08.its like -- people only see it the way it appears...

[B.o.B. - Where Are You? (B.o.B. vs. Bobby Ray]
[Album: Strange Clouds (2012)]

"but they never see the ropes and the pulleys and the gears."

hearts run on more than you think.

It has been a good while since I've been able to verbally unload unto this project -- my life raft -- bobbing up and down in the middle of this purgatory ocean known as the internet. At least it hasn't become sentient like Skynet with the subsequent enslavement of mankind...amiright nerd friends?

(Nerd Warning: Terminator Reference)

I have an explanation, however, and not an excuse I might add. Excuses are lame. Let's all just own up.

Yesterday we took our National Board of Medical Examiners (NBME) Shelf Exam for OB/GYN. And when I say we it wasn't just my group of baby catchers that took our end of rotation exam -- my colleagues in Pediatrics, Medicine, and Psychiatry also took their respective exams. In fact, my other colleagues in Family Medicine, Neurology, and Surgery should be close to finishing their exams as I write this.

So although I would much rather make feeble attempts at eloquence here I can not ignore the Crates in life no matter how bland and heavy they are. For better or worse these Shelf Exams are fairly heavy Crates at that.

crate -- 

}}} These are not the Shelves you are looking for...

I've always wondered why they are called 'Shelf' exams at all.

Do they literally keep these exams on a Shelf?

Do they mean we can put all our knowledge on the Shelf after this exam as we prepare for the next Rotation?

Do they intend for us to eventually turn it into a snazzy verb: "Yo bro, we just got Shelved!"?

We may never know. But one thing I do know is Shelves were made for Books and Papers and Crates and definitely not for Hippos. Definitely not. It's hard to find time to relax, and sleep, and write with a Shelf Exam around the corner.

As 3rd year Medical Students we are acutely aware that our grades are split somewhat evenly between our Clinical Performance throughout the Rotation and our Academic Performance on the Shelf Exam at the end of the course. A logical and perfectly acceptable system in my opinion. It's essentially an assessment of our Hippos and our Crates, respectively.

With that said these Shelves -- these Crates -- are designed to survey and make sure we've acquired enough technical knowledge and that we've memorized enough facts and figures to function adequately enough within the specialty we just experienced (at least at the level appropriate for this stage of our Careers.)

If we are lucky we learn what we need to learn in the best and most natural way possible: through experience with our Attendings, Residents, and Patients. No book or exam could ever make a fact stick the way a life experience effortlessly does. One can read about delivering babies in every textbook ever written and still not know where to stand, what to do, or what to say...let alone what to feel.

But experience even a single birth on Labor & Delivery and you will learn most everything you need to know. And you won't forget it. The best part? In the process of this effortless learning you fill in for yourself the gaps that Crates could never fill -- all the emotions and relationships that are the wonderful byproduct of being human -- the Hippos.

If Pictures are worth a thousand words...

then I submit that Experiences are worth a Million...+Infinity...+1.

"blood, sweat, and tears...

we cry blood all we sweat is tears."

More often than not, unfortunately, we don't have the opportunity to learn and see what we need to in the best way. For everything else we have to rely on the Crates (much like the first two years of Medical School) in order to obtain what is expected of us.

That can be a challenge given we spend most of our days nowadays in the Clinics and on the Wards. The last thing we all want to do when we get home is to crack open another dense Crate of books and endless question banks. 

We want to have an actual meal. We want a non-medical conversation. We want to laugh, and dance, and give libations. Never have I treasured 'trashy' and 'mindless' TV entertainment more than I do now. 

It is this need to be the un-scrutinized versions of ourselves that is constantly at odds with our drive to give all we have in the pursuit of our Careers and our future Profession. It's a tall order, but it is exactly what we signed up for. And in that respect this might be exactly the Shelves we are looking for.

"we put it all on the line, we gave up all our belongings..."

The Shelf like most, if not all, things in Medical School is our time to shine and prove ourselves. Not to outshine others but to collectively shine brighter than any singular source could ever hope to illuminate. But above all it is another way that Medical School seems to be testing Balance. The way we manage our time between Clinical Mastery and Academic Excellence. The way we manage the requirements and expectations of Medical School and the leisure time that keeps on dwindling away. Ultimately, it is testing the way we balance our time between our Attendings, our Patients, our Exams, our Loved Ones, and Ourselves.

Whether we all fully understood it or not (probably not) this is what we signed up for. Even though we may hate to admit it at times this is what we wanted and we wouldn't trade it for anything. Through the endless Crates I know we all find those hidden gems -- those fun little Hippos -- that remind us why we are doing what we are doing.

Congrats to all my colleagues on finishing this past Rotation and break a leg on the next one.

Here's to a Crate-free weekend (hopefully). After all, we just got Shelved.

"I live and die for my team...

these n****s are more than my homies."

hippo -- 

}}} Seesaw and what you See and what you Saw.

Balancing everything is hard.

Especially when what you Want to do is different from what you Have to do.

As Medical Students it is probably our families and loved ones that deserve the most praise as they hardly get enough recognition for the support and comfort they offer.

"We never hear from you, you're constantly changing.

And your relatives always miss you, at family occasions."

Being 3rd Year students maybe they're used to it now. Never understanding how or why we would spend hours upon hours sequestered away in libraries and coffee shops. Never understanding how academic performance and exam scores could dictate the rest of our lives. Being confused as to why we stress out at every minute not spent trying to memorize some fact or digesting some new concept. 

Even though they might be used to it after 2+ years of what may have been begrudging acceptance it doesn't make it any better. The recent experience of taking the Step 1 Exam is one filled with Hippo-sized sadness at times. Most of the time we are at least aware of the time we spend with our books instead of our loved ones. The weight of something like the Step 1, however, is so burdensome that one can even forget that much -- focusing all of one's existence on a set of questions and an eventual number that can determine what you do and where you live for the rest of your life.

"But we'll still stand beside you, 'cause somewhere deep inside you...

there's more than what meets the eye."

Our loved ones are always there though. The one's that matter most.

If there's one thing I took away from this past rotation it's that Crates are unavoidable and that Hippos are essential. Yes, I've learned how to deliver babies and how to assess and promote women's health. Above all, however, it's been a huge seesaw and the hardest balancing act of Medical School thus far. The only way to get through this relatively intact is with the homies that got yo' back.

"I watched my whole life change, in a couple of years.

Who woulda ever thought?"

The secret seems to be investing in people and relationships when there is any doubt. We should never ignore them but the Crates will always be there -- Hippos on the other hand are fleeting. I've realized my books and notes will still be there when I get back, but I could never raincheck a new inside joke or memory.

You can't buy those human connections but you can find them. And grow them. The Beatles (best band ever) were right on when they sang: "Can't Buy Me Love."

When I finished my OB/GYN Shelf Exam yesterday I naturally and instinctively sought some definitive closure on the subject. As I was answering the last 10 questions of the 100 question exam (and as I became more and more zombie-like as a result of extreme hunger and sleep deprivation) I thought about the most memorable aspects of my Rotation.

What I realized is that they all involved people:

-The hilarious OB/GYN-related nicknames my colleagues and I made for each other.

-Bonding with my Attending from L.A. over hip-hop and playing Too Short's Blow the Whistle while closing an incision after a Hysterectomy.

-Fighting off sleepiness on the Night Shift by teaching my Foreign Resident some common slang and pop culture conventions.

-Making eye contact with an Attending above her facemask and seeing her eyes fill with water and determination during a STAT C-section.

-Serving Birthday cakes in cups because we never had plates.

-Realizing that Attendings and Residents want to sneak away and find a cup of good coffee just as much as we all do.

-The patient who kept calling us "Doctors" despite constantly telling her we were just Medical Students because she was so grateful for her care and believed in us so much.

Call me biased but these are what stand out most. These are the important things and are the Hippos that could never be replaced. It is impossible to write a textbook on this, but if we have a cup a coffee together I could relate and relay at least a few.

"so hood, but so different at the same time.

It was like a breath of fresh air everytime he rhymed."

Balancing the seesaw of Medical School is something we will all have to continually tweak from time to time. It's not always rainbows and gumdrops as it can be flat-out terrible at times. But it is the absolute best feeling when those most important parts of your life result in experiences that are priceless and irreplaceable.

When I look back on this OB/GYN Rotation -- my first Rotation -- I will See the grade and the evaluation of my performance. But I'll remember that I Saw the frustration, motivation, and outright silliness that makes life worth living.

We got Shelved.

"I swear this sh*t is so much bigger than I had figured.

But if this wasn't meant to be this wouldn't be my Career."

07.you know very well who you are.

[Tamar Braxton - The One]

[Album: Love and War]

which samples...

[The Notorious B.I.G. aka Biggie Smalls - Juicy]

[Album: Ready to Die]

Tamar: 

"'Cause I don't look that far. Look where we are."

This past week was my final one on the Gynecology service, and it was a good one.

What has probably caught me most off-guard about GYN and this whole OB/GYN experience altogether is the amount of Surgery involved. For some reason I had the biggest misconception that OB/GYN would be overwhelmingly Medicine with but a hint of Surgery on the side. A garnish.

I've realized that the split between Medicine and Surgery is nearly equal if not, at times, slightly skewed in Surgery's favor. Of course I may be biased from my past 2 weeks. As far as Obstetrics v. Gynecology goes the GYN service definitely sees more Surgeries and a greater variety of it.

Well. Good thing.

I love Surgery. YOLO.

Biggie:

"Spread love...it's the Brooklyn way."

crate -- 

}}} Hysts on Hysts on Hysts.

I feel as if I've seen so many Hysterectomies that it's a wonder any uteruses (uteri?) are left in the world. I am exaggerating of course but it seems as if removing wombs is the mainstay of any Gynecologist's surgical repertoire. This is one mass-produced Crate and Mr. Ford would be proud.

There are a number of indications or reasons for performing a Hysterectomy...ranging from severe, uncontrollable bleeding to endometrial cancer at the most dire end. By far, however, the most prevalent indication I have seen (and what I believe is the most common one) is for symptomatic Uterine Fibroids...which, yes, in most cases results in the aforementioned uncontrollable bleeding.

Tamar:

"Without you I'm incomplete."

But won't they lose the ability to get pregnant and bear children?

Yes. But fortunately, Patients requiring a Hysterectomy are (most often) Post-menopausal and have either had all the children they desired or have already lost the ability due to the inevitable course of nature and time. This is not to discount the fact that younger women have, very unfortunately, had to receive Hysterectomies as well -- a reality which ranks high on the list of tragic circumstances I wish never existed. All of the Hysterectomies I have seen were, thankfully, in older women who would not miss the priceless ability to bring another life into the world. Though no major Surgery is desirable per say, in the Patients I have seen the procedure was life-saving and took away nothing but a spare organ that was no longer functioning. Thankfully.

Biggie:

"Uh, damn right I like the life I live.

Because I went from Negative to Positive."

As I mentioned in the previous post it is possible to use the Da Vinci robot for Hysterectomies. I've had the privilege of seeing both robot-assisted as well as the conventional 'open' version of the Hysterectomy. There are also different types of Hysterectomies where the one I have most commonly seen is the Total Hysterectomy, followed closely by the Supracervical Hysterectomy where the cervix of the Patient is spared.

At the end of the week I realize there is no better way to learn something than to actually and personally experience it. We took anatomy as first year medical students but I have never understood (as fully as I do now) the relationships between all the ligaments, nerves, and blood vessels that are within and around the human uterus. Just like the confusion that may follow the use of a professional moving service it's hard to remember and comprehend from hearsay rather than from one's own memories. 

What better way to get to know these Anatomy Crates than to pack and ship them yourself?

Despite these Hysts being life-saving. Despite these Hysts having no consequences as far as fertility. Despite these Hysts resulting in little to no Post-Operative complications. I still can't help but wonder what it's like to lose an organ. Yes. Just tissue. Unconscious, non-self-aware cells and mitochondria. 

But it's still a part of oneself. What is that like?

Any kind of loss -- physical, mental, emotional -- is bound to hurt. Right?

Tamar:

"I don't want nobody else.

Baby, all I need is you."

}}} The Ovarian Cancer National Alliance. (www.ovariancancer.org)

We have required OB/GYN lectures every week. And that is just what they are. 

Lectures. Schmectures. Crates. 

This past week, however, we had the greatest privilege of having a presentation from members of the OCNA. It changed the tone of everything. It was the most organic and unpredictable Crate you will ever see.

Many of them were Ovarian Cancer survivors and the rest experienced the blight of Ovarian Cancer within their loved ones. As such, not only were we taught the facts and statistics regarding Ovarian Cancer but some of the presenters would periodically share very personal stories and experiences to highlight just what it is like to experience that which is unwanted and unexpected and in every way terrible.

It's as if they were shipping Crates of Hippos. We learned. Then you opened the Crate to find the surprise Hippo -- and it surely took everything you had to hold back the mixture of surprise and tears and anger. Each personal story seemed to be more tragic and emotionally draining than the last.

Watery Eyes and Clenched Fists.

For the record, here is the most pertinent part of the Crate:

Ovarian Cancer Symptoms

1.One = Bloating

2.Two = Pelvic/Abdominal Pain

3.Three = Difficulty Eating or Feeling Full Quickly

4.Four = Urinary Frequency or Urinary Urgency

Ovarian Cancer is often missed and is, unfortunately, often diagnosed too late.

But you know what?

I'll always remember that Presentation for Ovarian Cancer.

What better way to learn than through Memories and Experiences?

Emotion can make things stick that books and lectures just can't.

Any kind of loss is bound to hurt.

Biggie:

"No heat. Wonder why Christmas missed us.

Birthdays was the worst days."

hippo -- 

}}} Why is Loss the ultimate Teacher?

Watery Eyes and Clenched Fists.

The strangest thing about all this is that we actually had a formal lecture on Ovarian Cancer earlier that morning. The presentation from OCNA was the last item on the agenda. By that time we were all hungry and restless and usually any lecturer to come at that point would have the hardest time holding our collective attention over our Hippo-loud bellies. Peristalsis to the max.

Admittedly, I did not remember anything about Ovarian Cancer from that formal lecture. (I accept all responsibility for that.) Yet. With hardly any pure mental effort I learned and still remember all the facts regarding Ovarian Cancer from the OCNA presentation and from the stories that were shared.

Every one of the presenters that chose to volunteer their personal experience did so willingly and painfully. It was obvious that despite the emotional scars being 'healed' that every word and memory they forcefully resurrected only served to lacerate their deepest wounds even further.

Why?

Tamar:

"It felt so personal.

You took the chance to get my love and now you know."

You know what? It doesn't matter why.

Just, Thank You.

Perhaps it was to fully and excruciatingly illustrate what it is like for those who may never experience it. Perhaps it was to break the monotony of a lecture -- a plain brown Crate -- and add the spontaneity and relative warmth of the Hippo human condition. Perhaps it was a form of personal healing for themselves....a chance...another to attempt to heal what may never be healed.

In all honesty it is likely to be all of the above. 

Just, Thank You.

Biggie:

"Don't let 'em hold you down. Reach for the stars."

A colleague of mine, following the OCNA presentation, remarked how he wasn't ready for that one. It made me think that, with all that we know and don't know, we're probably never ready for 'that one'.

How do you prepare for Loss? 

How do you prepare for something that you can only begin to understand after the frustrating fact?

Biggie:

"'Cause you're the only one. I'll give you good and plenty."

It was the big Hippo in the room. The specter and reality of loss. A lot of the time (and I will speak for myself here) it is gratifying to think of Medical School as a means to save lives. As we delve further and longer into these 3rd Year Clerkships it becomes clearer and clearer how much of a protective bubble Medical School really is.

Now I don't mean to burst this bubble for the sake of the burst. We are surely acquiring tools and attitudes -- Crates and Hippos -- to save lives. But perhaps we should not only learn about Living and Healing but do our best to learn what it is like to experience Love and Loss.

Tamar:

"And ain't none like you. One in a million.

But I'm the only one to count You."

Whether it's part of the Crate-y curriculum or an unintentional and inadvertent surprise Hippo it seems like Medical School provides the means to acquire what a physician will need to care and understand the human condition as best as she/he can. Whether it's a your favorite football team, or a Uterus, or a Life...

Any kind of loss is bound to hurt.

Yet Loss is the ultimate teacher.

It's really hard to forget. Maybe that's the point.

Biggie:

"And if you Don't Know, now You Know."

06.i be stuck to you like glue, baby. wanna spend it all on you, baby.

[Young Money - BedRock]
[Album: We Are Young Money]

Brief Explanation by Request:

Crates: the tangible facts and figures we are supposed to learn in Medical School.

Hippos: the intangible memories and experiences that we inadvertently pick up in Medical School.

"And now we murderers. Because we kill time."

Officially past the halfway point of this two-month rotation in OB/GYN.

Time is flyin', almost as if it's just dyin'. Fortunately, most of the time was spent smilin'.

Medical School has, amongst its greatest powers, the ability to warp time. Each year seems to go faster than the last. Sometimes it's welcome, as with the first 2 years of school, we couldn't wait to get into the hospitals and at least pretend to be doctors -- well we all but blinked and suddenly we're here. Then there are other times when time steals away priceless moments from right under our feet as is, unfortunately, the case with celebrations and farewells.

"I like the way you walkin' if you walkin' my way.

I'm that red bull, now let's fly away."

crate --

}}} Robot-Assisted Surgery

I have spent the past week with the Gynecology service and had my first exposure to the Da Vinci surgical robot. Change and progress is almost always welcome but I couldn't say if the benefits of a metal octopus (as the robot so effectively makes me think of) are worth it. Regardless of anything, however, the Da Vinci is impressive without a doubt.

"Pressin' me like button downs on a Friday night."

The robot itself is controlled entirely from a separate console and has been described as something close to a video game. Button presses and lever movements are translated to the quiver-less movements of each robotic arm. Those of us not controlling the robot are able to see all the action from multiple monitors that output directly from the robot's camera. It honestly looks like Call of Duty...except with tiny arms for guns and pesky fascia as your main enemy. 

The primary idea behind the Da Vinci robot is that it is 'minimally-invasive', which might be the hottest trend in surgery since sliced flesh. It does this through the use of multiple arms, cameras, and interchangeable tools that enter the body using incisions that are no bigger than an inch or so. It's quite ingenious. Especially when you find out the system makes use of CO2 gas to inflate body cavities in order for the arms to have enough room to function. Very clever.

I had the opportunity to assist with two major surgeries involving the Da Vinci: a myomectomy and a total hysterectomy -- both of which were performed as a definitive treatment for Menorrhagia secondary to Uterine Fibroids. 

How far surgical Crates have come. Instead of a wide open scimitar-like gash the Patient enters recovery with 3-5 baby stitches. Improved recovery time is supposed to be the biggest advantage and I've heard of Patients going home the same day or the the day after major surgeries that used to require a much longer hospital stay.

Each procedure approached 5 hours, which to some may sound reasonable, until you realize that the conventional 'open' versions of these procedures may only take 2 hours or less. Debating all the factors that go into Robot vs. Conventional are Crates I am entirely unfamiliar with, but as far as I can tell it's a constant tug-of-war between better Patient Comfort/Recovery and Cost of the Robot/Surgeon.

Is the Change worth it?

"I'll let you be the judge. And I'm the case."

}}} The Residents ended their Rotation Yesterday.

It's not only Medical Students that are shuffled from Rotation to Rotation but Resident Physicians as well. Admittedly I did not realize this until this past week even though it makes complete sense.

"That's when we disappear, you need GPS to find her."

It's a logistical Crate and the only way to make sure Students and Residents are allowed the opportunity to gain the knowledge and experience to become fully-fledged Physicians. 

It was a bittersweet moment, but it was part of the natural order of things in the world of a Teaching Hospital. We are always happy to accomplish something and to have gained not only the knowledge but the memories from time that has transpired. In the end, it ultimately serves as a reminder that time is one of the most fleeting things in existence. Too fleeting in this case.

They were amazing Residents.

hippo -- 

}}} Our Residents ended their Rotation Yesterday.

We have our First Hospitals. We meet our First Patients.

And seeing us through all of this are our First Residents.

It's an overused joke that July is the worst month to get sick and go to the hospital. Just like Zedd's Clarity, however, there is a reason popular music is constantly replayed on the radio and a reason why sayings become cliche. There is truth in the saying....and sometimes solid lyrics with a good beat.

First Year Residents/Interns historically start on July First along with 3rd Year Medical Students. Everything is new. Everything Changes. Everyone is trying to learn and adjust to different challenges, temperaments, and environments. The few Attendings and the handful of Veteran Residents are stretched thin in their HippoCratic obligation to their Patients and their dedication to Teaching.

As a Medical Student the sentiment is made very clear -- that we should not be in the way, learn all that we can, and should not be in the way. We hear horror stories of getting less-than-courteous superiors and of the ceaseless 'pimping' that goes on to simultaneously show us gaps in our knowledge while shattering any remnants of self-esteem.

I'm not sure if it is an anomaly but none of that really happened. It wasn't smooth and easy by any means. There were definitely more than a handful of times when the red hot spotlight was focused on us and the only escape was the dreaded sign of defeat, confessing: 'I don't know.'

"Don't stop you the bestest.

And I be coming off the top as-bestos."

We didn't dodge the usual rites of passage...where we fully realize our position at the bottom of the totem pole. We were told we were wrong. We were relegated to the furthest corners of operating rooms. We were interrogated about extensive lists of differential diagnoses and medication dosages. It was tough, but it was constructive. Tough-structive, if you will.

It seemed like our Residents knew exactly what we were going through and what was going through our minds. Of course when I think about it I give myself a mental slap in the face because for most, if not all, Residents they literally were in our position at least sometime in the last 5 years or so -- of course they knew. (Duh).

"Running back and forth -- soccer team."

As such, there was never a moment where we felt dumb or deficient. When one is 'pimped' and you don't know the answer it's a law of the universe that you never get that question wrong again. Now.

That law is fulfilled in one of two ways:

1.One. 

You feel guilty and inadequate so you learn the answer to escape negative thoughts/feelings.

2.Two. 

You are disappointed. You let your Attending/Resident down. 

You want to make them proud and there is no way you're going to let that happen again. 

You are, in a way, inspired. Driven.

It seemed like more of #2. One month. Our very First month as 3rd Year Medical Students and our First foray into the wards and clinics as pseudo-professionals...it could not have been better -- learning has been running on encouragement instead of being driven by guilt and that is without a single doubt the best way.

As far as Hippos go, encouragement is a much better fuel.

Hungry, hungry Hippos could never get enough.

I hope it doesn't come to pass that this experience truly was an anomaly. Regardless, whether this is normal or not, I know that our Residents made it this way. They were the First to start shaping the blank slate of our clinical acumen. Undoubtedly we will encounter a countless number of Residents in our career but none of us will ever have another set of First Residents.

These weren't just Residents or the Residents. These were Our Residents.

"I'm too loyal, and too focused.

To be losing, and be hopeless."

Really gonna miss them.

}}} The Double-Edge of Emotion

In discussing the sentimental repercussions of our Residents leaving, a colleague lightly joked that it is our duty to not get too emotionally attached -- that any Emotion in our profession is a bad idea. This is especially the case for our Patients, so as to not erode our objectivity and clinical judgement.

I agree.

(But that comes with a sharp pang of resistance.)

"Okay, I get it. Let me think. I guess it's my turn."

Because -- I don't agree that there should be zero Emotion. 

At that point we are just as good as the Da Vinci robot. Sure we may be a tad more precise, and we will be less shaky. We will move with greater surety and deliberation. But without anyone or anything at the controls we are useless. 

Who drives the robot but the human at the Da Vinci controls?

And what drives us but the Passion for our work and genuine Empathy for our Patients?

Emotion is the human fuel. Without it we have no explanations for what we do. No motivations for what we do. Medicine is an Art as well as a Science? A Hippo as well as a Crate?

Then we'd only be fulfilling half of our obligation. We would be practicing half-Medicine if we deny that part of us that makes us perfectly imperfect. There is such a thing as too much Emotion, there is no denying that, but to be devoid of it is just as bad if not worse. (At least Emotion provides Purpose).

Why do we care for terminally ill Patients?

Why do Children's Hospitals look different from conventional ones?

Why haven't Da Vinci robots taken over?

Why, despite the constant and accelerating pace of change in Medicine, 

has the role of Healer generally stayed the same for thousands of years?

Because we are Human. Only we could possibly come close to understanding what we are each going through. In the end, Change is generally good. Our Residents are moving on to master a new set of skills and circumstances. We, as Medical Students, will learn a fresh new set of Patient approaches and clinical techniques from the next set of Residents.

But, I can't deny that I'll miss Our First Residents. 

I'll leave the emotion-less circuits and calibrations to the robots.

Hippos don't run on electricity.

"Cold as a winter's day. Hot as a summer's eve."