The "Arte Y Pico" ... My First Blog Award ... and I got 2

If thou desire the love of God and man, be humble, for the proud heart, as it loves none but itself, is beloved of none but itself. Humility enforces where neither virtue, nor strength, nor reason can prevail.
~Francis Quarles

This year I have been honored with 2 awards that I don't know if I deserve, but have received them none the less. Every time I am given a compliment or an award, my first instinct is to say, "I am not worthy," or "so and so is better." A wise person once told me, instead of trying to be humble, just say thank you. So, Thank you.

I thank the residents for awarding me the Resident Teaching Award for 2008. I am particularly proud of this award.

I also thank my 2 blog friends, Make Mine Trauma and Chrysalis Angel, for awarding me the Arte Y Pico blog award.

Make Mine Trauma

Someonetc at Orthopaedic Residency. He cleverly incorporates everyday challenges and situations as a mirror into the challenges of training ortho residents as their attending. He is constantly striving for more creative, motivating and successful methods of teaching.

Chrysalis Angel

Orthopedic Residency – This blogger actually found me one day, and I’ve been the one reading him ever since. Occasionally he disappears and then reappears out from behind his work and home life, balance is essential you know. I hope he comes back to write more often, I’m going to be especially interested in what he has to say now.

The rules of this award are as follows:

1. You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.
4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.
5. To show these rules.

So as part of the rules, here are my chosen blogs:

1. Midwife with a Knife - This OB/GYN who specializes in maternal fetal medicine bring her insight about medicine, teaching, and life. Through her blog, she shares her personal struggles.
2. Musings of a Dinosaur - This is a well written blog by #1 Dinosaur, a family practice physician. His wisdom and experience in both medicine and life permeates his writings.
3. Medical School of Hard Knocks - This is a relatively new blog started this year. It is written by a medical student, CSTEW. He bring his humorous insight in tho the medical student mind.
4. Hurricane Jill - This former general surgery resident, future neurosurgeon, and now pharmacist consistently writes her humorously honest prose about her day to day life and struggles.
5. Crzegrl, Flight nurse - Crazygirl or Emily is an awesome flight nurse with a wicked sleeve. Her blog continues to evolve. She is a little crazy and maybe even zany. Her blog is no different. She is also military, Hooah.

Humility is the embarrassment you feel when you tell people how wonderful you are.
~Laurence J. Peter

"Sorry about Michigan" ...

Do not dwell in the past, do not dream of the future, concentrate the mind on the present moment.
~Buddha

Life is always throwing us curve balls. In medicine, it is easy to get caught up in work. Medicine consumes. As I have said before, I am a grunt. I work. I teach. I mentor. It is my work persona. Outside of work, I am a husband, father, friend, and blogger. Balancing these roles is very difficult. Often, one overshadows the other.

Over the last few months, I have been engrossed in medicine. My long days at work brought on by emergent surgeries, OR delays, and over booked clinics. Mentoring keeps me in the office answering the questions and concerns of residents and medical students. Administrative meetings for the residency, medical school, or hospital, fill my lunch hours and evenings with bad coffee and cookies. Mentally fatigued, I come home to a family starved for attention. The dog needs to be walked. My daughter needs to tell me about her day. My son needs to be read a story and put to bed. Then there is my wife who wants to share with me what the kids are doing, changes she wants to make on the house, vacation plans she has for the future, and things friends and family are doing. There were days that I don't think I had anytime for myself.

Last week started like every other week. Monday was a long clinic day. Tuesday was a long OR day because of OR delays. Wednesday kept my head spinning with OR, clinic, OR, Clinic, and then a consult that changed my week and probably helped to bring me back to humanity. I was consulted on a patient that is well known to me and the hospital. His disease is chronic and likely fatal. Studies were ordered. I reviewed them and realize that he needs surgery, a big surgery. I sit down with the patient and his father. We discussed the options and our goals. Mom was not present because of another family emergency. After going through the options and expectations, they elected for surgery.

Wednesday night, I was on call at the adult hospital. I was up all night. Thursday long OR day and I was on call at my little hospital, luckily did not have to go in. Friday, surgery day, we had a pre-, post- op spine conference, I gave Grand Rounds to rheumatology, and then went to clinic. The case was in the afternoon. OR was ready. All of the implants were available. Anesthesia was informed of all of the problems and they wereready. Pre-operative plan was done. I was ready.

I walked out to talk to the patient and his parents. Mom was there apologizing for being out of town dealing with a family tragedy. I explained the planned procedure to the mother and she understood. At the end of my discussion, my patient said to me, "dude, I am sorry about Michigan." He is a Notre Dame fan. Although he struggles to be like other kids, he was at ease here. He has been in the hospital more than he has been in school. He knows that he has a disease that is likely fatal. He and his family have come to terms with this. Now, it is about quality of life.

We went back to the OR and anesthesia places lines. I visualized my plan. My mind's eye showed me the procedure, step by step. I was ready. After lines were placed, we positioned the patient. At that moment, a wave of emotion came over me. Tears filled my eyes. I didn't want to make a mistake. I questioned whether I was doing the right thing. I didn't want to be the person that shortened young man's life. He trusted me. His family trusted me. Never before have I doubted my own skill. So, I composed myself, re-centered. I said a prayer and ask for guidance.

In the end, the case went flawlessly. My breathing became easier. I spoke with the family. They were sitting comfortably smiling and joking. I explained that everything went well. They were at ease. They were dealing with this big surgery and a family tragedy, yet they were comfortable. Their family was centered.

There are times when I feel sorry for myself. Whether I am working too hard or have too much family responsibility, my life is never as hard as my patients life. Dealing with death and dying requires strength of character and is by far more emotionally draining than anything I ever encounter. I wish I had the spirit of my patient. Today, I am going to follow his lead. It is time to re-balance. It is time to get out of myself and back to life. To my friend, I say thank you for your wisdom and GO BLUE.

The price of anything is the amount of life you exchange for it.

~Henry David Thoreau

All they need is calm assertive leadership ...

Pathetic/benign
Accept it/undermined
Your opinion/your justification
Happy/safe
Servant/caged
Malice/utter weakness
No toleration - Invade
Committed/enraged/admit it
Don't condescend/don't even disagree
Destroy/decay/Disappoint/delay
You've suffered then, now suffer unto me.

Obsession - take another look.
Remember - every chance you took.
Decide- either live with me
Or give up - any thought you had of being free

SLIPKNOT - The Nameless

We just got a new dog, a Rhodesian Ridgeback. She is a beautiful dog. She is both sweet and feisty. She is a puppy and, as such, has all the puppy traits. To break her of all these traits, we attend puppy class and read all sorts of opinionated books on puppy training. We have even watch, on occasion, Ceasar Millan . What I have learned is that dogs have a pack mentality. They look for a pack leader, and try to improve their position within the pack. As I work on my own family pack and being the pack leader within my home, I couldn't help but recognize the similarities of the dogs' approach to a pack and residents' approach to residency.

It is July. The month that all residencies have the transition. The Spring residents are experienced and polished. They understand their roles and are comfortable their position. This is in total contrast to the Summer residents. They have yet to figure out their role. Like dogs in a pack, they are all jockeying for position. As an attending, I am suppose to be the pack leader. I find humor in this battle for position. Sometimes, they challenge one another. On occasion, someone in the pack challenge the pack leader. How the pack leader approaches this confrontation determines his/her status in the pack and can not be taken lightly.

In training my dog, I have learned some training techniques that are different from when I had my first dog. The choker chain seems to be out. There is no more rubbing your dogs nose in their accidents. Now, the trend is crate training and the kinder gentler pack leader. The overall goal is still to assert your dominance in a less painful but assertive way.

As a residency pack leader, I can't follow Ceaser Millan's fulfillment formula of exercise, discipline, and affection. Although it would be fun, the ACGME may frown on it. Ceasar does have some advice that can be parlayed into residency education. He recommends setting rules, boundaries, and limitations. Along with being consistent and fair, these can be effective techniques in teaching/training adult learners.

In the past, if a resident would question or challenge his/her attending, s/he would be handed an embarrassing beat down comparable to a WWE smack down. Many would use their favorite tools of fear and humiliation. In the new age of the educator, things have changed. Socratic questioning is losing favor and may go the way of the choker chain. Although the techniques have changed, the ultimate goals have not. As a dog trainer, our goal is to have an obedient dog that follows commands, doesn't make a mess of the house, and is kind to others. As a physician educator, our goal is to produce a competent physician/surgeon who has the needed skills, is considerate of others, and understands his/her limitations.

Calm assertive leadership is Ceaser's recommendation to the pack leader. Following this rule is tough. When the puppy nips at your toes or the resident questions your treatment method, you just want to smack them, figuratively speaking. I like to tell my residents, "my pimp hand is strong." I know this is not the way to approach it, but the urge is there. In the end, I have to fight that urge and smile. Instead of the physical punishment, I have to use guidance, reinforcement, and occasionally a treat. Eventually, they will learn, and if they don't, I could always just take them to the pound.

“Patience and perseverance have a magical effect before which difficulties disappear and obstacles vanish.”

~ John Quincy Adams

I am the boss of me ...

Invictus

William Ernest Henley

Out of the night that covers me,
Black as the Pit from pole to pole,
I thank whatever gods may be
For my unconquerable soul.

In the fell clutch of circumstance
I have not winced nor cried aloud.
Under the bludgeonings of chance
My head is bloody, but unbowed.

Beyond this place of wrath and tears
Looms but the horror of the shade,
And yet the menace of the years
Finds, and shall find me, unafraid.

It matters not how strait the gate,
How charged with punishments the scroll,

I am the master of my fate;
I am the captain of my soul.

We are well into another July. Like all of the previous years, nothing seems to change except my age. The residents switch over and ascend to their new status: interns to residents, juniors to chiefs. Everyone is in their new role, but my role stays the same.

In this new academic year, I continue in my role as surgeon educator ... lecture, clinic, surgery. I am a team player. If my partners as for help, I am there. I have a difficult time "dumping" on others, instead "I suck it up". Again, I am a team player.

I try to model for my residents what I feel are good characteristics of an orthopaedic surgeon. Giving them insight into errors I and others have made in both thought and technique. I model characteristics I hope that they will pass on to those behind them and utilize in their practices. It is my way of giving back in homage to those who spent that time on me.

Today, I sit in my office after 7 waiting for a case and I am not on call. Why? I feel it is the right thing to do for the patient. On the other hand, my all of resident have gone home. I guess I can't expect that they too would feel the need to stay, but I can still hope.

So, I continue to model.

“Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.”
~Albert Einstein

Fly on Little Wing

“Fear of failure must never be a reason not to try something.”

~Frederick Smith

You know it is hard for me to resist a challenge. So, when my father-in-law asked me if I wanted to climb Snowdonia, I said sure. I am reasonable fit. I can put on some hiking shoes and walk up a mountain, no problem. I think I forgot I have a little fear of heights.

I looked up from the bottom of the mountain. The top was cloud covered. There was a chill in the air, a few clouds, but no rain. I put on my gear and away we went. We were the first on the well traveled. There had been many before us.

Like many journeys, it is hard to imagine how hard it will be. We rely on those before us to lead the way. Educational journeys are no different than physical ones.

The path residency is well worn. At the beginning, the end is hard to see. We are given a glimpse of the end by those ahead of us. For the most part, we feel prepared. Our gear has been packed.

We walked to the base of the mountain at a brisk pace. The mountain streams flowed into clear lakes. Barely breathing heavy, we reached the beginning of the difficult climb. My father-in-law led the way. This wasn't his first time. I needed his wisdom to show me the way.

In residency, it is important to be given guidance. Those with wisdom should guiding you way through the difficult tasks. Although the books and literature give you some perspective, they do not give the whole story. Those colored pictures by Netter do not give you an idea of how to place retractors or set up a room. Most technique books fail to give you all of the information needed to go through a procedure smoothly. This is when your guide comes in handy.

Walking up the mountain, it was clear to me I would not be physically challenged. Although it was steep in areas, it was not physically hard. I quickly over took my guide, bounding forward far ahead. As I looked back to see where my partner was, the reality of what we were doing hit me. We are climbing a F%#k#$g mountain. What was I thinking?

As the years go by, it is common for learners to feel that they have surpassed their educators. With more experience and confidence, the learner may question his/her educator's rationale for a specific treatment. They may feel there s a better way, but lack the experience to know all of the positives and negatives of the treatment they have chosen. It is only when they are allowed to go forth with their choice or to complete a procedure without much educator input that they see their inexperience and the holes in their education. With their errors in thought or technique brought to light, the learner and educator can work together to improve and in the end succeed.

My heart beat faster. How am I going to complete this task? I adjusted. I found ways of decreasing my fear and improving my chance at succeeding. Keeping my head down and pushing forward, I overcame my fear and made it to the top. I completed the challenge.

With every other step forward, there may be a step back. But it is only with being self critical, that we can grow. It is only with acknowledging you weaknesses, fears, and errors that you can improve. It is important to continue to push forward, always taking into account your limits.

As I smile for my summit picture, I had the scary realization that I wasn't done. I still had to walk down.

For all of you graduates, remember this is not the end, only the beginning. Your education has just begun. This is only the first peak at the beginning of your career. As you begin in your journey, here are a few words to remember: stay self aware, listen to you gut and your patients, you can always be better, and always do the next right thing.

So, with my task only partially completed, I grabbed a hold of the mountain and walked down.

“Courage is not the absence of fear, but rather the judgement that something else is more important than fear.”
~Ambrose Redmoon

6 word meme

MWWAK tagged me with a 6 word meme.

Life is a constant process of improving on previous experiences. We should learn something everyday. Our lives should be constantly adapting, changing, growing, and improving. When I stop learning, then it will be time to retire.

"I live; therefore, I must learn."

I have chosen not to pass it along. Sorry MWWAK.

Total Awesomeness.....

“Don't wait until everything is just right. It will never be perfect. There will always be challenges, obstacles and less than perfect conditions. So what. Get started now. With each step you take, you will grow stronger and stronger, more and more skilled, more and more self-confident and more and more successful.”

~ Mark Victor Hansen

Life is beautiful. There are a number of times in our lives that we achieve something and feel like we are on top of the world. Whether it is a graduation or the birth of a child, the feelings of accomplishment are overwhelming. These are probably the most appropriate time to use the word awesomeness.

I have done all of my graduating and I think I am done with the kid thing, so the only thing I have that gives me the feeling of awesomeness is completing marathons. I recently finished the Vancouver marathon. I chose Vancouver because, well, I thought it would be a nice run in a beautiful town. Since it was a beautiful course and an awesome town, I thought I would document the race with pictures so that maybe you all could share in my total awesomeness.

The morning is May 4, 2008. It is a clear Sunday. A good day for running. I reach the start, my head phones in my ears. You may ask what is playing, but those of you who are familiar with my blog have already guessed it .... TOOL



I look down, and visualize the course in my mind's eye.
The horn blows. I look up as I make our way to the start line. My hand is on my watch .... the timer is started.

The weather is beautiful. A slight chill in the air. Everyone is in good spirits. The first part of the course is in the city. I pass a wheelchair racer along the way. He waves.

I come up to about mile 3. This is where I see the front runners for the only time during the race. They were moving.


We make our way through Vancouver. As with most marathons, for some reason you have to go through China town. I am not really sure why.




As we crossed one of the bridges, you can see the city amongst the mountains. Breath taking....

At mile 10, I see my family and friends cheering me on. It was nice. I got a high five from my son. Total awesomeness....

Ahhh ... water stop ... I caught this dude by surprise. The water was much appreciated though.


Ah, there is nothing like running though a park. Out of the concrete jungle and into paradise.



(ROCK HANDS IN THE AIR) The band is rocking out doing some cover songs of 80's music.


Now at this water station I did not suprise her. Look at the smile.

Ahh, looking at Vancouver from the park, what a city.

How would you like to have this gig. Hanging out in the park playing for the runners. What a view.


Ok, this woman was at about the 16 mile point. I have never seen someone having so much fun by herself. She was just high on life, I guess. The only thing that would have made this better would have been a disco ball.


And back into the city we go. We are welcomed with a 1/2 mile up hill at mile 24. Nice .....


Ok, right about now the blisters on my feet were killing me. I came to a corner and this little guy was just cheering for us. Awesomeness ....


At this point, I can smell the finish. Foot pain, quad burn ..... irrelevant. It is the finish line.


So there you have it. It was a nice time. I hope you enjoyed it. It was total awesomeness.



Ok, four cellos rocking out with the singer from slipknot is also qualifies as total awesomeness.

“Success means having the courage, the determination, and the will to become the person you believe you were meant to be”

~ George Sheehan

Not everyone will like you - part 2

“For my part I know nothing with any certainty, but the sight of the stars makes me dream.”

~Vincent van Gogh

I posted last year about a good patient experience. It was a story about a patient that actually liked me. I titled it "Not everyone will like you." Some people criticized the title as false advertisement. I received some comments that stated I was basically tooting my own horn. For those that know me, they know that is not the case. For most of us in clinical practice, we hear more of the bad than good and occasionally someone will actually like you. My personal opinion is that we should not practice so that people will like you, because not everyone will; you should treat people like human beings. It is not a popularity contest. So for all of those who were a fan of that one, here is another.

It is Sunday. As usually, I am completing some work, signing forms, writing letters, etc.. In my pile of work, I came across a hand written letter from one of my patients. I will share it with you.

Dr. Someonect,

Although you may not remember me, I wanted to thank you for the tremendous impact you've had on me this year. At the beginning of my Junior year, I was feeling overwhelmed by stress - I didn't have any of my best friends in my classes, I had just been rejected by a girl I'd been trying to charm for two years, and to top it off, I fractured my ankle in three places. I'd been in surgery before and broke a finger too, so at first it just seemed like a nuisance (I was the fastest cripple on two crutches at XXX school, which has a surprisingly large number of cripples), but then there came the worries that I might limp for the rest of my life - something about my growth plates, I still don't really understand it.

But when I met you and was told you'd be performing the operation, I had total confidence that I'd be back to my old ways in no time. I was especially impressed by your knowledge of Hendrix, RATM, Megadeth, and all the other guitar greats (I'm starting my lessons with my friend - I think he's the next Steve Vai) Just to see that a doctor could be that awesome yet so talented really inspired me. I'm not really sure what career path I'll take in life, but I've definitely added "awesome surgeon" to the list. The entire staff at XXX really made an impression me; I've never met a friendlier staff that seemed genuinely concerned with their patients, and I know that without their help I'd still be lurching around my house on home-school watching Seinfeld re-runs. You're the best doctor I've ever had.

Sincerely,
My Patient

*P.S. - My step dad's getting getting his summer Mohawk next weekend.

That letter made my weekend. So I thought I would share it. It was nice.

“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”
~John Quincy Adam

Stepping to the plate ....

“Nobody can go back and start a new beginning, but anyone can start today and make a new ending.”

~Maria Robin

It is Spring. It is the time for flowers, yard work, and baseball. I was watching the Cardinals the other day, and I got a great idea. Wouldn't it be awesome if surgeons came into the OR like a player stepping up to the plate to bat?

(Down with the Sickness playing in the background)

ANNOUNCER:

"Coming into room 9, we have Somonect. This year he is operating very well with an infection rate of less than 0.01%. He has only thrown 2 instruments this year with no personnel injuries. His surgery times are steadily improving, only gone over his operative time twice in the last 30 case. Today, his is handicapped by a first year orthopaedic resident, a new scrub tech, and a circulator that "doesn't usually do orthopaedics." In these situations, he averages 15 minutes over his scheduled time, no thrown instruments, and 4 curse words."

How would you step to the plate?

“Don’t ask what the world needs. Ask what makes you come alive, and go do it. Because what the world needs is people who have come alive.”

~Howard Thurman

Brain mouth filter ...

“A lot of truth is said in jest.”

~Eminem

Socratic questioning has been at the heart of clinical medical education many years. Traditionally, the educator asks a question so that the original question is responded to as though it were an answer. The central technique of Socratic questioning is known as elenchus, meaning a cross-examination for the purpose of refutation. In medical school, this technique of education is more commonly referred to as pimping. This style of teaching is seen as a way of the educator showing his/her greater knowledge of a subject. Depending on how and where it is enacted, pimping is perceived as a unique kind of questioning practice with a wide range of intentions from knowledge checking to humiliation. Some educators use elenchus for knowledge checking; others educators pimp. The students perspective of this style is the same regardless of the intended purpose.

The earliest use of the term pimping dates back to 1628 in a statement made by Harvey in London. Harvey, feeling his students lacked enthusiasm for learning the circulation of the blood, stated: "They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped." In Heidelberg (1889) a series of questions titled "Pumpfrage" or "pimp questions" were recorded by Koch for use on his rounds. And the first American reference to this was by Flexner in 1916. He wrote about his visit to Johns Hopkins: "Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it 'pimping.' Delightful."

Now, if we look truly at the Socratic questioning, its purpose is not politically motivated. It is for the purpose of educating and to improve the students understanding of a subject through questioning. On the other hand pimping can be more politically motivated. Many times pimping is used as a way for an attending to show his/her knowledge. Knowledge is power. Pimping sets the hierarchy.

In the art of pimping, questions should come in rapid succession and be somewhat unanswerable. Questioning can be grouped into approximately 6 categories:

1. Arcane points of history - facts not taught in medical school that have no relevance to medical practice.
2. Teleology and metaphysics - questions that lie outside the realm of conventional scientific inquiry. Most often found in the National Enquirer and addressed by medieval philosophers.
3. Exceedingly broad questions - for example, what is the differential for a fever of unknown origin. These questions are best asked at the end of conference. Regardless of how many good points the student makes, s/he will always be criticized on the points missed.
4. Eponyms - questions like, what is the Hoffa fracture? These are usually dated terms that should be struck from memory.
5. Technical points of basic science research - enough said. These technical points, although showing academic prowess, have no clinical relevance.
6. The Devil's Advocate (my personal favorite) - with this technique, the educator takes the opposing view. This challenges the learner to understand the strengths and weaknesses of both views. For learners, defending against this takes experience, skill, and understanding. Novice learners are easily swayed away from their correct thought process down the wrong path.
   

For a master pimp, these are important categories to understand. Their utilization, while at a nursing station or in front of many naive on lookers, can gain the questioner many power points. It is like flexing your muscle in the gym mirror in front of the elliptical machines.

While understanding the ways of pimping tactics is interesting, it is more important for the student to understand the classic defense strategies to stymie the master pimp. When using these tactics, the student must be careful not to anger the questioner making the situation worse. If done improperly or if the technique is not properly disguised, it will quickly be countered with quickly countered. There are several classic techniques: the stall, the dodge and the bluff.

• The stall - this is commonly used in x-ray conferences. The student typically looks at the study squinting, and bring their face so close their nose almost touches it. Then the study characteristics are described. "This is an AP, Sunrise, Notch, and lateral in a skeletally mature patient dated January 5, 2007." The next step is to describe what is not present. It is important interject pauses, face holding, and pointing, as diverting gestures. The hope with this technique is that the questioner will fatigue and ask someone else.

• The dodge - this is a way of avoiding the question and wasting time. The most common ways this is applied are by answering the question with a question and/or answering a different question.

• The Bluff - (3 classes)

1. Hand gesturing - this is making reference to hot topics in medicine without supplying either substance, detail, or explanation.
   
2. Feigned erudition - answering as if you have an intimate understanding of the literature and a cautiousness born of experience. For example, "To my knowledge, that has not been addressed in a randomized prospective controlled study." These statements are usually made after clearing the throat, standing professorially, and while holding something, coffee cup, glasses, etc.
   
3. Higher authority - this is done by referencing someone higher up in the hierarchy or another institution. Using a senior attending as a reference is common. "In my discussion with Dr. x, he stated ...." It is also common to mention another institution where the student may have trained. "At Duke we .... "

Now, once the offensive questioning tactic is put into play and the student's defense is chosen, where do the errors occur. Probably the most common error for the inexperienced student is the misuse of defensive tactics. When a student shows his/her hand early, it allows the educator to see their lack of understanding of the subject and is like blood in the water for some educators. These are easy pickings for malignant educators. Just as problematic as improper use of a defensive tacts is not having good control of the "Brain Mouth Filter." Although knowledge is power, welding a little knowledge without an understanding will get a novice in deeper than s/he can handle. Once a novice learner gains some experience and knowledge, they begin to overstep their understanding and bring up other topics and controversies without being asked. Students that has a running dialog of his/her thoughts, it opens them to more questioning.When this is done, one of 2 things can happen: the student can get an endless onslaught of questioning there by saving all others from questioning or the team will share in the beating. The learner must develop ways of diverting questioning and putting a closure to the questions. Filtering their thoughts prior to speaking is a must.

In the end, the pimping phenomenon is a game. The educator is the game master controlling the many of the parameters of play. With time, a learner will develop both a knowledge base and thought process. They develop there own styles of processing and answering "pimp" questions. Hopefully at end game, education occurs.

“Sometimes questions are more important than answers.”
~Nancy Willard

Putting a comment on blast ...

“Life is best enjoyed when time periods are evenly divided between labor, sleep, and recreation...all people should spend one-third of their time in recreation which is rebuilding, voluntary activity, never idleness.”

~Brigham Young

I received this comment from p3/4md. It is a bit of a rant, but speaks directly to many of my frustrations with some of the medical students that I encounter.

'I know he's only eleven months, but we think he might be a genius.'

Being a third year med student, almost done with my core clerkships, I'd like to comment on this from our perspective, and then, from my perspective.

First: Medical students are quick learners to do what is most efficient. We always have our eye on the end game. In college, it was medical school, in medical school, it is residency.

Let's just forget about the first two years of medical school in this talk, because quite frankly, in my opinion, it has little to do with how the students will act, clinically.

These statements are true. Like many things we do, it is about end game. What I try to stress to my residents is that they are not training to be residents. End game is becoming a physician. in our case an orthopaedic surgeon. Practice like it.

Residency is based primarily on your step I/II scores and your grades, most probably, your clinical grades.

In our Surgery clerkship for instance, our grade is basically derived 50% from shelf exam score, and 50% by your ward attending/resident.

We as med students know that if we show up on time, and blend in with our peers, we're going to get 80-85% for our clerkship grade. If our resident/attending likes us, and we're actually halfway competant and helpful, we'll get a grade of 85%-90%. If we're lucky, and the attending is nice, we'll get a grade in the 90's.

If we bust our behinds, work hard, and become advocates for our patients, we're still going to ride that luck factor to get a grade above 90% (which is honors.) I've had attendings/residents praise me, say they've learned more from me than they thought they taught me, and still give me an 87.5. Tell me, what do you expect of me to do well? I've had residents and attendings put down "the best medical student I have ever had" etc. etc. in the their comments, and still give me a 95%, why not a 100%? If I performed above expectations, and was the best you have ever seen, doesn't that logically warrant a grade of 100%?

Granted, I know no one is perfect, and some can be more stringent than others, but seriously, give me a break. I've had (in college and other areas,) people say "I don't believe in giving 100's, no one is perfect." Well, by that same logic, if no one is perfect, and 100% can never be achieved, why have the score there to begin with??? In that case, should it not be assumed that 100% is "just less than perfect" ??

Anyway, enough with that rant :) The point is, in order to do really well in our clerkships, the effort required can be overwhelming. The extra effort required to get into the 90's for our grade is tremendous, and many times, regardless of how well you perform, there's still a significant chance that you won't get an exceptional grade.

We all know this. We've all been there. We know that attending "He's a jerk.. it's not worth it".

In the face of studying for a shelf exam or the myriad of ungraded pass/fail papers that you have us write, I am intelligent, I can balance my time.

Why do I do this? Well, I know that if I do well on the shelf, the 5-10% of the clinical grade that may be impossible to receive, will be easily superceded. Enough said.

So why should I bust my hump.. when I can study more, and make up for it on exam, and then some.

I think this is what really frustrates me. It is one of the reasons that I posted previously about grade inflation. When I look at a resident and a student, I don't look at hours spent in the hospital or the kiss @$$ stuff. Most of us can see through the false smiles. What I look for is someone who is worried about doing the next right thing for both patient and team.

Consider the following (and this isn't me being arrogant or whatever.. this is just how it is):

Unfortunately (or fortunately, depending on how you look at it) my parents instilled a good work ethic in this young doctor. I care.. I really do. I work hard, examining patients, talking to them, building rapport, etc. I showed up 30 minutes before everyone else to preround on my patients, even though no one would ever hear my morning report. Yes, I can hear murmurs that residents can't pick up. Yes, I can put in IV's faster/more efficiently than my interns. Yes, when a patient is desat'ing, I have the ABG kit in my hand, and am feeling for a radial pulse before my resident says "we need an ABG." Yes, I've out diagnosed my resident and my attending. Yes, I paid attention, I read alot, and I understood. If i'm thrown in an ICU/SICU, I can navigate my way around, manage patients, and be confident. No, I know I'm not an attending, I know my limitations, but I also know that they're far beyond that of my peers.

Do I think that's because I am smarter, or better than my peers? No. It's because I know I worked harder to know this. And I damn well have the right to be proud of it. :)

Why did I learn this stuff? Because I think that doctors should graduate and know how to save people's lives. To be useful, and not just know a bunch of facts.

So I bust my hump, etc. And I am proud of myself..But then, I look at a peer of mine:

She shows up late, and does the bare minimum. It's a big month if she actually talks/puts her hands on a patient. She's "going into optho... why should she care?" She leaves early.. and studies while the attending is speaking.

No attending/resident is going to bad mouth her.. they're all too nice. They'll say something benign in her evaluation, and give her a grade of ~85. Then, she'll do well on the shelf.. and get honors.

Her transcript says honors
My transcript says honors.

To the residency world,.. we are equal.

I know more, I worked significantly harder.. but in the end, what difference did it make for the "end game?"

Yes, ideally, we all should be looking for the benefit for the patient.. and should learn to be the best that we can be.. Well, I say fiddle sticks to that.

The most important patient in this scenario is yourself. Who is going to sacrifice in a selfless way before themselves. Yes, there are a few.. but that is certainly not the majority.

So we are in a constant battle. And the grade is king, it truly is.

Although grade is king, you should always do what is right. End game is being a physician.

So, after a year of dealing with this junk.. yes, I now sometimes I find myself debating if I should put that extra effort in. I do it anyway, because I think it is the right thing to do. I feel obligated. I know I am not well accompanied in this thinking.

Most of us learn to just "get by".. and this is evident by the strength of the interns. Most of the interns I've encountered are babbling fools. Why? Because they "just got by" in medical school. It creates a vicious cycle. It sets the stage for residency.

In the wake of the recent match.. I feel bad for the folks who have to decide on these candidates. They all have honors.. they all did well. How do they judge work ethic and good clinical skills? It's almost impossible.

*sigh* what is ahead in the future..

-p3/4md

p3/4md, I love this comment because I can feel your frustration with the system and the abuses of the system by your peers. The hardest thing for a residency selection committee to do is find people who have good work ethic and clinical skill. It is one of the reasons so many programs take people who rotated with them. Hang in there young padawan.

“The self-confidence of the warrior is not the self-confidence of the average man. The average man seeks certainty in the eyes of the onlooker and calls that self-confidence. The warrior seeks impeccability in his own eyes and calls that humbleness. The average man is hooked to his fellow men, while the warrior is hooked only to infinity.”

~Carlos Castaneda

Regardless of how many times I do it 20 miles is still a long frickin run ...

"The range of what we think and do is limited by what we fail to notice. And because we fail to notice that we fail to notice, there is little we can do to change until we notice how failing to notice shapes our thoughts and deeds."

~R. D. Laing

About 5 years ago, I started running. On a dare, I ran a 1/2 marathon. I needed to be challenged. For someone who had never been a runner, the 13.1 mile distance seemed like an unsurmountable distance. After the race, I realized that it wasn't as difficult as I had expected. It didn't require a lot of training. Like many amateur runners, I quickly made the leap from 1/2 marathon to marathon. I read the books and got training plans. I talked to marathoners. The truth is that the marathon is not just running a 1/2 marathon twice. Most will tell you it is much more; the marathon begins after the 20th mile.

Marathon training can be painful. In the beginning, it's fun. Most of the runs are rather short. The average training plan is about 3-4 months. If you run regularly, the first few weeks are just a continuation of what you have been doing previously. The challenges come when the middle distance run is greater than 8 miles and your long run is greater that 16 miles. Training runs that use to be 30-60 minutes become 1 1/2 - 2 1/2 hrs. Injuries begin to pile up. Your body aches. You ask yourself on a number of occasions the question, why? For me the answer is, because it is there. It is a challenge. I will defeat the 26.1 mile monster. The training is a necessary evil. The long runs of 18-22 miles on a Sunday must be done to prepare me for the marathon day. If I don't prepare, I won't be ready and I will fail.

In one of the early posts, I wrote about how I felt residents and medical students today are soft. Maybe that was a little harsh; they are more like the new, the proud, and the privileged. Some who read this thought I was speaking to the hot button issue of the 80 hour work week. My opinions don't have anything to do with the hours spent in the hospital. It has nothing to do with them wanting to have a life, i.e. not being in the hospital all the time. It has more to do with how they view their chosen career. When you are training, you can't do it part time. Medicine is not a DELL computer where you choose only your favorite components. You can't come into a specialty without having at least a basic knowledge. These basic components become the building blocks for future learning and professional growth.

When I look at my residents and the young medical students, there is an inherent lack of drive to learn their craft. It is no longer a priority. Like many of my generation, Gen X, and even more so in the Mellinial generation, there is a undercurrent of entitlement. It is their right to be taught this information and to do these procedures. They are not here for so called "scut." Heaven forbid we talk about patient care and continuity of care. We are in the era of teams and patient hand offs. No one is responsible for a patient. Patients are handed from one person to another like a hot potato. The residents are well rested but who is actually responsible for the patient. Who is taking ownership? Ah yes, it is the attending's responsibility. So, now if I am going to do everything, why should I teach? And if the attendings and mid level providers are going to be doing a majority of the patient care, are we training 1/2 a physician? Are we training physicians who can pass a test but can't treat a patient?

Regardless of the rules and regulations placed on training, patients still expect you to be a physician. When a patient asks you a question, you can't answer "I missed that lecture because I was over hours." No matter how low the hour restrictions go, physicians in training will still need to gain the experience. They must put in the time to train.

Medicine is mountain, regardless of your specialty. The amount of information that you need to understand is increasing. In todays medicine, the number of known diseases, medications, diagnostic testing, and procedures, are probably double of what they were 20 years ago. The business end of medicine is more complicated. Medical practices have adjusted because of medical legal issues. The style of medicine practiced is affected by both private insurance and CMS. There are regulating agencies, like JCAHO, that make suggestions hospitals have to follow. Then there is the possibility of P4P. You must be a physician, business man, politician, and lawyer. To say we teach them all well would be the understatement of the century.

Like the marathon, medicine requires endurance training. It can be fun, but for the most part it is painful. For clinical medicine, you simply have to get the clinical experience. Book learning helps but experience solidifies the information and places the written word into perspective. Regardless of how smart you are, you still have to put in time outside of the hospital to read. The reading must be not only on clinical and basic science, but also on the business, and health policy, ect. You must train yourself to prepare for the end game, you medical career and practice. Everyday is a school day and contrary to popular belief, your learning and educating does not end at 80 hours; just like my run doesn't stop at 20 miles.

“Never mistake knowledge for wisdom. One helps you make a living; the other helps you make a life.”

~Sandra Carey

March madness ...

“Luck is what happens when preparation meets opportunity.”

~Seneca

I love the NCAA tournament. Every year there is a team who goes further than predicted. I join a poll every year and every year I am high on a team that gets knocked out early. When the brackets come out, all of the analysts put in their 2 cents. Dicky V always has an opinion. "It's march madness baby."

Every year there are teams on the bubble. The "at large" bids are the big question. Which bubble team should be in the tournament? Each year there is a team that has an argument. This year it is Arizona State who missed out while the team they beat twice, Arizona, made it. Dayton may have an argument as well. For the tournament committee, it can't be easy.

Tomorrow is known as Black Monday. The day that all resident applicants find out if they matched or did not match. I remember this day well. I previously posted about how the process had affected me. Black Monday reminds me of tournament Sunday. Teams on the bubble sit waiting to hear if they are in the tournament.

To all of you in the match, good luck.

“Serendipity. Look for something, find something else, and realize that what you've found is more suited to your needs than what you thought you were looking for.”

~Lawrence Block

I wish I had this much courage ....

“Whatever course you decide upon, there is always someone to tell you that you are wrong. There are always difficulties arising which tempt you to believe that your critics are right. To map out a course of action and follow it to an end requires courage.”

~Ralph Waldo Emerson

I was catching up on my blog reading and I ran across a note on Over My Med Body. It congratulated Cheri Blauwet for winning the LA Marathon. So, I check out her site. All I could say was WOW. She is a superstar amongst stars and a inspiration to all. Cheri good luck in Beijing.

"Only as a warrior can one withstand the path of knowledge. A warrior cannot complain or regret anything. His life is an endless challenge, and challenges cannot possibly be good or bad. Challenges are simply challenges."

~Carlos Castaneda

There'll be no shelter here ...

"They who have put out the people's eyes, reproach them of their blindness."
~ John Milton

...
I need to watch things die
From a good safe distance
Vicariously, I
Live while the whole world dies
You all feel the same so
Why can't we just admit it?
...

Vicarious
TOOL

I remember when it began. At the time, it was a novel thought. I don't know if MTV knew it at the time, but The Real World was ground breaking. It opened a whole new genre, entertaining through others' fortunes or misfortunes. For Generation Y, this has always been a part of their lives. Caricatured lives placed in the open for all to see. Computers and the Internet have perpetuated our desire to create worlds for make believe lives. Avatars are created; caricatures of our inner selves. Social networking sites explode. We don't call any more, just text. In this make believe world, we can live our fantasy lives and project our opinions in a forum with little anxiety, fear, or regulation. For those who felt they had something worth being heard, they took to blogging.

When I began blogging, I wasn't sure what to expect. What I found was that it was a wonderful community of people with different opinions on any number of topics. For many of the anonymous posters, it is a world where their voices could be heard. Like the wild west, it is an unstructured platform where opinions can be made, discussed, and debated without fear of repercussion. This community has its own set of rules. For many of the medical students and residents, it is their venue. They grew up here. From Myspace to Facebook to Twitter, their lives and ideas have been free form on the Internet. In this brave new world, I am a learner.

...
Hospitals not profit full
The market bull's got pockets full
To advertise some hip disguise
View the world from American eyes
Tha poor adore keep feeding for more
Tha thin line between entertainment and war
fix the need, develop the taste
Buy their products or get laid to waste
Coca-Cola was back in our veins in Saigon
And Rambo too, we got a dope pair of Nikes on
Godzilla pure m@#*&fu%@n' filler
Get your eyes off the real killer

Cinema, simulated life, ill drama
Fourth reich culture, Americana
Chained to the dream they got you searchin for
Tha thin line between entertainment and war
...

There'll Be No Shelter Here
~Rage Against The Machine

In terms of technology and popular information, the medical community is generally behind the times. Caught up in our world of IV's and Ambu bags, we lose perspective on the real world. We teach the youth of America, yet we have no perspective on what is important in their world. Our eyes open only when topics are discussed in the media or cause a direct effect on us (the medical community). We are naive on many issues and undereducated outside of our world.

Change and the unknown create fear. Blogging and social networking is an uncontrolled medium. A venue where opinions can be voiced anonymously open forum. The paranoid mind says this medium will be used to slander the institution or organization and must be regulated. Although universities claim to welcome differences, there are policies that prevent true open discussion of all opposing views. In the Ivory Towers of academic medicine, popular ideas flourish. We feign tolerance. Unpopular thoughts are discounted and discarded. Hierarchy and politics rule. In this atmosphere, subordinates believe they lack the power to question. In an open forum, would I voice my opinions to a superior? As a subordinate, where is my platform?

Born with insight and a raised fist
A witness to the slit wrist, thats with
As we move into 92
Still in a room without a view
Ya got to know
Ya got to know
That when I say go, go, go
Amp up and amplify
Defy
I'm a brother with a furious mind
Action must be taken
We don't need the key
Well break in

Something must be done
About vengeance, a badge and a gun
cause I'll rip the mike, rip the stage, rip the system
I was born to rage against 'em

Fist in ya face, in the place
And I'll drop the style clearly
Know your enemy...know your enemy!

Yeah!

Hey yo, and d!$k with this...uggh!
Word is born
Fight the war, f@!k the norm
Now I got no patience
So sick of complacence
With the d the e the f the I the a the n the c the e
Mind of a revolutionary
So clear the lane
The finger to the land of the chains
What? the land of the free?
Whoever told you that is your enemy?
...

Know You Enemy
~Rage Against The Machine