The 12 Days of Trauma

Inside the hospital, the only sign of the season comes in the form of festive bake sales, the occasional floor decorations, and maybe the occasional Christmas music in the OR. For those on the trauma service, winter is most welcome because it marks a decrease in the number of traumas. Unfortunately, people will drop by for a visit. During my trauma rotation I have experienced the following:

Black people shootings.
Old people falling (while hopped up on coumadin)
Young women motor vehicles colliding (into trees, other cars, +/- intoxication)
Many bones fracturing
Much rectal examining
And healthy dose of X-ray/CT imaging.

General Surgery

Having wrapped up the general surgery portion of my surgery rotation, I'm pretty glad that I had decided to not join any fantasy basketball leagues this year. Having been an avid fan since junior high, I decided last year to start playing again when a family member enticed me to join his uber-competitive cash-incentive laden league. I won that league, marking a successful comeback from my three year hiatus from fantasy sports. This year, however, I didn't think I'd have the time to really invest as I would like so I had to painfully decline the couple invitations this year.

These days, I find myself myself jumping on my computer to check on how my patients are doing. Instead of points, rebounds, and assists, I'm looking at vitals, progress notes, test results. Admittedly, these aren't the most exciting stats especially since we're not really shooting for extremes. Still, I'd like to think there's a certain head to head match up going on with death or even just surgical complications.

So every night I watch in anticipation and the following morning, I go see the results first hand. I realize it's probably not the wisest thing to compare patient care with fantasy sports, but the more I think about it, there's probably a good number of similarities that could be made. That's another post for another time.

Three things

One of the surgeons came up to me today and told me that I needed to learn three new things about every surgery I attended so that by the end of the rotation, I would have accumulated a nice fund of information from which to draw.

Today, I had only one surgery--the ventral/umbilical/incisional hernia repair. This is what I learned.

1. Repair necessitates cutting through the falciform ligament
2. Mesh should have at least 5 cm around the hole to ensure stability
3. Suturing the fascia to the mesh helps with stability and hematoma development.

I also present three things from the OR discussion relating to the implementation of new CT scans/pat downs in airports and the needless radiation exposure/invasion of privacy that this will generate.

Surgeon: I shouldn't have to subject my children to this (pat downs) just because I don't want to expose them needlessly to radiation.
OR nurse: If it wasn't the government doing this, these would qualify for sexual abuse.

OR nurse: I'll take the pat-downs over the X-ray any day. Heck, I'll even do it twice.
Scrub tech: Yeah, and while she's getting them, she'll probably forget why she's even getting them in the first place.
OR nurse: Everything I've learned I owe to you.

Nurse: my (Caucasian) friend recently got patted down at the airport while a 25-year old fellow Arab passenger got through untouched.
Indian Doctor: In that case, I'll be expecting my rectal exam when I go through one of those lines.
Nurse: Yeah, you'll be like, "Hey, that's not your hand..."

Thursday morning cancer conference

It was the weekly cancer conference, and it was optional. Yes, his attending would be presenting a couple cases, but this short white coat had long grown tired of playing this game of impressing his superiors. But, he went anyway. Come to think of it, he probably only went because he was chasing an interest that he really didn’t have—and, on a deeper level, a calling he could never fully embrace.
The first case presented sounded familiar: Adenocarcinoma of the lung. Brain metastasis. Post-radiation treatment VATS pneumonectomy. PFTs had checked out pre-operatively. Patient recovered relatively well. Residual ataxia from the neurological deficits.

This was unfortunate because he painted houses. How would he make a living for himself if he could not stand on a ladder? The cardiothoracic surgeon wasn’t sure. His shoulders shrugged with a hint of sadness and sympathy. This was the story that was often left untold when a patient left the hospital—even if the surgery was a clinical success.

The painter had a name, and the short white coat sat there scrolling through the list of patients he had been generating over the last three weeks. All he remembered was watching the surgeons pull his diseased lung out between the ribs, and the painter’s face the day he was discharged to go home. He remembered that the painter had voiced concern about his job, but despite all this, the name eluded him.

He played the harmonica. He had brought in his harmonica that last day to see if he could still play it after the surgery. Indeed, he had found that he could. So strange; this was all he could remember. He played the harmonica.

The purpose of the conference was to provide a venue for oncologists, pathologists, and surgeons to discuss treatment plans, to collaborate so that future patients could be better served. At the same time, these conferences became a place to commemorate those that had passed through their care. Because for every 55 year old with adenocarcinoma of the lung and brain mets, there was a painter who painted no more—a painter who was recovering at home and playing his harmonica.

Fences and Elbow Room

Today while waiting for a cholecystectomy, my team of one attending, two residents, and two medical students sat in the physician's lounge chatting about various subjects. My attending raised the issue of how everyone in his affluent neighborhood was putting up fences around their yards. It was silly, my attending bemused, how our relationships with our neighbors were becoming increasingly defined by such a strict sense of privacy.

Sometime later in the conversation, my attending went on to share this story.

"So I took my kids to Disneyland and my son was all up in people's butts the whole time. I had to finally pull him aside and tell him that part of what defines Americans is how we want our elbow room," He propped his elbows up accordingly to show how he symbolically demonstrated to his young toddler the concept of privacy.

"And," he continued, "for the rest of our time there, my son was walking around with his elbows like this," he repeated the gesture a second time.

Thinking back to this conversation, I realize that the hospital is the exact antithesis of the coveted privacy that Americans pursue. Here, a patient is stripped down to their most basic needs (pain, passing flatus, urinating, ambulating, and appetite). In order to receive help, he must be examined, poked, prodded, cut open, and assisted in rudimentary clothing (the hospital gown) by strangers not of the patient's choosing. He is furthermore forced to trust strangers with their most intimate details (sexual history and social history) with really no way to ensure that their confidentiality will be preserved (nurse gossip anyone?). This is both uncomfortably alarming and yet intrinsically necessary to the current health care process (because even the nurse gossip becomes a way to preserve the sanity of the participating parties).

If people were willing to subject themselves to such treatment for the sake of personal health, how different our society would be if we were willing to place ourselves in similarly compromising situations for the sake of our fellow man?

The Bubble Boy

He showed up to his first day of perinatology not sure of what to expect. He was typing notes at a work station when his eyes met those of the attending to which he was assigned for the week.

"Are you with us this week?"
He nodded his head.
"Come along, then," the doctor said gesturing in a somewhat inviting somewhat melodramatic fashion.

And so, just like Jesus called his disciples, the slightly bewildered med student pended his note and followed his attending for the morning rounds. They were soon joined by a resident, a couple nurses, and a nursing graduate student. The rounds started off as benign as any other. Patients were seen, pleasantries were exchanged, and they moved on to the next room. Rounds went quickly with little explanation of the problems and little discussion. This was expected from this attending so the medical student thought nothing of it.

Throughout the day, the attending talked with pretty much everyone in his path. He treated patients kindly, cracked dry jokes from time to time, and went out of his way to try to make sure the nursing student would be able to do the things she needed to do for her schooling.

To the medical student, he said very little, and there was no harm in this in and of itself, but when a group of them would be in a room shooting the breeze waiting for the next patient, it became evident that the attending had very little to say to the medical student. The student in the short white coat thought this to be rather strange for someone who was so cordial to everyone else, and wondered if he had done something to offend the doctor, but could not think of a single interaction that had lasted long enough to even warrant taking offense.

And this continued throughout the rest of the week. The MS3 became increasingly annoyed with the indifference, and found his attending's behavior, in some ways, to be childish. He became annoyed with the whole system of large universities making heaping sums off indebted students for a training that often exposed them to "volunteer" faculty who simply didn't care to teach And, of course, much of these loans were government-sponsored. In some ways, it was a circle of futility. No one person could be singled out and yet everyone was at fault.

and so the week dragged on. Patients were followed, discharged, and admitted. It was a daily grind on the floors with nurses, physicians, even maintenance people, scurrying about, and somewhere, amid the routine of the hospital machine, a single medical student found himself lost within a world of progress notes, shelf exams, and meaningless rounds that went on as if that short white coat was but a ghost of the imagination.

Matthew 26:6-13

And it came to pass that a doctor was on duty at the charity clinic sitting in the office talking with her colleagues when they were interrupted by a nurse

“Doctor, there is a patient here to see you.”
“Oh?”
“Yes, she is in the front right now.”

So the resident left the room and came back several minutes later bearing a fruit basket and a bag of cupcakes.

“Look, the patient I delivered a week ago remembered my birthday and came by with these. Aren’t they beautiful? I feel bad because these are so nice and she shouldn’t have spent money on me like this.”
“Aww, how sweet,” another one of her fellow physicians commented.
“Yeah, and she also had brought me cake and cookies when I delivered her in the hospital. She really shouldn’t have.”
“That’s a nice gesture indeed,” their attending remarked, “Those fruit baskets are really expensive. She probably shouldn’t have even bothered.”

This last physician said this because he knew that this patient had a couple of other children to support and received monthly public aid checks--the same checks that paid for her expensive new cell phone, cigarettes, and the oral contraceptives that enabled her to carouse around with whomever, whenever. Such purchases often left the patient unable to pay her cell phone bill, which prevented the physicians from being able to contact her and follow up during her prenatal care. This was troublesome because her baby had a condition that needed consistent monitoring to ensure that it did not get worse. Of course, all of this was made possible by taxing other economically-burdened citizens who were struggling to make ends meet on a daily basis.

One of the nurses came in to the room.

“Wasn’t she sweet? She even brought cupcakes for the nursing staff. You know, it’s people like this that really uplift our spirits because so many of the people in this clinic just aren’t very grateful.”

And all of them could agree on this. Gratitude was a scarce commodity in the charity clinic. One would think that those without any health insurance would be extremely grateful for the services they received at no cost, but the reality of this situation was that many of them were non-compliant, refused to make lifestyle changes, and would simply come back with a sense of entitlement that would make even the most sympathetic health care provider shudder.

Despite this sobering reality, this was still a day to celebrate and be thankful. The doctor asked one of her colleagues if she wanted to split a cupcake and the other happily obliged.

The efficiency of social medicine

Yesterday I spent time at the free clinic that the ob-gyn residents run for indigenous patients. The last patient we saw that day was a post-menopausal elderly woman who presented with chronic cystocele and rectocele issues. This patient had already had significant spinal surgeries in the past and was wary of the complications involved in the post-surgical healing process. My resident showed a remarkable amount of tact over discussing the option of surgery. From a physician point of view, it's easy to take such delicate matters lightly when discussing patient options. It would be nice to believe that the decision is a simple yes or no decision or as medical people like to put it, "a matter of doing what's best for you," but the cost of surgery is more than a financial one; it is also an emotional and social one as well. Several times over the interview, my resident repeated herself to the patient regarding treatment options and quality of life issues. On one hand, this took more time, but on the other hand, I believe it also played a role in helping the patient make her decision. In the end, the patient still had to weigh her options.

Today, I went to see an ophthalmologist in town to discuss possible cataract surgery. The group here in town has a cushy facility that is a stark contrast to the clinic I spent time in the day before. The place was packed with the elderly. Having had to deal with congenital cataracts growing up, this was an all too familiar setting.

Somewhere in the large waiting room, an elderly lady voice asked a nurse,"Excuse me ma'm. Did they forget about me?"

As I ran through the litany of eye exams--the measurements, the letter charts, the dilation drops--I became increasingly impatient over the whole process. These were the things I had gone through my entire life, but over the past couple years, my failing eye sight had become a bit of sore topic whenever it came up among my classmates who really never understood quite what I was going through. "You really should get those checked out," they would say, or "I think you need glasses or something." These were the words of future physicians of the future. Beware of such "sympathies."

The ophthalmologist was a middle-aged male physician. A brief greeting without the handshake tipped me off that he might have been in a hurry, and as the interview progressed it became even more apparent that he was probably thinking more about the long line of people in the waiting room. He took a look at my eyes and asked me the purpose of this meeting. i told him my concerns and he presented with the surgical options. Somewhere in the conversation, the "doing what's best for you" cliche came out. When I had concerns about scheduling and financing, he referred me to his nurses. When I asked him about recent studies over new lens implants, he said they were "very good." As the conversation progressed, I began to feel hurried in my questions and concerns and increasingly irritated as well. I found myself repeating similar concerns because I sensed a growing anxiety within myself, but the hurried doctor sensed none of this. The interview ended with him getting up before me and having his nurse guide me out the door.

The moment a physician begins to feel or act hurried, regardless of how behind he or she is, you lose the essence of what it means to be a physician. What you essentially tell a patient through your body language or lack of explanation is that your time and comfort is more important than their well-being. Emotions are messy; they are, by definition, inefficient. They do not fit in your 15 minute blocks that a physician constructs in his or her schedule. I have little sympathy for doctors that take on heavy schedules to make more money at the cost of quality of patient interaction, especially in a private practice setting.

Driving home, I realized two things. One, I was going to find another one of his partners to do the surgery. Two, if I ever became a physician, I hoped that I would never conduct myself in such a manner. I understand stress makes people do things they might not normally do, but the doctor left a sour taste in my mouth. It's encounters such as the one I had today that make me even more cynical about the medical profession. Fortunately, for every doc like this one, I have had the chance to be with others, such as the ob-gyn resident, who demonstrate the ideals that I struggle to hold to as I continue in my medical training.

Marginal Zone Lymphoma with Recurring Abscess

This past Monday I met a marginal zone lymphoma patient and his wife. He had long grey hair that looked like it had seen better days and suspenders that one might find on the old college professor. The first question he asked after my attending introduced me was “So where are you from?”

Here in Central Illinois, my ethnicity is a conversation starter for the predominantly white population. Thanks to desensitization, my hairs no long bristle at the broaching of this topic.

Quickly understanding the question’s intent, I skipped the “Chicago suburb” formality and answered, “My parents are from Taiwan.”
“Oh.” he says, “The reason why I ask is because 12-14 of my students are Chinese. I teach piano.” And as he said this, his long, sinewy fingers played the invisible Steinway as fluidly as one could imagine possible.

The bulk of the appointment dealt with a persistent abscess that had developed in his right lung unrelated to the cancer. Though his cancer had remitted, this pulmonary lesion periodically forced him out of commission. We talked about the limited nature of antibiotics and the possibility of surgery. Our patient obviously hated how his illness forced him to cancel teaching. He pointed to his suspenders as evidence of the amount of weight he had lost over the last year.

On their way out, I felt compelled to speak with our patient again. I asked him what type of piano he taught. “Classical,” he answered. “I used to teach at universities.” When I asked him where, his wife quickly chimed it “He graduated from Julliard.” Her voice dripped with the kind of pride that remembers a spouse’s greatest moments.

I briefly told them about my musical background, and how I had a piano teacher who passed away from cancer. Before I could explain to him just how much she had meant to me, I had already begun to recall the bittersweet memories of our final lessons together. Even as the couple walked away, I could feel my dry hands chapped from freshman year gymnastics—because it always started with the hands—and those frustrated admonishments for not putting in the necessary practice. I could hear her pleading yet stern hoarse voice telling me that I needed to stop wasting both her and my time. I remember being at my sister’s condo on Michigan Ave. when I found out that she had passed, and I remember attending her funeral at her suburban Lutheran church, my back pressed up against the brick wall in the rear listening to her son uncontrollably weep in the middle of his testimony.

But of course you can’t tell all of this to a patient because life must go on (and lest we forget, the insurance companies will certainly remind us). As we age, we learn to be content with vignettes—if we’re lucky short stories—from each individual that steps through the door. Our fellow man, therefore, gives us snapshots by which we extrapolate the past, and we, in turn, are endowed with a memory through which we begin to move forward in the present.

And for a moment I found myself speechless, wishing that time would stop and let me ponder all of this further. Unfortunately, time halts for no one, and as we began to move on to the next patient of the afternoon, I gave thanks for the people that imbue our lives with meaning

the shrink's office

Perhaps the most depressing part about a psychiatrist's office is that it has become a medical McDonald's serving medication. The time constraints compounded by the medical profession's inherent inability to deal with social problems makes this one of the saddest places to visit. Psychiatry has essentially reduced human suffering to the brain because it is much easier to throw medication at the brain than it is to deal with the complexity of people's lives. The most insidious part of all of this is that patients and physicians alike come to believe in the power of medication.

I try not to be so pessimistic about this but this is what psychiatry has become. You can speak of genetic predispositions, chemical imbalances, or even the glory of psycho- and behavior cognitive therapy but in the end, you are still dealing with a spiritual creature. Psychiatry categorizes disorders with nice lists. Meet 5 of 8 of these conditions for 6 months and you have this episode or that personality disorder. People were never meant to be viewed in this manner. But, psychiatry protests and fights back. It tries to defend its validity with more diagnostic criteria, more brain studies, and more drug trials that show "progress." It kicks and screams while its progeny stare back with their flat, constricted, ghost-like affect.

"home"

I went back up to Chicago this past weekend to spend time with other people's families. One of my high school buddies has to move back to the burbs this weekend to take care of his sick mother. Ironically, his dad and two older brothers are all doctors/doctors in training but for various reasons are unable to be home that weekend. So, my friend, the high school English teacher, was ironically the only one that was able to make it home to fulfill his filial duties. I am thankful that I don't need much to be amused and so I have no problem catching up over running errands for his mom, ping-pong wars, and even the obligatory basement poker night with high school acquaintances. In addition to playing many games of rummy with his mom to help keep her mind off her illness, we even have time to scurry downtown to play some ball with his city friends, which turns out to be an excellent opportunity to remind myself of the extent of my physical decline. Yes, it is 90+ and humid but even I can't blame that for the tightness I feel in my hamstrings.

The next stop this weekend was at my college roommate's parent's house in Naperville, IL. The reason why I am here instead of his place in the city is another family matter--his seven year old cousin from India needs baby-sitting. I am able to spend time not only with my college buddy but also get to see his younger brother and girlfriend who are here for the summer. Not that my friend anticipates having children any time soon, but watching him and his girlfriend take turns reprimanding, teaching, and playing with him gives me that eerie feeling of how fast time has flown by--and as if I didn't need any more reminders, my college buddy's younger brother is going to college next year.

Third stop takes me about 15 minutes south to my another friend's parent's place to meet more college-bound siblings and another girlfriend/fiance. Dave's family has always been pretty fun to hang out with, but at this point of the weekend, this theme of family (and the absence of my own) is starting to gnaw at me. It's hard to precisely define the exact feeling, but even if I am the type that is always trying to not get boxed into a specific category or group, growing up these last couple years has precipitated a sense of isolation that has caused me to yearn for familiarity and withdraw from initial discomfort of new experiences.

Last stop is to see my nephew and niece. I find myself almost envying their ability to play all day with few worries. Watching them grow up gives me the ultimate sense that time passes quickly My nephew is beginning to cry when it's time for people to leave. He hugs my leg repeatedly and I have to stop my own tears as I turn to leave to drive back to Peoria. I hate to say it but I'm not enthralled about third year--perhaps this is why weekends like this one are so bittersweet.

A book opens itself as much as it is read

As a mentioned in my last post, the phlebotomist at the clinic I spent time at was a memorable character. To me, she was a hidden story tucked away in a room between the kitchen and the area where patients were seen--a quiet yet bubbly woman who waddled in and out to get her blood draws. She would spend her free moments burying herself in a novel or knitting a pillowcases as wedding gifts for friends. Whenever I came by, I would trade pictures of my nephews and niece for her children. She always had stories to tell, beginning them as if they were a continuation of a previous conversation. What always struck me was how surprisingly detailed her succinct stories always seemed. Perhaps it was my vivid imagination that gave pictures to her words--images not drawn from prior experiences but perhaps conjured from a separate life that had merged with a collective conscience.

One story that struck me in particular was one that she shared about her mother when she passed away. She and her sister had decided to live with her mom during those last weeks trying all the while to hold themselves together emotionally. Alcohol was as as abundant as the grief. Mom used to bake pastries and pies all the time for the family, it became a family tradition of sorts. So during those last days, the two daughters baked pies for mom and when alone drank in the melancholy of the moment.

When I hear stories like this, my somber soul insists that somewhere therein lies a serenity that supersedes sadness. I can't quite grasp how this is logically possible, but if sacrifice can surrender to salvation, then something about this must be true.

Perception of Competency

During my M1 year, I shadowed a local rheumatologist in the area. She was pretty good at explaining concepts, most of which I wouldn't learn until my second year. I remember talking to her secretary and how she said that this doctor could have done anything she wanted: surgery, other medicine specialties...she was that good. Based on what I saw and heard from my personal conversations with her, I could believe it.

This past year I was able to spend some time in clinic with one of the FPs here in town. He worked at the federal clinic, and though I spent most of my time with my preceptor, I also had the chance to talk to the staff around the office. During my first week in clinic, the phlebotomist (who actually let me stick her because I needed practice drawing blood) remarked that "nothing seemed to faze him." Throughout my three weeks in clinic, however, I couldn't shake the feeling that there were many times where he wasn't sure what to do with certain patients or when I had questions, he didn't have an answer. To be fair, perhaps some of these questions were more geared towards specialists (I mean this is why they have extra training, right?) or the patient he had was indeed a difficult case. I could think of a plethora of variables to consider (town vs. gown, indigenous population, etc.) but the bottom line is that I began to realize that just like any other profession, there exists a wide range of competency when it comes to medicine.

I think this fact disturbed more because, to me, this seemed to insinuate that there are doctors out there who might be better off not practicing. I think about my own classmates and I see a wide range of ambition, competence, and motivation. I look at myself these past years and wonder where along this spectrum I will fall. I sometimes think that if people knew where doctors came from, we wouldn't be nearly as trusting of the medical profession as we are.

The second thought about all of this was the different levels at which people view their doctors. The FP had plenty of patients that had been with him for a long time and loved the guy. Certainly, this not only suggested that he was helping people medically, but that they saw something either about his personality or professional demeanor that led them to believe that he was doing a satisfactory job. The phlebotomist felt like the physician was always on top of things or at least in control. I, on the other hand, saw things differently.

the problem with blogging

I remember the first time I started this whole online "journal" thing it was like I found the golden ticket to meaningful mind dumping. Unfortunately, I soon realized that like most forms of electronic correspondence, this can easily translate to babble or really. bad. writing.

In addition to general negligence, I think part of my reluctance to write here is the ever present anxiety that comes with being vulnerable to an unknown audience. Context is so crucial when writing about anything meaningful that it can be the difference between generating incendiary remarks and constructive dialogue. I had a wake-up call a couple summers ago when one of my former co-workers said that my summer job boss came across one of my blog entries about my work experience. Of course, it was pretty much a harmless, feel-good post at the time but it has made me much more wary of the type of things that I talk about.

Still, in weighing the pros and cons of spilling out details of my life on the internets, I have decided that I would like to make a more concerted effort in keeping this thing going. This doesn't necessarily mean I'll be posting about that girl that I'm currently dating (because if I did, it would be, among other things, a total fabrication at this point) or like a twitter account.

Another reason for starting anew is that I will most certainly always find myself behind when it comes to corresponding to people individually (email, phone calls, etc). For those of you to who are waiting (or have given up on reaching me), my lack of responses have been due in part to a paucity of words these last few months. I find that especially this past year, written words are hard to come by. I won't blame school on this one but there is something about a style of learning that embraces study books and bullet point memorization that has squashed my expressiveness. Even when I journal on occasion, mind dumping comes at a much reduced flow rate and with much higher resistance--a "literary constipation" if you will.

So where to begin? I have finished my second year of medical school and am preparing for national examinations on the 24th. I won't bore you with all the details, but I have lost count of how many times I have asked myself if medicine is really for me. School starts almost immediately after boards and as of now, I am giving myself another year before taking any drastic action.

I have occasionally found myself at church on Sunday mornings, but usually sneaking out pretty soon after. It's been a unique experience for me in terms of the interactions I've had with the people there. The church is small enough that everyone is aware of me, but I think three of them actually have spoken to me or know my name. I recall the weekend of Palm Sunday where they were handing out palms during the last song of the service and one of the ushers got to my row with the palms (I was the only one in that row), stared at me somewhat awkwardly, and then moved on to the next row. The couple in front me of me actually got a palm for me, but looking back, I think this epitomized the type of detached relationship I've had with this congregation. Considering that the church is so small, I'm sure I am known as "that Asian guy that sporadically shows up."

hello, there, still in Peoria...quite so.

I've been admittedly poor about updating this thing and I'm not sure who still reads this. This will probably be the easiest medium to write to the largest number of people, and since I've come to realize that my one email to one person ratio is becoming increasingly impossible, I'll have to settle for this. Hey, at least I haven't settled for constant one liners on Facebook.

Concerning this whole keeping in touch thing, I've realized that the combination of my introversion with the excuse called school has provided a ripe environment for scarce updates. I'll do what I can in the next few months leading up to boards (another wonderful excuse) and see how it goes.

I just had my History OSCE this morning which is an examination of our history taking skills. Aside from running out of time at one of the stations (I didn't get a chance to take the woman's temperature), I was able to get through each patient with varying degrees of accuracy. I realized sometime in the last few days that it will be difficult for me to really polish any sort of bedside manner until I've become comfortable enough with the basic skills involved in history/physical exams. I find that I either spend too much time trying to be friendly that I overlook certain details or that I become too business like to really crack a smile of some sort. And, I'm okay with that for now, because, I need to get good good at figuring out what's going on with the patient before trying to show them what an awesome person I am.

Second year has been admittedly difficult in terms of learning large amounts of material. Part of that is discipline, and part of it is trying to figure what's really important. I've been fortunate to have some friends here without whose help I could be really struggling--even more than I am now. I these last few years have taught me anything, it's that I've become more comfortable finding help.

I'm currently waiting to find out where I'll be doing 3rd year. I signed up to do my rotations in a rural community somewhere in Illinois. The pros are that I would have a specific preceptor who i work with (Family Med) on a day in day out basis, and that I would get a lot more hands on learning which I am finding is much more effective for me. I'm even finding that my most effective learning this year has come from discussing topics with friends and that my efficiency from reading has quite literally gone down the tubes (scary).

At the same time, I am also wary of moving to an even smaller town especially since my time in Peoria has been a mix of both lonely at times and busy. Of course if I got to know the people there and found a niche, it could be great. Many possibilities. I'm supposed to hear back about whether there will be enough spots to do this next year. Either way, I've come to a certain degree of peace about the whole situation, even if I can't completely understand it.

I'm thinking primary care, but am also interested in medicine. There is a part of me that thinks that I would need to work even harder if I were to go into primary care precisely because it is the gateway from which all referrals are made. Specialists (at least in medicine) seem to have a more focused spectrum of topics to deal with. This kind of makes things exciting, but given my ability to grasp material this year, it's also intimidating. As for surgery, I'll just wait till next year.

It goes without saying but I miss the familiar faces whether it's family or old friends. I know that it becomes harder to really get to know people as one gets older. I am not in any hurry to date anyone but I acknowledge the perks of having a lifelong companion. I realize that there's still so much to learn when it comes people and that I have a tendency to want to fit people into stereotypes not simply because it simplify things, but because somehow it becomes a sort of stabilizing pillar in my attempt to make sense of the world around me. With my parents in California and one of my sisters soon to be moving to Hong Kong for a couple years, I have been increasingly aware of my solitude (even if it is only a perceived one) and no doubt that this has contributed to this loneliness.

As for my faith in God, that continues to be a sort of mystery. I wish things could be much simpler in this regard. If it is not possible to straddle the fence, then i do not know where I am. I am well aware of my own limitations, as well as other peoples limitation, and I know that I can never fully depend either on own strength nor on the infallibility of otehrs. If God is that stabilizing force (and much more I presume), then I can only trust that he will find me in all of this.