Fun, and Not Fun

I love vacation. Partly because I get to reflect back on the accomplishments of the past seven months (we haven't had a significant break since the wedding), and partly because... well, because it's vacation. I can drink beer and play video games at 3 in the afternoon if I like. And, people: to a certain point, a point which represents admittedly more than Teslagrl might be hoping for but much, much less than it would have been not so long ago, I like.

It's been a very good year overall, and the clinical phase of school has been different in ways that are almost entirely good. If I made New Year's resolutions, I'd think seriously about promising to 'splain some more about how this phase of my education works. Now that time has passed, it's probably safe to jumble up patient-specific characteristics and tell some stories about each rotation, to give a sense of what this is all about.

But for today, I'm talking about video games. There's a really cool discussion going on at a blog I read called Twenty-Sided, where Shamus the host put up a ten-minute YouTube video he made, for discussion and comment. The video itself is a commentary, wherein he asks deep questions about the nature of games (he's a programmer himself, as well as a creative-type). He wonders how come some of them are no damn fun to play. A related question is about why there are so many folks, even in the age of Wii, who can't or won't get into games that don't involve bowling and whatnot. If this sounds even remotely interesting, and you have ten minutes, you should check it out. He's a smart guy, and knows what he's talking about.

Like everything I see on the Web and then run back here to write about, it got me thinking. And I've formed kind of a wobbly early version of a Unified Theory of Fun. But before I go spewing my opinions and deep thoughts about the subject, see what Shamus has to say. I have a hearty handful of readers. A few might have a little time to kill. I'd like to see how his arguments sound, to gamers and (maybe especially) to non-gamers.

Compare and Contrast

Hi.

For the past 6 weeks, I was someplace far from home, on my Surgery rotation. I was at a hospital where the PA service is run unlike almost any other, and I had an amazing experience there. I've never worked harder, or been better-educated. I like to learn by doing, and I was in my element out there.

Here's an idea of what I mean: 6 weeks ago I could suture, and tie a knot... but I wasn't making sugical incisions, I wasn't the first-assist on several different types of operations ranging from hernia repair to hand surgery, and I wasn't solely responsible for sewing up lacerations. I had full, unrestricted Internet access (including Blogger, which was blocked by the network), but I didn't need to use it to research the 20-minute talk I had to give on a new assigned topic each day. I was sleeping in my own bed, rather than crashing at the dorm-style 1970s-era apartment building a block from the hospital's Emergency entrance, but I wasn't working 80- to 90-hour weeks.

I'd watched brain surgery on the Discovery Channel, but hadn't observed an awake craniotomy live and in person. And I certainly didn't have to excuse myself to respond to a trauma alert. I've known folks who had gastric bypass, and god knows I've played some video games, but I definitely hadn't operated a laparoscopic camera (by the by, this is something I have now done multiple times -- by the end, the surgeons were requesting me, and it's possible I may have gained -- gasp! -- a lucrative, marketable skill).

I mean, I really like Scorcese, but let's see how Gangs of New York would have looked if all he had was a fiberoptic light source jacked into a glass rod as big around as a wooden spoon handle, and the whole thing had to be filmed on location inside the abdominal cavity. Right?

Okay, true, I'd been present for a few hundred trauma activations. So those were nice.

I can tell some stories and talk some specifics at a later date, but basically this rotation (#4 of 8) seems to have been some kind of a turning point. Long-time readers will recall how I struggled all through Post-Bac and the first year of PA school; basically there's been a conflict (internal, external, or both) between studying to be a student, and studying to practice.

This rotation was one where the accent is on preparing to do the work. And not coincidentally, it's the one where I've had the best success. Sure, there's a lot to know, and every morning I had to be ready to stand at a marker board and give a talk, proving I understood the concepts and memorized the facts. But as the veteran PA* in charge said, "you're standing there because medical folks think sitting down, around a table. In surgery, we think standing up."

It's good to be back, to be sure. And it's a new world for lots of reasons. Next up, it's Family Medicine on the West Side.



* literally; there are a few bona fide Vietnam-era Army medic/ Navy corpsman-type 1st-generation PAs at this place

What's in my open windows right now?

Wow, long time, sorry, etc. School does this to a guy.

I'm watching the debate live, and here's what's on the laptop:

1) This window, natch.
2) Facebook, where several of my peeps are being all political and clever.
3) FiveThirtyEight.com, so I can watch their liveblog.
4) The messageboard community I've been part of for several years, for more live reaction and discussion.

And I'm seeing the debate on CNN, where I get live info about how various voter blocs respond to what they're watching... which is what I'm watching. I'm struck by how just how much information is available at once. And the thing is, it isn't too much.

Is this because I have ADHD, or because this is a hell of an election?

For the Record

Every time Teslagrl gets a text message now, I have to ask if it's Sen. Obama. That right there is some pretty great politicking.

I think it would be cool if he takes the stage tomorrow in Springfield, and says "hang on a minute, I just have to send a quick text" before starting his speech.

SOS

I'll have more to say about it later, but I saw Mamma Mia, it was partly-to-mostly awful, and I can't wait to talk all about why. A few key points:

1) Watching people act as though they are having fun is not the same thing as having fun. (I have a similar opinion, this one more controversial, about The Blair Witch, as regards things that are frightening.) Watching people screech like 9-year-olds and stomp around like giant city-wrecking monsters on Ecstasy is not the same as being a witness to ecstasy.

2) Salon.com's Stephanie Zacharek is spot on: James Bond can't exactly sing, but as an actor he GOES FOR IT, and god bless 'im for it.

3) Speaking of effective expressions from the UK, to review this movie in five words or less I found I had to go beyond American English and use British English, which in general is far better for the occasional verbal sniper-shot. It's not that the film was poorly made (which it was), or that it was not fun (which it wasn't, really, and certainly not as much as it thought it was). It's that, all in all, this movie is just utterly pants.

From http://www.peevish.co.uk/slang/p.htm:

Pants(!) Noun/Adj. Nonsense, rubbish, bad. From the standard British English of pants, meaning underwear; also a variation on 'knickers'. E.g."The first half was pants but I stayed until the end and it was actually a great film." [1990s]
Exclam. An exclamation of annoyance or frustration. From the noun, (above).

Blogopenia

CC: "My blog sucks because I never update it."

HPI: 38yo WM with 3+yr hx of intermittent blog activity, ranging from thoughtful to snarky to extreme cheese-sandwichy. Last post about one month ago.

FHx: non-contributory.

SHx: ETOH 3-5/ wk, no cigarettes, no recreational drugs. Positive for PS2 with recent additions of Nintendo Wii (~2mos) and XBox 360 (~1wk). Works as scut-monkey scum, currently with urban Peds clinic, between 40-60h/wk.

PE: Lethargic subject in mildly poor physical condition, but in no acute distress. Personal hygiene WNL, but positive 1990s signs to some clothing. Cell phone, shoes, messenger bag, and PDA adequately cool.

A: Mild to moderate blog-malnourishment, secondary to lack of free time. Reduced motivation is a parallel problem worth noting.

P: Watchful waiting. Recommend shorter, more frequent posts. Hold off on initiation of Twitter or similar modalities until the situation is more critical. Short-range goal should be one post per week. Re-assess in six to eight weeks.

I diagnosed impetigo today...

I diagnosed the crap out of it!

What happens is, as the student I'm there to collect the info. I've been with an Internal Med doctor with a thriving practice and a ton of patients. Almost all of them have some kind of chronic issue going on, and even when that's not the reason for the visit, it's important to know how things are going. So I talk a lot about diabetes, and heart disease, and medications. I spend a lot of time writing down the ten different meds* the patient is on, the dose, what they've changed recently, and what they don't like to take.

I also do a review of systems, which is where I ask a ton of questions about all kinds of stuff that isn't what the patient came in for. The detail and length of this list increases proportionally with the length of time since the last visit, too. And since I don't want to take all day with this, it's a good thing that the actual physical exam portion of my standard history-and-physical can be made pretty snappy.

I do my writing, which has also become much faster, and then I go speak with the attending physician. We'll talk for a moment, maybe while walking, and then he'll open the door to the exam room, say hi to the patient, and do what I just did, except so much more quickly and efficiently it's kind of embarrassing.

Now, true, part of the reason he can do that is he already knows this patient well. In a lot of cases, they've been seeing this same doc for years. Another reason he can be speedy is that I just did the time-consuming stuff, and I've just distilled down the most important 30 seconds of the 20 minutes it took me to find it. But also, he's been doing this a long time and I just started.

So. I've filled in half the page or more, with my block-printing marching a couple dozen rows down. Then he'll scrawl "IMP" (for "clinical impression," which is like diagnosis except that it doesn't necessarily have to be something that is truly, technically a diagnosis), and then put in a word or two the answer to the question I started asking back at the beginning of my interview: "what is it that we can help you with today?" The MD then scrawls "PLAN" and lists the tests, the meds, the treatments that will be needed to get the patient to the next step, so we can start all over in a week or a month, or whenever the next visit should happen.

I like it this way. My own "IMP" and "PLAN" are part of the conversation we have outside, of course. I'm not just a note-taker or an inquisitor -- although the key to a good diagnosis is asking the right questions (and hopefully not too many that turn out to be dead ends). You've seen "House." You know the score. But my impression doesn't go in the chart, because that's not the way we do it here. And that's cool with me.

Except when I'm really, really sure. There have been a few things that I've felt so confident that I would have been just shocked if I was wrong about them. I sent a woman to the ER because right in the middle of telling me about the vertigo with a horrible headache that comprised the attacks she'd started having, she had one... and there was a little bit of a seizure too. The doc agreed that she needed to get down there, so we whisked her away. We admitted her, and it turns out she had a nasty infection in the bones of her skull.

Today was a case that kind of jumped right out of the mental version of my dermatology notes. So I wrote "IMP: Impetigo" before I went to fetch the doctor. He looked at the patient, said, "yep, I agree," and did the rest of his scribbling.

Maybe it's a Stockholm Syndrome kind of thing, with the hours and the intensity, but it's really nice to get props of this nature.



* seriously, sometimes it's 12 or more. Rarely it's only one or two, and I'm like, "huh." And then there are the patients younger than 45 or so who take no meds at all -- they're the minority, and I don't tend to see them twice within my six-week term, ya know?

Milestones

Sorry I've been so quiet. A lot has happened since the last post, but I've been so wiped out as a result of the activity that I've been less able to write about it.
Here's something that crossed my mind recently...

My 35th birthday, I seem to recall, was spent either packing, or driving out east to start my post-bacc program. My girlfriend (now wife) made the trip with me, but I dropped her at the Albany, NY airport for the first of what would be several times, before I continued on the last little bit to Bennington, Vermont.

On my 36th, I had finished up that one intense year of pre-req courses, having had a few successes, a few painful encounters with my own limitations, and a whole lot of educating on what my life would be like for the next phase of my adventure. I had come out there with a goal, and come back with a plan. In the interim, I had learned a lot, including the difference between the two. Also, I read Diablo's book, I listened to Jonny's record, and I started to see how I could be good at medicine, for real real.

My 37th was spent driving back home. All my stuff fit in my 4-door car. Well, except for the futon and furniture I'd stashed in my dad's shed, and the books and whatnot I'd left behind in the woman's basement.

I just had another birthday this week. The day started with me arriving to the clinic a little ahead of my supervising MD, so I took the first patient on the list, with the MD following up a little later on. He agreed with my diagnosis, too.

Weird, how fast it all seems to go by. Next year I'll be within days of graduation, and I may even have an idea of where I'll work when school is done.

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?