Doing Nothing

You know what I did yesterday? Nothing. That's right, absolutely nothing. I woke up with zero aspirations for getting anything accomplished, and then I realized that I could absolutely accomplish that goal. Let's be honest (LBH), I made a To-Do-List. It had two things on it: 1) work out, 2) watch 10 hours of television. So I went for a run. Lifted. Then I watched 10 hours of television. Exactly 10 hours. Glorious day? Check and mate. I watched the Olympics, Around the Horn, Pardon The Interruption, and half of an old movie with my Pops. It was a beautiful display of complete apathy. All hail the ability to do absolutely nothing. All hail the amazing "year off."

I would be lying to you if I said it wasn't tough. I broke a sweat. It has been a long time since I've had nothing on my To-Do-List, and if this went more than one day, I would probably go crazy... LBH. Even today I have a few things on my list: wash the car, clean the car, organize my photos and backup my computers, get back on the Facebook. That's a whole freaking morning right there. And, what do I do afterwards? Recently I have spent the late afternoon cooking... 30-minute chicken tagine on warm couscous, or rotini in a roasted red pepper vinegar cream sauce. It's a rough life, but someone has to live it.

So, what else do I do? Obviously peruse the interwebs, or perhaps read a novel (although I wouldn't call 50 Shades of Grey a "novel" per se). A couple days ago I hopped on the Harvard Kennedy School (let's just call it HKS from meow on) in an attempt to figure out my schedule for next year. It was an amazing turn of events. In brief, this fall I will have 4 required semester long courses (HKS is on the quarter system, with four Modules). Each course is worth 1 credit, while single module courses are given half a credit. There are 7.5 credits of required coursework that I must take, and I need 12 credits to graduate. The plan so far is to take 5 in the fall, 1 in January (a super condensed course), 5 in the spring, and then 1 more next January. So to fill out this fall's curriculum, I will probably take a class in Health Policy. Five classes a semester; feels like I'm back in undergrad.

And if this plan does indeed come true, my skedge (or "schedule") will be uber-legit. Class Mondays through Thursdays, giving me a three day weekend, you ready for it?? Every single weekend. My first class would be at 10:10a every day, and most days I would finish up around 1600 EST. I don't care how much reading and extra course work that is. Coming off of third year of medical school (preceded by Step 1 and those daggum molecules to cells), this skedge sounds absolutely wonderful. Absolutely ridiculous. Absolutely glorious. Yeah, yeah, I know. I will add research, extra-curricks galore, and probably try to hop up in a clinic to keep the medicine going, but seriously... 10am. TEN IN THE FREAKING MORNING. THAT IS WHEN MY FIRST CLASS WILL BE. TEN A.M.

Oh yeah, AND I'LL HAVE THREE DAY WEEKENDS.

And so, things to fill the void?

• Read books for fun. What?!?!?
• Lift weights like I'm on the Jersey Shore.
• Swim Masters.
• Keep cooking delicious a** ish.
• See an Alabama football game, IN TUSCALOOSA. Saaaaaaban! Iron Bowl War Eagle anyone?
• Med Skew prom, round #4.
• More awesome trips.
• Live off my parents' dollar when I'm home for breaks (the rent is too damn high in Boston).
• If you wanna marry a shoe, I'll marry ya.
• Learn to speak the Spanish.
• Maintain baller status.
• Get money.

Don't know when I'm going to accomplish all this... but maybe during my THREE DAY WEEKENDS?!?

Spoiled Rotten

I realized as I was stitching up a lady's uterus today that I have been just downright spoiled in the operating room (OR) this year. Downright spoiled. I am going to need this year off just to come back to reality. This rotation in rural surgery has been unbelievably hands on - first-assisting on colectomies, hysterectomies, and gallbladders; sewing skin, fascia, and uteri; and scalpel-ing incisions, lipomas, and basal cell carcinomas. "See one, do one, teach one" is almost spot on. Third year in Asheville was similar. Day #1 we were expected to hop in and first-assist. The more and more I talk to my compatriots back at THE BIG HOUSE, I realize how lucky we are for these opportunities. It sounds like there was a lot of standing and watching.

So over the next year it's time to put my feet back on solid ground again. You are a medical student, Robert, not a surgical intern. Thus, I must set my expectations lower in the OR (and be ready for a lot more pimping). It's just hard when at eighteen you were learning to sew and certifying as a laparoscopic camera kid (LCK, it's official)... downright spoiled!

I'm mainly writing this post so I can remind myself later how much it meant to me to have these experiences. At some point, I see myself teaching, and it's easy to get caught up in what has been mundane over the years. To the medical student though, nothing is ordinary. Every suture, every staple, every SteriStrip is worth it. So, hey, Dr. Swendiman of the future, let the med students get their mitts in there! It will make their day.

I may be repeating myself this ad nauseum, but I am finding again and again that choosing to spend the year in Asheville was one of the best decisions I've ever made. Minus all the good early years of my life (eat, sleep, poop, play), third year of medical school was the best year of my life to date. I can say that with confidence. It was unparalleled professionally, academically, ethically, and culinarily (is that a word?). I missed my best friends, and my living situation was horrible, but hey, there has to be room for improvement. This training set me up for the Dubin Fellowship, and connected me with the research I will do this fall (check back later for more detes). And finishing up with this rotation in Linville certainly caps off the year.

I'm leaving Asheville with a smile on my face from ear to ear.

Now, sticking to the theme of August, here's the Quote of the Week:

“The moral test of government is how it treats people in the dawn of life, the children, in the twilight of life, the aged, and in the shadows of life, the sick, the needy, and the handicapped.”

If you haven't read Donald Berwick's (a real MD/MPP!) address to the Harvard Medical School's graduating class of 2012, entitled To Isaiah, it is a must read. This quote is from that speech. You can find it online and on PubMed.

Three Lessons

I finally have a moment to reflect on third year (phew!). The grades are in, Step 2 has been completed, and I've started to get comfortable in my new home in Linville (despite the lack of Internet at times, and absence of cell phone service almost all the time). I realize I've learned some very important lessons from last year. These are more the Art of Medicine variety rather than hard science. I'm sure there are many more, but a few have really stuck out as I have had to take more responsibility for my patients, and have been seen as a true provider. Most patients here refer to me as their "doctor" (despite my corrections), and I know that what I say, and how I say it, matters. So, if I could go back one year and teach myself three lessons, they would go something like this:

• All doctors practice as a subspecialists in Psychiatry. Every physician is a psychiatrist first, specialist later. I hope to be a "Shrink with Surgical Training" later in my career. So much about a patient's health revolves around where they are mentally. Unbearable back pain may just be back pain, but it often is also a cry for help. I just can't take this anymore. I'm suffering. I can't pay my bills, my marriage is strained, I'm depressed, and I just can't cope. I think a lot of the time something else is going on, and it is our job as providers to recognize this and treat it. Here in Surgery, I see quite a bit of Irritable Bowel Syndrome (IBS), in which psychiatric pathology may play a strong role. Taking out a gallbladder is not going to fix IBS, but often patients get nonspecific test results that point them in that direction. I think this is where the team-approach to health care is so important: working with the primary care provider, a shrink (if needed), and of course, the patient. I think because of the way we are taught psychiatry, it has been one of the most important parts of my review of systems, and I will try to incorporate it more as I go on. So thank you Dr. Buie and Dr. Meacham.
• Ask yourself: "What would I do if I were seeing this patient in the office?" I have a second year MAHEC Family Med resident to thank for this one, but it is one of my biggest pet-peeves in the hospital. A patient walks in to the ER for a very minor complaint. They end up getting a CT (which one of my attendings refers to as an "important emergency room vital sign"), CBC, CMP, and the works. In reality, they have a runny nose. But it's not just the ER, and I don't mean to pick on ER physicians, because it's everybody. If we were to all step back and say, "Hey, just because I'm in the hospital it does not mean I need to order a hundred tests. There's no reason to get a chest x-ray here. Maybe a referral or some Simply Saline is all you need (or a PCP...)." I think asking this is important not only for the patient, but it might eliminate a lot of waste to the system. And when in doubt, go back to Lesson #1. Why did coryza bring you in, today?
• The diagnosis of fibromyalgia is given out like candy. Don't get me wrong, I think there is good evidence for fibro, even though it frustrates many physicians. But, just because someone is in pain, it does not mean they need to be given a diagnosis of fibromyalgia (which they will read about on the Internet and then all hell will break loose). I recently saw a patient with horrible rheumatoid arthritis, complicated by even worse osteoarthritis. And, the gentleman was in severe pain. Of course he was in pain! He's got an extremely debilitating disease! Why the elderly man needs another diagnosis to skew the picture is beyond me. But, it seems like there are sooo many patients walking around with this diagnosis, and when you sit down and actually talk to them, it just doesn't make sense. Depression + back pain does not necessarily equal fibromyalgia. Carrying that diagnosis may affect how a physician treats the patient (unfortunately), so let's stick to giving that out only when it's appropriate. And when in doubt, go back to Lesson #1...

Food for thought. For more food, I leave you with my Week #2 Quote:

"Robert. There are two things I like talking about. My Lord and Savior Jesus Christ... and guns. So now. What kind of gun do you own?"

AHEC 425: Acting Internship in Surgery, Rural Western NC

Welcome to Linville, North Carolina! In my first clerkship as a fourth year medical student (damn it feels good to say "MS4" at the end of my dictations), I decided to grab a one month rotation in Western NC before heading north. What better place to go than the area where I spent my five community weeks my first two years (Linville is very close to Boone)? In fact, I am actually working at the hospital where my community week preceptor has a satellite office. Here, I will spend four weeks working with two general surgeons, learning how medicine is practiced away from THE BIG HOUSE (i.e., Chapel Hill or Mission). One of the surgeons is the third in his family to serve this area as a general surgeon in a practice established before the turn of the century. And by turn of the century, I don't mean the year 2000...

The best way to describe my experience so far is through a short vignette. The only place in Linville where I can get good cell phone service is in the Cannon Memorial Hospital parking lot (burn in hell, AT&T!). I don't have service at home or in the coffee shop I now frequent. So, after we finish rounding in the evenings, I may often be found sitting in my car catching up on phone calls. One night this week I left the door open, welcoming the cool mountain breeze. Mid-conversation, a police officer walks up to the car and starts messing with me a bit...

Dispatch, we have a 10-87-12 going on in the Cannon parking lot. Send 2 units back-up.

I put the caller on hold and start chatting pleasantly. Suddenly he realizes I'm on the phone and says, "Son, I just came by to see if you were going to take that lady back for a C-section." I was a little taken aback (one, because I don't take anyone back for sections; two, how did he know?; and three, HIPAA?). The doctors had only been discussing whether or not this patient would need to go to the OR less than 30 minutes ago. He says, "She's my cousin; I was just curious. Heard you might be in there."

News travels fast.

That gives you an idea of how small and tight-knit the community is where I have the privilege of working. It seems that the lines of HIPAA are a little blurred. Before leaving Asheville, one of the surgeons asked me what my plans were for the year. I told him that I was on my way to Boston, via Linville. He said, "Well, Linville is just sliiightly different than Boston, so good luck." I can imagine. To which our great and wise ethicist replied (in her usual, sage manner),

In the words of psychologist/philosopher Harry Stack Sullivan, "We're all more alike than we are different."

Agreed. It is a different ball game here, though. Because there are only two surgeons for the whole area, we are always on call. If something happens in the middle of the night, I am expected to be there. Morning, noon, night, and weekends. Now, given that it is a small town, emergencies occur less frequently. But the responsibilities are greater. We pre-round on our patients in the morning, see patients and take cases all day, and then round again at night. I have been the first-assist on cases that first year residents don't even get to take (I don't think it happens like that in THE BIG HOUSE). There is less "see one, do one, teach one," and more "go do one." It's fantastic. Mind you I don't "do one" if I'm not comfortable or don't know what I'm doing. I feel a responsibility for my patients here. I also feel a bit like a real practitioner.

I think I'm going to miss the medicine in my year off. I will leave you with my quote of the week:

"My dad used to say, 'If you take a son-of-a-bitch and educate him, what do you get? You get an educated son-of-a-bitch."