Saturday, August 27, 2016

Plot Twist

I guess my life just had a season finale. No, I’m not dying or anything even moderately close to it… That opening sentence comes across pretty melodramatic, which was not my goal. This is based on something I saw on tumblr the other day. I can’t find it again, but it was something to the effect of “Do you ever feel like your life is a TV show and the writers have started doing some crazy shit just to keep it interesting?” For some reason, likely the eloquent way in which the poetry was written, that line of prose stuck a chord with me. In my life there has been some “crazy shit” lately, or, as they could be called affectionately if I had any affection for them: character building opportunities.

Character building opportunity #1: Failing step 3. Subtitle: Irony is not funny at all.

I failed step 3, or step 3 failed me. Both of these statements have a lot of emotional baggage so allow me to lay out the facts. As of December 11th, 2015, the minimum passing score was increased from 190 to 196. My score, which I received a morning approximately 6 months later was 195.

This score is obviously not a percent… clearly 195% of correct answers would be an adequate score to pass. For those unfamiliar, Step 3 scores are assigned a magical number that is somehow calculated based on the number of multiple choice questions you answer correctly and various interactive cases in which you proceed with patient care correctly. How the cases are weighted in relation to each other and in relation to the questions is unclear. How the cases are graded at all are unclear: obviously if the patient dies, I assume you lose all credit, but is it partially right if you intubate them before they die? Or reorder the right chronic medication?  Or diagnose them properly post mortem?  Clearly, my bedside manner is not the problem.

It is a terrible experience. All of the step exams are. Ask any attending physician if they enjoyed studying for Step 1, 2, or 3. Better yet, tell them that you are – likely they will grimace and express condolences. Even worse, step 3 is a two days of a terrible experience. Day one, you arrive bright eyed and bushy tailed, ready to slay the dragon before you. All 233 multiple-choice questions of dragon. These are divided into 6 blocks of approximately 38-40 questions. Factor in forty five minutes of break time to be divided up between hunger, thirst, nature calling, emotional breakdowns, google searches for how much a plane ticket out of town that same night would cost and a 5 minute tutorial and you have about 7 hours of fun.

When you arrive for day two, you’re already tired. You no longer have the benefit of cautious optimism that has grown as a scab since your last step exam. The raw tissue is now exposed. You know exactly how much pain is involved in staring at a computer screen for an entire day and trying to remember that one day in Immunity and Infection when you went over the mechanism and side effects of Isoniazid and whether or not it interacts with this pretend patient’s lengthy list of medications. You are still haunted by the half dozen questions you knew you didn’t know yesterday – the ones that stuck in your mind and you looked up on break or when you got home, hopeful that you remembered the correct antibiotic, contraindication or physiology. Of course the ones that stuck are the ones you don’t know – at this point, you’ve fully lost sight of every question you got correct. Success is simply what is expected of us – the system has taught us what we need to know, but failure – that is a burden you carry alone: you should have worked harder, studied longer, known more.

You would think that with all this factored in…. For a test for doctors, theoretically designed by doctors – others of our cohort who have faced other exams, medical school, stress, fatigue and anxiety… There are a million reasons to see the logic behind making the second day of testing the shorter of the two. It is like putting the last 100 meters of a 5K on a downhill slope, while it will not drastically change the race outcome, everyone feels a lot better as they cross the finish line.

On day two, the dragon is bigger. As if this post weren’t already nerdy enough, he is the Hungarian horntail of test dragons. There are fewer total multiple choice questions, but because simulated patient cases are involved, the day is longer overall and involves almost 9 hours of sitting in front of a computer screen, pulling out your hair and (in my case) getting yelled at for sitting Indian style in the chair. (Which deserves a separate rant, but seriously? If anyone has figured out a way to cheat simply by sitting Indian style after the invasive full body search performed each time you enter the room, perhaps that person has earned the right to 4 more questions correct.) There are an additional 180 test questions to be answered and 13 individual simulated patient cases to complete. Generously, they once again provide 45 minutes of time to get coffee, buy chocolate and rethink your life choices.

Let’s do the math. I have no idea how these scores are computed and I can’t find much evidence of it online. I’m not sure what threat to medical integrity would be risked by ensuring transparency of these procedures, but apparently it’s not a risk worth taking. However, there are approximations posted on forums: one such equation is 3 digit score = % correct * 2.8

Here goes. Score of 195 – my percentage correct would have been 69.64%. Passing score = 196, which is equivalent to 70% of questions correct. There are 233+180 multiple choice questions for a total of 413. I have no idea how the cases are weighted, especially factoring in that some are longer than others, take place in different locations (ER vs Clinic vs hospital room vs ICU) and have different amount of knowledge involved. For the heck of it, I will assume each case is equivalent in weight to 10 questions. So 13 cases at 10 questions per case = 130 more questions, for a total working count of 543. 69.6% correct of 543 is… drumroll please… 377.9 questions correct. I’ll give the graders the benefit of the doubt and round down… 377 questions that I answered correctly. The passing score, 196, or 70% corresponds to 380.1 questions correct.

Based on an arbitrary number, I have fallen 3 questions short of “what it takes to be a doctor”.

That seems like just the kind of plot twist one would expect in a season finale… actually, didn’t that happen to George in season 1 of Grey’s Anatomy? Sorry… spoiler alert! I understand that the whole point of calling a spoiler alert is to announce it prior to the actual spoiler, but if you’re 12 years behind in that particular show, I just saved you a season’s worth of time.

Character building opportunity #2: Moving away. Subtitle: There is not enough room at the inn.

The Joint Treatment Facility for military medicine of the National Capital Region employs over 12,000 military members and civilians to care for over 545,000 eligible beneficiaries and 282,000 eligible enrollees. (Numbers from the Comprehensive Master Plan for the National Capital Region Medical provided to Congress). Those numbers speak to a pretty impressive staff in the area, so when I was told that after leaving residency, I would be re-employed as a GMO (general medical officer) in the area. Why not? There are literally thousands of jobs around here… it makes sense that the needs of the army would coincide with a job I was qualified for, AKA another faceless GMO in the mass within commuting distance of the National Capital Consortium.

Turns out, these promises that I would stay in the area were misinformed and almost immediately after my resignation was accepted, discussion of new postings were tossed out. Apparently, despite looking for a place for me here, there was simply no room for another GMO. So they considered options – wouldn’t I like to be near family? Where was home for me exactly anyways?

When I informed the person responsible for taking my best interest into account that home was Ohio and sure I would love to be placed near my family, the response was, “Ohio, is there a large army presence there?” which was disheartening for 2 reasons: 1. Shouldn’t the person responsible for assigning jobs in the army know already where there is and isn’t a ‘large army presence’. 2. No, there is not a large army presence in Ohio, so it looked as though being near family would not be an option. I responded that no, the army has not had a major presence in Ohio since our last war with Michigan, which was taken with what has become the company line for my sarcasm here – either the recipient doesn’t understand it or they pretend not to in order to prevent encouraging such behavior.

The back-up options to “move her to Ohio to be with family” were obviously Alaska and Korea. Maybe they understand sarcasm after all.

Someone somewhere in the infinite chains of command where my future was being discussed without my input decided that sending a girl with diagnosed depression to Alaska where the sun apparently just doesn’t shine sometimes might be counter-productive to the needs of the Army. Korea, while certainly sunnier, would leave me similarly isolated.

Long story short, it was decided that if I can’t be close to home I should be somewhere that is going to minimize depression and set me up for success should I decide to return to residency. Lucky for everyone involved, it turns out a GMO spot was available only a short 10 hour plane ride from home.

As much as I love new places, I always hate saying goodbye to the faces. Dr. Seuss should write a book about that. It is going to be sad to leave the home that DC has become and all of the new friends, but I’m excited to say Aloha to new adventures and greener pastures (metaphorically… I guess bluer waters would be a better line) in Oahu - time for me and Lola to learn to surf! Who wants to go on vacation?

Monday, August 15, 2016


“Every single thing you do in your life, somebody else is doing a better version of it.” -The Oatmeal, The terrible and wonderful reasons I run long distances part 6, the Void.
I have never been the best at anything. As a child, I always expected to be… I thought that was how growing up worked, you try a bunch of different things until you find your niche and then you excel, simple as that. I grew frustrated as I got older and continued to realize my lack of talent in a variety of fields. Everyone else seemed to be the best at something and here I was just crossing options off of an ever-lengthening list. To me, “Jack of all trades, master of none” always seemed a horribly depressing title.

At lot of children start their ventures of practice and developing skill in the soccer or T-ball arenas. I preferred to pick flowers on the sidelines of my brother’s games or play in the woods when I had free time. Next up, Ballet. I’m still not convinced why a small child who hated to have people look at her thought that ballet was going to be her life’s great calling. Perhaps I was just too oblivious to my own lack of talent. Unfortunately, my parents loved me enough to commit a couple of my performances to video evidence which I now occasionally watch through my fingers while making mental notes of topics to share with my therapist. Then I tried basketball. Since I didn’t enjoy being the center of attention, I didn’t really like to catch the ball or have it thrown to me at all… Not an ideal quality for a member of a basketball team. I also lacked hand-eye coordination, team spirit and a general understanding of the rules of basketball. Another item crossed off. I took to acting in church plays, and I was about as skilled as the average 7 year old actress in a low-budget reproduction of the story of the birth of Christ. What I lacked in volume and expression I made up for in my ability to memorize lines. I became a regular appearance in the plays – often landing leading roles simply because they could count on me to learn lines. This was not the Oscar I had anticipated. I asked for a skateboard one year, determined to become the next Tony Hawk… several skinned knees later, I had mastered riding the board in a straight line for a short distance on a smooth surface only at slow speeds. It would not appear that Tony Hawk had much to be nervous about.

My failed endeavors of later childhood were not quite as pathetic as my attempts at ballet and skateboarding. I actually found moderate success in a variety of activities by the time I got to high school, I ran varsity cross country (never the team’s front runner, but far enough up to count in the scoring), I played trumpet with some small amount of skill (if I spent a long time practicing the songs given to me). I began to grasp the concept that every skill was earned… at least, by me.  Talent was a misnomer and true success comes from repeated attempts to get better.

I was never valedictorian in my high school class. I got the occasional B for work turned in late. Once I got an D because I had not bothered to turn in 2/3’s of the work for the semester. The next assignment of the semester was to bring back the signed progress report with our grade. My parents didn’t sign the progress report – I was afraid to show it to them, so I procrastinated, so by the day it was due, I had already arrived at school, progress report unsigned. It seemed like a stupid reason to loose even more grade points so I signed it myself. Turns out that high school teachers are smart enough to figure out that when a largely straight-A student brings home a D grade, her parents generally don’t sign the form without some sort of discussion with the teacher. I got a little grounded for my practicality. … The point is, I generally did well in high school with minimal effort when I remembered to do it. Most of my sub-par grades were from either procrastination or inadequate effort in the few and far between moments where the material did challenge me.

This should have been a set-up for failure when I attended college, but it wasn’t. I did not excel at time management, but was generally able to cram enough for each test that I would get the grades I wanted. I always used to wonder what my grades could be like if I actually had the discipline to focus. At the beginning of each semester I would construct intricate study schedules, goals, outlines and plans for the weeks ahead – this time, I would not fall behind and cram! Of course, those generally lasted a month at best and there I was, two days before the test wondering why I thought Ecology was important in the long run anyways.

The trend continued in medical school, but with far more devastating results. Cramming is not an option in med school. At the time of my first exam, I had been a student there for approximately 3 weeks. We had covered over 400 pages of material – more than an entire semester of undergraduate learning. If I studied 2 hours per day on weekdays and 5 per day on weekends (which may be an underestimate) that is a solid 50 hours of studying on top of the hours already involved in the classroom learning. That is the most I had ever studied for any test up to that point in my life. It wasn’t assigned homework or busywork or problems – just me and my notes, face to face.

My exam score was acceptable but certainly not perfect. At that time, I made my peace with it. There is a phrase well known in the medical community, “P equals MD”. If you earn a passing grade in all of your course work, you will become an MD. You do not have to be number one. The person who ranks 99th in the graduating class is just as much a doctor as the person who ranks 1st. My sanity would not allow for the level of focus it would require for me to excel in all of my classes. I resigned myself to passing my courses with the goal of also finding some manner of enjoyable life.

Without striving to be number one, medical school was palatable. Goals and structure were still indicated. I knew the direction I needed to head and all I needed to do was determine the hours I would put in getting there.  I chose my sanity over my grades and again was reminded that the only path to skill is unending hard work.

I’m not sure where I was going with this.

I’ve recently begun a boxing instructional course. In it, my coach broke down all of my previously learned boxing training so that he could build on them. While I was pretty good at throwing punches, footwork and evasive maneuvering are not my strong suits. When we were first starting to slip punches, I would quickly become frustrated and angry. He had to remind me on several occasions that it is okay that I am bad at this, I’m a beginner.  I may not have the raw talent to be a prize fighter tomorrow, but I could become one if I decided I truly wanted to commit to it.

One of the highlights of my nervous breakdown that led to my life-altering decision is that it has led to some strongly recommended (required) therapy. Therapy has been surprisingly good for me. I don’t know why it is surprising, actually. We could all benefit from it certainly – I just never saw my life panning out in such a way that therapy would be a thing I would need to benefit from. My therapist has been supportive and non-judgmental from the start – just as most people in my life have been. Initially, I did not anticipate that response. I thought she was accepting because she had to be and other people in my life… I would be letting them down. They had vested interest. Reason to be disappointed. When I told her I was growing frustrated with blogging, she helped me realize that we often hold ourselves to higher standards than others do. After a 2 month trial, I felt that I had written all I had to say. There are millions of writers out there - bookstores are full of names I’ve never heard. Nonetheless, they are names with enough success to publish a book and wind up in a bookstore. It seems like everyone has a blog these days and even those who don’t occasionally post eloquent facebook statuses or heartfelt instagram captions. Everyone has talent and a voice – why would anyone want to hear mine? It felt as though everyone who’s writing I got to read was infinitely better than mine – they were better than me. She reminded me that of course they are… Some of the people I am comparing myself to have gone to school for this, been trained in this and been perfecting their craft their entire life. I’ve recently returned to it as to an old hobby, so in a way… I’m a beginner, it’s okay that I’m bad at this.

I think I want to be a writer. I’m not sure why – it seems to be the happy middle ground of something I enjoy and something I’ve been told I am good at. (We can disregard that I was told I was good at it in eigth grade… that translates, right?)

Maybe I have wanted to for a long time… as a dream or a hobby, something too magical to actually pursue. I planned on throwing it in there, penning a novel in my free time between seeing patients and saving the world, as if it were something easy to do. Now that it is looking as though I have more free time to play with, I have come to realize that I want to fill that chasm with writing. I have also come to find that this intimidates me. This goal seems far more unattainable than becoming a doctor. In becoming a doctor, there is a checklist – the tasks involved are certainly not simple but they are well delineated: graduate college, volunteer, shadow, interview, go to medical school, pass your boards. It has always seemed to me that there is one specific path to follow if that is your end goal. There are dozens of check points along the way: college advisors, requirements, mentors, interviews, essays and qualifying exams.

Being a writer seems more nebulous. I don’t know where to start or who to talk to. I don’t know how to figure out if I “have what it takes” or if I’ll make the cut. Who knows if my book will ever make it big time or if I’ll even have a regular following to my blog? ...Maybe I’m dreaming too big. Millions of writers make an impact without becoming a household name or a staple on a college reading list. Why do I measure success as some level of recognition?

Taking a step even further back, why do I need to be successful? I didn’t start writing because I thought it would help me pay the bills, I did it because it is something I enjoy doing. It helps me organize my madness and find calm in my inner storm. It makes me feel productive even when I’ve accomplished nothing but putting words on paper. Clearly I’ve spent a lot of time being trained to think like a student. In medical school and residency, with such extreme demands on your time, it is important to make even your free time productive. We become masters at time management, excising anything that may take up more than it is worth. (Even studying if the 99% on paper is worth less than the memories you make with the people around you)

It is taking a surprising amount of effort on my part to restructure my thinking: not everything that is worthwhile becomes a line on a CV. It is okay to have a hobby and be unsuccessful or quietly successful. It is okay that after opting out of medicine that I don’t have an immediate plan to be the best at something.

When I told my mom I wasn’t going to be a doctor, she told me she was not disappointed in me. She said I had already accomplished far more than she had imagined for me. It’s not that she doubted me (although she did drop me on my head as a child, so I anticipate her aspirations for me are at least slightly lower than they were initially), but simply that I had already graduated medical school… in her eyes, I had succeeded. Walking away wasn’t going to make me a failure. Actually, most people I told were supportive. No one said aloud what I was telling myself: that I wasn’t good enough, that I had strived to be one of the elite and ultimately failed, that this was obviously going to happen from the start.

One of my good friends in high school knew from that early age exactly what she wanted to do with her life. She interned at a local paper, writing small pieces and learning the trade while I wasted time bussing tables and doing whatever jobs were available. I may have been paid more, but she gained far more. She used to refer to me affectionately as smart ass… which is probably the most accurate nickname I’ve ever been given. She went to college for journalism and has now written for a lot of widely read publications. Me on the other hand, I feel like I’m 18 again… my whole life in front of me, some lofty goal but no experience, no concept of what it will take to get to where I want to go or even how to begin.

Maybe I will have nothing to write about for forever… perhaps the rest of my life will be this endless narcissistic drone about how I wanted to be a doctor and then I didn’t and how that changed me. The problem with a blog is that I’m constrained to writing my own opinions and stories, things I know to be true. Am I doomed to this venue and all of its limitations? Is this the best I will ever be?

I’ve been working my whole life towards one goal and I now have nothing to show for it.

I suppose that isn’t true. I’ve gained some things in getting here… I’ve almost drowned in the Nile, met the Taliban, ridden on a caribou, bathed in a hot spring, climbed down the “wall of death”. I’ve acquired some stories worth telling. I’ve often thought that what I lack in talent I make up for in something else… hopefully one of these days, I’ll figure out in what.

Wednesday, August 10, 2016

Just some more Toledo nostalgia

I have nothing to write about.

 I have been on a small hiatus from my daily blogging for several reasons – I’ve had family visiting, I’ve been on vacation, I’ve received word that I failed step three and felt that my time previously allotted for writing should be redirected into studying. Again. Easily the thing I will miss the least about medicine is studying – the sensation that even when I am done, I am never done. After a long day of patients, there is still a topic to read about. After finishing a rotation there is still step preparation. After completing intern year there is still board prep. After board certification there is re-certification, PI projects, new studies and medications… There will always be something that I don’t know. When there is something I don’t know, there is risk – possibility that I will do something wrong, select the wrong medication, prioritize the wrong intervention, diagnose the wrong illness… when I do something wrong, a patient could get hurt or die. Obviously, the learning needs to continue, day in and day out I need to do everything in my own power to minimize what I could get wrong. With that line of thought, time off feels selfish, not studying feels like rebellion. I will never know everything and it is time to give myself absolution from that. I am not guilty for being human – I am simply human.

Regardless, the point is, I have nothing to write about. So I’ve stooped to looking through old documents saved to my hard drive wondering if any of them is worth finishing. (Or pulling the trigger and just deleting). While doing this, I happened across something I’d written shortly after moving out of Toledo after graduating medical school. See below.  I guess I anticipated that I was going to miss them.  I was right. 

Resilient bonds are formed in the trenches of medical school.

For a blog that contains the words “Medical School” in the title, it may be surprising how rarely the topic is breached in my rantings. However, to anyone who has ever asked me the dreaded question, “how was school” (and hopefully learned quickly to never make that mistake again), it will come as no surprise that to the outside world medical school is dreadfully uninteresting. Sure, there’s the macabre fascination with the thought of spending several hours a week for months on end cutting into a dead body, and I personally enjoy learning about the many bugs that can kill me should I undercook my food or drink the water in Africa… but when people ask, it’s not like there’s ever much exciting news to share.

Maybe that’s why I have made such good friends in school – because they found the same things interesting. Maybe I was simply lucky enough to end up with an awesome group of people purely by chance. Maybe it is universal to find camaraderie in anyone who can help you escape the mundanity of the library. But one thing I can say with absolute certainty is that many of my classmates have become some of the best friends I have ever had. 

That being said, I have long been dreading the day when it came time to part ways.

In the match process, which is how medical school graduates are selected for positions at teaching hospitals, students have little control over where they will end up. My classmates have now spread out across the country and for the most part are unlikely to return to Ohio. While I know that I will see great things from all of them in the future, in a selfish way, I would much rather we all stayed close together and continued our life together.

Over the past four years, the people who started as classmates have slowly become friends and ultimately family. They are my cheerleaders when I have exciting news to share, fashion consultants when I need to select and outfit, my counselor when I need advice for a difficult situation and my audience when I have a funny anecdote from the wards to share. They are the faces I miss when I travel the world, the person I can count on when I need a favor or just some company, who I text when its late and I want to grab a drink and the people I worry about when I haven’t heard from them. They are the people who ask how my day was. The ones who hold me when I cry.

Or at least they were. 

Time, change, progress. – You can’t stop any of them, no matter how hard you wish for it.

But I digress.

I had been anticipating saying goodbye to my friends for weeks. I didn’t mean to, but I just couldn’t stop dwelling on what it was going to be like to hug this person goodbye for the last time for a very long while. Or how it would feel knowing that as we made our usual walk down Huron street that we weren’t going to do it again…

Goodbyes in the movies are different than in real life.

I knew this going in, but still, it was fairly anticlimactic. 

I wanted it to be meaningful…. Powerful… cathartic.

I wanted to tell each of them how much they meant to me. What I admire them for. What I am going to miss about seeing them all the time.

Often, my expectations are incongruent with reality. Predictably, this instance fit that pattern. In those moments, I lacked the words to express the depth of my feelings and the emotion to appreciate the gravity of the situation.

However, just because I didn’t get to say what I wanted to say when I wanted to say it does not diminish the value of the sentiments themselves. So here goes. To the irreplaceable bunch of people I was so lucky to suffer through med school with…

(Taken over here in 2016)

I’ve decided to keep those words within my heart. While they are all on paper, and I’ll happily share them with their intended recipients at request, it turns out they are actually unnecessary. Although the friendships I’ve treasured have changed shape and shifted to accommodate distance, schedules and separate lives, the people I miss are still there for me when I need them. I have always assumed that I remember people better than they remember me. I was shy as a child and I think I spent so much time and effort fading into the background and striving not to be noticed, that it worked. It worked especially well on me it seems, because for some reason, I just assume I’m forgettable, replaceable… that in any relationship, I’m the one who is lucky to be involved. I don’t mean to convey that I have low self-esteem, because that is not the case in the slightest, in fact, I’m often way too pleased with myself (that did not come across how it was intended). At the time I wrote the first half of this, the chance that I would be placed with another group of people as awesome as those I had in Toledo seemed so unlikely as to be impossible. But it wasn’t – the people here are pretty great too.

We have all gone forward as our Toledo diaspora and found new niches and new friendfamilies. Over the past year and the coming years these new bonds will strengthen as the crucible of residency takes its toll. I feared that in changing the cast of characters in my day to day life, I was losing them completely (well, filing them away for a chapter in my memoir anyways). That didn’t happen – although separated, we’re still connected, not forgotten. Oddly enough, maybe this is just what the transition to adult friendship is… even though we value these relationships, life takes priority. 

We still have each other when push comes to shove and wish the best for each other in the meantime. To all of my wonderful friends who know what Cock and Bull is, who have participated in the beer olympics, or gone to Bretz, who hold Mulford in a special place in their heart or remember the day the gallows appeared in the courtyard... I still wish you the best.