only want to see through pictures in magazines or newspapers is now something I am truly enjoying.

Second, the clinic & the patients. The clinic I'm working at isn't exactly the most modern up-to-date clinic on earth, but the nurses and the staff treat me well. For instance, as I was leaving today, one of them shouted out the window as they were backing out of the space, Have a good one! It made me smile as this friendly gesture went against my original assumptions of people here in the area. It also surprised me that I've seen my interesting share of cases in a primary care clinic. Folks, the material that's present in textbooks really happens. Last, but not least, the patients I have worked so far with have been extremely cooperative with me, and I'm thankful for them contributing to my learning.

Third, the experience. For the first two-weeks, my assignment was one-on-one to a doctor instead of a larger group of 3-5 students, as in my last rotation. What this provides is some awesome personal attention. As for my attending, she's awesome. She really trusts me, and is patient as I'm still trying to master the art of history taking and diagnosis making. I am able to make the clinic an effective learning environment as she is always accommodating my questions.

As one of the travel program hosts on PBS always suggests (I think its Rick Steves), travel with an open mind. It's true. It's that open mind that helped turn what I thought was going to be disaster into pure pleasure.

BTW - There's a fourth reason: The weather. But that's kinda expected in Florida, so for me, that doesn't count.