Can Being the Best of the Best Make Us Collectively the Worst? The happy medium in diversity, unity, and empathy.

Imagine a class where someone educated you in the ways of socially appropriate action, emotional intelligence even.  A course constructed in a Socratic fashion, public forum question and response format whereby the prompt is usually always something along the lines of "A patient presents with xyz health concern confounded by xyz social and environmental factors, all muddled amongst this xyz moral dilemma woven into this vignette. As a provider, you use your ethically sound judgment to consider a solution that will simultaneously CYA and also be impressively upstanding

Do you:

A)Choose the distracter answer because you weren't paying attention to the entire last 50 minutes

B)Choose choice B, because it isn't choice A and you really don't care

C)Choose C, which uses recognizable words from the lecture and seems neither radical nor vague

D)Choose D, which has carefully crafted semantics with an emphasis on one word that renders the answer  technically invalid but is appealing nonetheless

And such is the redundancy of Medical Ethics and Law, which is not so much boring just because of the subject material and of little fault of the instructor, but maybe because we think we all just know better. 

We shouldn't have to hear this, be subjected to the make-believe gravity of a hypothetical situation of ignoring patient autonomy in this vignette about a ventilator and Health Agents and etc, because of course we would do the right thing.  Of course we are above the obvious flaws of inattentiveness, or negligence, or carelessness.  Of course we would, when put in a situation that is more than about being a good diagnostician or shot-giver or band-aid applier, use both common sense and emotional acuity and of course we would never make a novice mistake like not consider a patient's rights or blow off their caregiver or make an insensitive joke because they don't speak English and just like we suspected, aren't compliant with their Metformin and are huge and now borderline comatose. Of course, we are better than that.

But sometimes, amidst the groans and eye rolls and gossip and general apathy that will invariably come with classroom boredom, the drone of laptop typing and neurotic Facebook skimming and the creeping depression that seems to coincide with shorter days and colder weather and a nostalgia for summer,  I have to wonder if we are as emotionally, empathetically aware as we staunchly claim to be.  If we are as 'of course' as we'd like to think.

And while I don't doubt the selflessness and capacity to give that we all have to work as future physicians, those whose lives and decision-making revolves around their patients, I think we often are guilty of forgetting.  I am; I have forgotten many times that I have chosen a profession that is not always all about me. 

Think about what people say, or said, when you told them you were going to medical school.  Put aside, for a moment, the initial shock or even expectation, and consider the things you were told, verbally, would happen to you.  For the most part it was optimism and excitatory support (for my mom and grandma, probably a huge sigh of "thank god, she has a future beyond street performance and painting"), but you would be hard-pressed to find a matriculate that didn't say they weren't warned about how hard it would be, about the trials of exams and late nights and lack of sleep and miscellaneous debbie-downer-word-of-wisdom doled before they packed their bags for their 4 year journey.   And yea, so much of that is true!  I do stay up late, I do take exams (and hopefully pass them), it is hard, and it should be, and I don't sleep very much, unless it's an accident.

But always implied with those ubiquitous debbie-downerisms was the expectation that this was something of a bold sacrifice, an acknowledgement of accomplishment but also one of understated heroism: you, Chosen and Accepted, one who bears great weight of academia and endures the cold hard winter of caffeine and perpetual standardized testing all for the selfless fee of 250,000 dollars.  For a moment, you are recognized and reaffirmed that what you are doing is not at all about you, because it honestly sounds more sadistic than it does a fun new adventure, so you must, you have to, truly want this for some higher purpose than just the social recognition, the embroidered credentials on a white coat. Right?

But consider this. You've made it in, you are part of the crème de la crème, walking and learning amongst the finest and brightest from the land, collaborating and supporting one another in a 200-person sized medical paradise, compelled by the competitive atmosphere but all looking in the same direction toward the same selfless goal: to work for the betterment of the health of our communities, to advance in science and education and technology.  Of course.

And for all of those virtues and necessary benevolence that got you here in the first place, no one is immune from gossip, jealousy, pride, or self-interest.  As a whole entity, medical students are intelligent and motivated, successful academically and to some degree, socially, at least according to our AACOMAS application or preliminary interview. But like anyone else, we are subject to the same baggage, frivolous drama, propagating or feeding into slander or whatever. We have physiologic and psychological urges like everyone else; we do what we want and say what we want without thinking of the repercussions.  Big surprise, this is nothing new.  Most certainly, we are not saints.  But what we easily forget is that although we don't wear the big hat yet, we do wear the short white coat.

To most people, this is the universal sign of medical gumshoe.  The bottom of the totem pole.  The all-too-clean, too-crisp, awkwardly boxy reminder that we don't know enough just yet; we are in practice, we are mistake-makers, and in a sense, the short white coat serves as your scapegoat, your loophole from too much reprimand and finger-wagging.

Underneath those short coats are hundreds of applicants, many of which are chosen specifically for being "statistical outliers,": not just the intellectually competent, but the non-traditional, second career applicant, the impressively devout and human rights activist, the insane prodigy published in nine journals, the Big Ten athlete whose medical school journey was an afterthought.

And this very eclectic social milieu, seemingly homogenous with a sea of short white coats, creates a bit of a dissonance from one another, I think. Just how interesting each of us is can be, in a sense, a conflict of interest. I would venture to say 99% of us want the same thing: to make a noticeable, if at the very least positive, contribution to healthcare, in whatever capacity of specialty speaks to you.

Of course.

But what is most interesting to me is how often we fall back on our personal vices, our status of "short coat" as an excuse for making our poor unprofessional behavior admissible. We maintain the perpetual student attitude of "not my fault, not my problem, not yet."   We insist that, of course, when we graduate, when the time is right, we would do the right thing.  Of course  we know that treating one another poorly, spreading unsubstantiated water-cooler talk is stupid and silly and of course, assuming the worst in people is only something we do transiently, we will forget all that when we have to work together. 

And you may argue, "So what if I hook up with nine of my classmates without concern for the feelings of my colleagues? So what if I don't do anything to stop cheating, so what if I don't put an end to inflammatory rumors.  So what if I notice someone who needs help, but don't necessarily do anything?" Of course, if this was the real world, if this was not merely school, if this was my hypothetical, vignette-crafted patient, of course, I would help them.

We are in a profession that is all about taking care of people, but sometimes, it startles me how very little we often take care of one another.  This is hard work.  It is hard to smile at someone you don't know when they look miserable, it is hard to abstain from deprecating comments about a classmate (maybe one day, your boss, your best friend, your best man),  when everyone else is.  It is hard to remember sometimes, that empathy is not a class, it's not an algorithm.  It should (and I believe it is), a basic tenet of your character.  But in a land of short white coats, where it is easy to deflect the blame to our inexperience or intellectual naiveté, we should always remember that crafting and working on our emotional intelligence is an active process.

October is Community Outreach month (I know I know, everything is a "Month" of Something), but I write this because it's hard to give people the benefit of the doubt sometimes, let alone reach out to them. The parallels between high school superficiality, click-like behavior, and other forms of emptiness can be striking with the attitudes we find in medical school. We are students, sure, and have been for what seems like forever.  But after we are done hiding behind our books and our laptops and our short white coats, after we are done with Tegrity and scrounging for empty classrooms like animals finding their dens, we are adults.  Technically, we have been adults for a long time now.  But we are human, we forget.

So in addition to being the empathetic, community-service driven pillars of society you can be, I challenge you to start locally.  Start by helping the person in the seat next to you.  Start today, because it might make all the difference to them tomorrow.   

But of course, you already knew that. 

Restless in RGU

We are, for the most part, very aware of the significance of the sun.  But sometimes, I think we take the moon for granted. 

For example: tidal motion.  The moon's gravitational forces are strong enough to disrupt the delicate balance of Earth's inward gravity and outward centifugal force, making the water of our ocean's swell and bulge.  As the moon orbits Earth and we rotate like we always do, it creates high and low tides, depending on our distance from the moon and this centrifugal force and moon's pull, justified by a bunch of math I won't bore you with and any surfer who will tell you why they get up at 4:45am.

In college, some of us rogue lap swimmers formed an open water swimming club.

It was banded by a few of us who swam Masters and Intramurals, but were tired of the confines of a pool and lane lines and passive-aggressive circle swimming.  I harp on my alma mater a lot for its superficiality, affluence and protective bubble of safety (the safest city in America!), lack of crime and any sort of miscreant behavior, a sterile, slightly naive and carefully delineated city of Irvine bred out of commercialism and technological growth and median incomes over 120k, but it doesn't mean that I didn't enjoy the 2.0 mile walk down the Orange County Newport Beach coast straight from campus.  

If there was one thing I enjoyed when I felt trapped or stagnant, it was the ocean.

When you're under water, it's like you are safer than anywhere else. You are immersed in a medium nearly 1000 times more dense than air; the protective effect of a being in a place with subtle but undeniable entrance requirements.  You cannot be in water if you don't know how to swim or you drown.  You can't submerge yourself if you cannot withstand a little hypoxia.  You cannot make forward progress if you have not learned how to effectively stroke, how to get from A to B in ways other than your bipedal default.

It's not a matter of a sense of elitism because you can swim, at least not for me.  It's a sense of security knowing that, when I am stressed or lost or cannot talk or think or engage or humor others, I can run to the ocean with bare minimum: a suit, a cap, maybe goggles, and my bare feet, and I just can run in and the waves hit your shins and your body locks up because this isn't the Gulf of Mexico and its freezing even in summer, and you can keep running until you finally just hold your breath and dive forward and then you are free, and all those problems are on the shore behind you, and they cannot necessarily catch up to you in that moment. 

It's a matter of knowing that you have to possess a basic knowledge of self-sustenance and survival and skill to go somewhere that others might be too afraid to go, and that reassures me that I will be happy, successful, even if I am not shattering world records or swimming to a finish line.  

In the water, you make changes.  You take up space: you matter, and you are also matter.  But in the same way that you do not change the Volume of the Ocean, you don't just dissolve into it.  You can be inconspicuous in the vastness but not dissolving, not becoming insignificant.

We are a little more than halfway through our Reproductive-Genitourinary-Ob/Gyn (lots of hyphens) course and I cannot lie: I do not enjoy this.  I just don't.  Am I a baby-hating lady?  Eh.  I am just disinterested.  Not everyone feels this way, so don't freak out if your prerogative and life dream was to be a smiling obstetrician with forceps and lollipops.  Like any course, some people are in heaven, but in RGU, I am not one of them.

I find this ironic, because my grades have never been better than they are now.  And believe me, I am trying to care.  You would hope that one's enthusiasm would mirror their numeric grade, but I suppose if that were true, I would have a 200% in OMM or 99% in GI.  But I don't feel a personal connection to RGU, no fire is lit underneath me, no zeal for mechanics of delivery, and even the pathology seems redundant (an area I normally get excited about-a game of "what cell is that?"  "What stain is that?").

As medical students, even as physicians, you're not supposed to become disenchanted so early.  "Supposed to."  But it happens; it would be unrealistic and negligible of me to mention otherwise and say that all subjects in school will be rainbows and Zebra cases with fascinating outcomes.

But I think it's something else too.  Something that gives me that urgency to find the ocean, the way that the Ocean seeks the Moon to make a tide, the way the water seek the shore to make a wave, to dive in and escape for a moment, to chase something with purpose. I'm not necessarily overwhelmed either.  I'm not behind, I'm not sick, I'm not (too) depressed and I'm not ungrateful.  I'm training for the Philadelphia Marathon, so I should be running, but all I want to do is be under the water, to be away without having to go too far, to be untouchable for a second, to be alone but not lonely.

And to balance some of this feeling of inadequacy (not necessarily personal, but an lack of fulfillment, so to speak), I've tried to be a little more involved in the community.  This isn't a shameless plug for a high-five or public commendation, but I put this here because I think it does, or has, helped me be a little less jaded.  It makes me feel less like the Moon beckoning a tide, needing something to respond to me to produce a tangible, visual effect, and more like the ocean water seeking a higher purpose, a reason to have motion and a goal.  In essence, to make it less about me, as 25 years of living have shown me that when we start thoughts or phrases with "I wish," "I want," "I need," or end them with "for me," "to me," it is deeply and perpetually unsatisfying.

And singing, running, in Pulmonics A Capella or PCOM Running Club with Philadelphia's Back on My Feet (a running club dedicated to ending homelessness through personal growth and setting goals), have filled some of the void that used to be gratified by diving headfirst into my ocean when I was confused or sad, when I wanted to think without being perturbed.

A lot of photobombing going on at PCOM Pulmonics A Capella volunteering (aka singing) at CASA's Superhero 5k.

No picture without a Justin cameo.

Pretending like 13.1 miles is nbd.

It's still a strange and sometimes disconcerting feeling to realize that, unlike much of my early adulthood, I cannot just pack up the car and change my plan and drive 400 miles from my problems, my disappointment with something that is then and there and somehow could be escaped if only I took my car to the highway and made it to San Francisco overnight and turned off my phone.  I can't really do that anymore; I cannot fly back to California the way people drive to their home in Hershey, I cannot book a trip to Toronto just because it is perfect and immaculate in my eyes and this is not.
I cannot just ignore things, because I am 25 years old and I can be selfish sometimes, but I have to be malleable and willing to adapt, not make my scenery adapt for me hoping it wipes the slate clean.

Maybe you have felt the same way.  Maybe you have felt like, you are doing the right things according to the Algorithm of Leading a Successful and Satisfying Life but they just don't fall into place, the margins are frayed and the puzzle doesn't complete itself so perfectly.  Maybe you feel like you always are travelling but not necessarily arriving.  And that is normal, that is ok.  But it's when you feel that way that you, aspiring medical student or new little doctor or whomever you are; that's when you have to decide if you let yourself drown in your ocean, if you don't want to try to make yourself look harder, seek harder, work harder, looking for your moon.  If you're going to feel sorry for yourself or if you're going to get up at 5:00am to hang out with that homeless woman who is more Gloria than she is homeless, if you're going to help your struggling friend in the Anatomy lab and see it as a burden or change, no-challenge- the way you think about helping people selflessly because it will make you BOTH better doctors.

This post was a little more allegorical than I would have liked, but the message is the same either way.  You cannot change where you are and you cannot change the pull of the Moon or the rotation of the Earth or the flares of the sun or the grade you got on that last test.  You cannot alter the tides merely by being in the ocean; you can't hide in the sea forever because eventually, you'll have to go back to the shore where everything you tried to neglect is obviously unmoved.

And I'll end on this note, an excerpt from David Foster Wallace's "This is Water," because frankly, I cannot say it any better.  So if you have skimmed this incredibly lengthy blog, at the very least, read this part. It is the most important.

'Worship power, you will end up feeling weak and afraid, and you will need ever more power over others to numb you to your own fear. Worship your intellect, being seen as smart, you will end up feeling stupid, a fraud, always on the verge of being found out. But the insidious thing about these forms of worship is not that they're evil or sinful, it's that they're unconscious. They are default settings.

They're the kind of worship you just gradually slip into, day after day, getting more and more selective about what you see and how you measure value without ever being fully aware that that's what you're doing.

And the so-called real world will not discourage you from operating on your default settings, because the so-called real world of men and money and power hums merrily along in a pool of fear and anger and frustration and craving and worship of self. Our own present culture has harnessed these forces in ways that have yielded extraordinary wealth and comfort and personal freedom. The freedom all to be lords of our tiny skull-sized kingdoms, alone at the centre of all creation. This kind of freedom has much to recommend it. But of course there are all different kinds of freedom, and the kind that is most precious you will not hear much talk about much in the great outside world of wanting and achieving.... The really important kind of freedom involves attention and awareness and discipline, and being able truly to care about other people and to sacrifice for them over and over in myriad petty, unsexy ways every day.

That is real freedom. That is being educated, and understanding how to think. The alternative is unconsciousness, the default setting, the rat race, the constant gnawing sense of having had, and lost, some infinite thing."