My Nuptuals are Impending...

...and it feels wonderful.

Many of you I'll see this weekend, for the wedding. Others I'll see later on, after we're back from a week in Vegas, baby!

One anticipated highlight: finding a cinema near the Strip, so we can see the new Indiana Jones.

See ya post-matrimony, everybody.

gsnlzzxhwgh!

Hey marathoners and people who run, like, 10K's,

Do the last few yards make you feel like you want to finish because you're happy and proud to have made it this far? Or is it more that you want to finish because if the aggravation kills you dead on the spot, while that would be a blessed relief it would also mean you won't have the pleasure of saying "I'm never doing THAT again"?

Oh, there's good news too. I had my white-coat ceremony, so my own classmates were looking like the stylized figures in the header image. We got to take a practice version of the national boards exam I'll do a little more than a year from now, after I've graduated. I passed. I was actually a touch above the class average. In theory, then, the real boards should be just fine.

But who wants to concentrate on the positive stuff? I'm tired, finals are next week, and sitting in a chair looking at PowerPoint presentations for a year has helped me gain 10 to 15 pounds. I'd rather be ONLY concentrating on the wedding (yayy!).

Anyway, that's my deal. Big fun coming up.

The Short White Coat

I've had a couple of very nice e-mails, in response to the last post. People want to know when I'll be in town, or what I'm doing when, or generally the whole dealio with the clinical year thing. So here's the two scoops, my raisin brahs:

As of the end of May, after the wedding and once we've returned from Las Vegas, I start up the second year of my two-year program. Basically, now that I've sat in a classroom for a full year, learning a little about everything and a lot about a few things, I now get to run around all day and try to apply it all. This would be the clerkship year.

It's a series of six-week stints in various specialty areas. Because we students (we PA kids are interchangeable with the med students at this point) move from place to place as the year wears on, each of these is called a 'rotation.' As I mentioned earlier, I'll begin by being the student in an Internal Medicine practice not far from where I live. And that means I'll be seeing people with hypertension, diabetes, and everything else that can go awry in the adult human body; the MD will be right behind me.

I'll move on to different practice situations at different locations, in my case covering private offices and hospital departments, in three states. I'll spend time working in Women's Health, Pediatrics, Family Medicine, General Surgery, Emergency Medicine, and then I get to set up an elective rotation. I head back to school periodically, to sit and take a test on the subjects I should have mastered. The year ends with a super-sized eight-week preceptorship, which depending on how you look at it is a chance for a wild fling or a marriage. You can use the time to do something cool and exotic you may not feel like doing for a job the rest of your life, or create a chance to impress some practice group enough that they offer you a job when school is over.

So. I'll be back home just after New Year's 2009, and I still have to figure out what to do with that eight-weeker. For the elective rotation I have lined up something pretty cool... but that's another post.

Here's a crazy thought...

I'm getting married, in less than 40 days.

I have about 35 days of school left, and that means I'll be halfway done with the official part of my training. It also means I'll be ENTIRELY done with the "sitting in a classroom, taking notes" part of my schooling.

Mostly, this scares the crap out of me. Now and then, however, I get a little glimmer of how things are going to work in the next year. Small, sometimes reassuring flashes of the kind of problem-solving and connection-making I will get to practice, and occasionally be really good at.

I also got my letter: when it's time to do my six-week Emergency Med rotation, guess which site they're sending me to?

Here's a hint: I already know where they keep all the supplies, and I can work the computers.

Finally, the new REM is amazing. It's a good week for old guys.

Yup. New Template.

Hey, it's getting toward the end of my classroom phase -- and that means it's that much plus a few days until my wedding. Seems like as good a time as any to tinker with the settings. And that old customized teal-and-orange stripe was looking old n' busted.

Um, yes, I am also studying for a test. Why do you ask?

I'm Going In...

Wish me luck. The last of the standardized patient training deals is coming up for me.

You'll recall that just a month or so ago, I learned the correct way to perform a breast exam. The right kind and amount of pressure; the right technique to make sure you don't leave anything out, so I'd feel a suspicious lump, but I wouldn't take forever either.

Then I learned how to work the male exam; the outer and inner survey of the twig n' berries, the dreaded hernia check. I'd had these in yearly checks, but this was from the examiner's side. And then I got schooled in the prostate, a skill that I know will eventually become not just un-special, but actually boring.

Consider that, right? A day is coming, and it's not too far, when I'll not only be the guy responsible for giving the one-fingered salute to people, I'll grow to hate it not because eww, it's my finger in somebody's pooper, but because gawd those are so boring.

Well, another one of those things we do a lot of in the ol' clinic or Emergency Department is the friendly neighborhood pelvic exam. Guess what I'm doing this week?

I definitely feel like I'm turning into a clinician, so that's good. But, man... I am getting SO TIRED of looking at either male or female genitals. And how messed up is that?

It may look like a walnut...

There is a notorious phenomenon that occurs in people who are in medical training; as you learn more and more about the various things that can go haywire with the human body, you gradually come to believe that an implausible number of them are happening to you. I believe that some of the reason my school's student-health clinic is staffed with semi-retired old docs is that they've seen and done everything, and most of the reason is that none of us are ever actually sick.

I, being older and presumably wiser than many of my classmates, have avoided too much trouble with this. I had a hacking, body-shaking cough for about 8 or 9 weeks, but I knew that was just a virus, combined with the dry air, combined with my train commute and incarceration in the same windowless classroom every day. Even when Teslagrl told me to go get a damn chest x-ray, I knew it wouldn't show anything. And anyway, we covered chests & lungs in the Physical Exam class, and nobody could hear anything wrong.

But then, a couple weeks ago, we got around to the male genito-urinary exam. Yeah... so I'm 37. You see where this is headed?

Before learning the correct way to inspect, cradle, squoosh, and prod another man's junk, and then go around back and knock on the back door, we learned the right way to talk about the exam. What it is, what it isn't, and why it's important. At my school we use 'professional patients,' people who are trained in much the same way we are, with all the attendant anatomy, physiology, and pathology... but from the other side. They learn how the exam is supposed to feel, when done correctly, so they can tell us stuff like "okay, you can press a lot harder than that," or "yep, you're right over it now; you should be able to feel it."

Yes, it's weird, and even though we'd already done the breast exams, the five dozen or so in my program were all quietly freaking out on "Nuts & Butts" day. We went into rooms in groups of four, which somehow made it worse. But once the guy did his intro speech, dropped the Caesar Ocatvius sheet he had added to his patient gown, and the first volunteer got to business, it was all very technical and interesting, and somehow we were all professional and more or less relaxed.

So, speaking now as a future professional, it's not a big deal. And the thing is, it's really super-imporant. A decent exam takes three minutes out of your life, it doesn't hurt, and it involves no needles and no radiation, unlike so many other tests. And the risks of being a big wuss about it and doing nothing are fairly dire. Ask Lance Armstrong about that.

Which brings me back to my own experience. Having honed my little speech, I had to consider my own very mild symptoms, from the past year or so. Nothing major, really, but some research pointed me toward an issue with the tissue, in the palace of the pants. Gradually I had to admit that if I were hearing from a friend what I was thinking, I'd tell that friend to go in and get checked. So I had to go see the stately, joke-cracking, HMO-hating doc over at the clinic.

This is a guy who graduated the very same medical school, more than 40 years ago. He's kind of a role model for me. He works pretty much because he loves medicine, and he'd be bored out of his mind puttering around at home with, I don't know, bonsai trees or model trains or some shit. He'd much rather be gloving up and getting to know me better than either of us anticipated.

He needed to leave for a minute to go find the tube of lube. I told him to TAKE ALL THE TIME YOU NEED, man. Search high and low.

And it turned out fine. My prostate is, apparently, awesome. I have no blood anywhere it's not supposed to be. Best of all, that info is documented, bitches! I'm not saying the exam doesn't suck just a little, but it's no worse a sensation than, say, the feeling of having crud stuck under your contact lens. It's less painful than irritating. You go ow ow ow ow shit ow, and you take out the lens to wash it. Then you're fine. And I'd rather have a rectal than some of that bullshit that dentists do to your gums with metal hooks.

The preliminary diagnosis? It would be nice if I didn't have to sit motionless for ten hours a day. So basically, my man-bits are suffering from IRONY. But yes, I absolutely did the right thing by going in.

The moral of the story for all my friends who are, or who love, guys: a dude should check his sack, once a month. And don't fear the finger.

Dang, I forgot Albania

This was harder than I thought. Admittedly, it's also something of a spelling (and typing) test.

62

But hey, naming a new country once every five seconds for five minutes solid isn't so bad, right? Give it a shot; how many did you come up with?

Such Conflict!

Here's pretty much the central dilemma for any health-sciences student who has a blog, and tries to tell interesting stories: how much can you say, without messing up the educational experience for yourself, your classmates, or your patients?

Anyway, wait for a respectable period of time to pass -- I'll think of ways to change around the identifying details, and then I'll be able to talk about my first breast exam.

(Note: not my breasts. I'm not a skinny guy, like I was in high school, but aside from that thirty-something softness in the belly, I'm not hefty either.)

Vacation is Almost Over

So soon, I'll be back to the grind. I passed a course that I might not have, and made some rather huge changes to my habits... my outlook... my inner world, really. More on that later, when I'm not so Oscar-drunk.

I'm reading some excellent books; I'm studying some interesting stuff; I have weird hours this term. I hope to be here more often.

Thanks, Michael Stipe!

This is amusing... to me, anyway. I have this lame little blog, about my career change and now my medical education, right? About how I'm trying to retain a shred of the geeky, funny personality that got me this far in life, while also becoming a responsible, reasonably knowledgeable person.

Okay, so that's the back-story. Now, anyone with a blog that lasts a while will eventually amass enough content that some of it will come up in Web searches. The Web being the Web, there's always that slim chance that one's own little blog will be lumped among the best, or at least the very few, places to go for the answer to a question. And that's happened to me.

Is it a question about being an older student, and going back to school? Not really, no. About the PA profession, maybe? Well, that has happened, true, but this is more of a multiple-people thing, over several weeks.

Is it about comparing and contrasting the arts world to medicine? Um... no.

Well, okay then, you would think; I can't seem to shut up about my friend from Minneapolis, the Academy-Award-nominated Diablo Cody*. Surely that was it.

And once again... no.

I wrote a post a while back, capturing one of my random 'WTF?' moments over a small thing that captured my attention. It neatly summed up the way the outside world has become confusing and dreamlike, since I started my stupidly intense grad school thing last summer.

I was convinced I was hearing REM's Michael Stipe doing voice-over in the new Chevron ad. (Not in a 'this famous person is sending me messages through my TV' way, just in a 'holy crap! Is that Michael Stipe?' way.) And I've had a few comments to this old post pop up, with e-mails resulting.

Don't get me wrong. I'm sincerely glad to have been helpful in some way. It's just so fittingly weird and random that THIS would be the thing that gathers... oh, at least 5 to 10 people... from the world out there to my own tiny, dusty square of the Internet.

So for the record, the voice is Campbell Scott's. He does sound a lot like Stipe. And here's some good news: Stipe sounds more like Stipe lately too. For the lowdown on what could be the best REM album in quite a while, click here.

Come back whenever you like, though. Cheers.

* Who won the WGA Award for Best Original Screenplay 2008 about two hours ago, by the way.

Found Object

I'm sleepy. I need to knock this off and get to bed. But I just wrote something I really like, in the comments section for a very sweet, sad, lovely post over at Jon's blog. Which you should read, because it's excellent, as indeed is Jon.

Because I lack for time (and therefore worthwhile content), and have almost no shame, I'm putting it here as well. Our theme is nostalgia, especially for childhood and simpler times.

* * *

We lived on a cul-de-sac, and rather than being a bulging bulb made all of road, there was a circular patch of lawn, surrounded by curb, in the middle of the turnaround. We neighborhood kids called it "the circle." There were marigolds planted around its perimeter. It can't have been more than 12 or 15 feet across, but it was an island. It was a world to itself, where you could stand and take in the whole neighborhood.

There was a buzzing flying-saucer-shaped streetlight in the center of the circle. If you looked closely, you'd see it had a solar cell down on its base, to sense when it was getting dark. That was when the parents said it was time to come home, in the summer; when the light came on.

If you put your small hand over the block of sensor dots even in the bright afternoon, and you waited, it would make the light turn on. Then you'd move your hand, and it wasn't time to go in after all.

And so, I could kind of control the whole world, a little. I think that's what I miss.

Um...

...right. Sorry.

Maybe I'll talk more later about my interesting new study plan thing. Suffice to say, when you actually plot out the hours on a chart, there are not that many of them available for anything, fun or otherwise. So there you go.

But writing = good, and writing = fun, so I'll try to make sure I shovel the walk to this blog before it gets too deep.

How was your holidays?

What's in a name? A really long post, that's what

Today's post comes to us courtesy of the Reader Mailbag, where a sharp and doubtless lovely person named Barb writes:

OK, so I've got a question for you.

Is there a "proper" form of address for a PA? or is it an individual preference?

I ask because at my husband's neurologist's office the ratio of time spent with the PA to time spent with the doctor is running roughly 25 to 1 in the PA's favor. Calling her by her first name seems somehow not quite right, (too casual and familiar, I think); but calling her Ms {lastname} feels off-kilter, too.

Ahh, yes, Barb, one of the eternal questions of PA-dom. This is just one more way in which the pioneers of the field... how do I say this kindly... kinda screwed us (without meaning to, of course).

The best answer is that it's an individual preference, and if it were me, I'd just go ahead and ask your PA how she feels about it. It could be a non-issue, or you could prompt the kind of long-winded discussion I'm about to launch into. I agree, that using "Ms. ______" in the context feels weird, as though you're talking to a grade-school teacher or you're entertaining a guest in the parlor for tea.

Within the PA profession, there are some even sillier ways to try and be formal, there are ways to just ignore the difference between an MD and a PA, and then there's the first name thing. There's no perfect answer. In my experience, most of the time fellow practitioners of all levels use first names with one another, and patients call everybody "doctor" whether they are one or not.

In the small town where I shadowed a PA for 8 or 10 weeks, everybody in town was on a first-name basis anyway, so those PAs used the trusty first name basis. One guy explained that the weirdest part about practicing medicine in the same small town where you grew up was the collision of the social roles -- guys he had played football with now needed yearly prostate checks; their wives, some of whom he had dated in those high-school days and some of whom had turned him down flat, needed Pap smears. And come to mention it, so did some of their moms. So the small-town factor was bigger than the problem of what to call people.

Even so, I couldn't help noticing that with the MDs, many of the townsfolk seemed reassured by the ability to use the title "Doctor" in speaking with them, probably for the sense of decorum and legitimacy it imparts. After all, when you're in the exam room getting that super-personal exam, I imagine it's easier if you can think of those gloved hands as belonging to "doctor" somebody, rather than "good ol' Bill, the kid who really loved tater tots, and peed his pants in third grade*."

The really nervous patients called the PAs "doctor" too, out of a sense that they basically do the same job. And for all that's about 99% true, it's still incumbent on the PA to gently say, "actually, no, I'm not a doctor. I have a [Master's / Bachelor's / Whatever] degree in Medicine, not a doctorate. So just call me _______, okay?" And I've heard a few versions of that speech, in many settings. After a few years out of school, PAs seem to settle into a mode where they will give it their best shot, and if a patient insists on saying "doctor" anyway, correcting every usage doesn't seem to help.

From its conception, the PA role was always meant to dispense with that kind of formality and social hierarchy. It was the Sixties, after all, and there was a legitimate need to question all the stuff that had built up over the years, around the idea of doctor-hood. No doubt there are situations and people even today, around which rather a lot of that not so desirable, paternalistic, know-it-all identity has built up. On the other side of the coin, fewer of today's patients listen to what somebody says just because they have extra letters after their name... for better and for worse.

PAs were meant to be different in several ways, and that lack of entitlement was one of them. The profession grew in part out of wartime experiences that proved to the grander institution of capital-M Medicine that a competent, hardworking man or woman could be trusted with serious medical stuff even though they'd had less of the advanced hard-sciences-style training -- as long there was a solid foundation in how to think about and how to perform the component tasks of medicine, and as long as the conditions were right. Meaning, if help is available from some Captain not so far away, you can trust a Lieutenant to patch somebody up M*A*S*H style, or treat all the runny noses on base. As a matter of fact, the PA can be trusted to treat 3,000 runny noses and STILL catch that one brain tumor, with the right training. And so that's the training we get.

But for all that, in the planning stages it was decided that we should never really try to cross over into that special, ill-defined, highfalutin' area that marks where official doctor-hood starts. Some of it is politics, of course. Some is a return to the good ol' accessible "country doc" spirit of the earlier 20th century (and Star Trek), and some is a look forward to a more competency-based way of thinking, where a person's title means less than their skills. Over the years this has played out in good ways and bad.

We saw a video in one of our classes last term, demonstrating some ethical dilemmas and providing a point of departure for some really good discussions. One thing everybody commented on was the way the people in white coats were calling one another "PA Smith" and "PA Jones," as in, "I see here in your chart that you spoke to PA Jones about this." Our instructors assured us that we would not have to act like gigantic dorks and call one another "PA" anything. It turns out that's how it's done in the military, bless their hearts, but after all that's an environment where titles give important information and everybody has one. Calling somebody by a first name there might be an embarrassing breach of protocol.

And lastly, I was really fascinated by something I noticed back in my job at the County ER: as the Emergency Med residents got farther and farther in their training, they seemed to appreciate the PAs more and more. The way this manifested sometimes was that the senior residents, the ones about to graduate and go out into the world to become attendings, would be talking with patients and refer to the PAs as "doctor [lastname]." I found this to be pretty weird, but eventually caught on that it was the same kind of shorthand that patients use, where the word "doctor" doesn't mean "person who has completed a terminal degree that's beyond what other fields might consider a grad program," it means "person who completed a program sufficient to allow that person to provide medical care," and even more than that it means "person who provides medical care."

Which is all pretty cool, I suppose, because it means that in some places, the idea of competency over credentials is becoming the reality. And that's nice. But I specifically didn't want to be, and don't want to be, a doctor. So I will be correcting people, both patients and colleagues, at least once.

Hope that answers the question, Barb. Thanks for reading!


* There is no story about any of the nice practitioners in that town peeing themselves. At least, not as far as I know.

I also knew this season of "Heroes" would be lame

Here's me, in October of last year:

"...my pal, future Golden Globe-winning screenwriter (and eventual Hollywood Squares center square) Diablo Cody..."

Here's today's news:

"Besides Cody's screenplay nomination, "Juno" was nominated for best comedy or musical. Star Ellen Page, who portrays a precocious 16-year-old who decides to give up her baby to a yuppie couple, was nominated for best actress in a comedy or musical."

Yes, yes. Those chickens don't hatch until January 13. Duly noted. I'm just saying, is all.

Hollywood Squares 2025 will be rated TV-14, for adult situations, suggestive dialogue, and fantasy violence.