Many miles

I just had my first week of clinicals - it brought a smashing and resounding end to all of the free time I'd thought I was going to have during 5th semester. We've got to be extra-prepared; no more of my customary wait-till-the-last minute, fly-by-the seat-of-my-pants attitude. On Sunday, Nicole and I drove out to see exactly where we were going to be for the week -we hopped on one of the many turnpikes, and made our way down to Cutler Bay, 20 or so miles from home. Strangely enough, we were going to be one place Monday and someplace else entirely the rest of the week. This made more sense when we arrived at one of the main buildings for Community Health of South Florida Inc (CHI), "a not-for-profit corporation partially sponsored/funded by the Florida Department of Children and Families". Having laid eyes on the place, we turned around and returned to south Miami.

Bright and early the next day (Monday), we showed up at CHI entirely too early; given the traffic-jam fiasco from the last clinical assignment, I thought it best to leave way early. The thing is, rush hour traffic in the morning is coming into Miami, and in the evening is leaving Miami - thus, heading the way we were, it was against the traffic both ways. If I recall correctly, we arrived roundabout 7:30 am for our 8:15 scheduled time. No matter - whereas I should have been studying, I dove back into Irving Stone's The Agony and the Ecstasy (No...it's not a trashy romance - it's the life story of Michelangelo). Around 8, we went and sat inside the community health center, waiting for the great gates to open. I really didn't like this part - there was a little seating area where folks had gathered, but separating them from the business end of the health center - doctor's offices and such - was locked gate, that promptly opened at 8:10 or something. It bothered me to see folks line up in front of the gate, as if they were waiting for the only bread they could count on all day.

As if often the case when I'm standing someplace wearing a tie, people came up and asked me when things were going to be open, etc. etc., assuming that I worked there. Happens all the time.

Once they opened the gates, Nicole and I headed back to the information desk. Once we found out no one knew where we were supposed to be, we waited with some other Ross students. Eventually, we were taken to the cafeteria, to await the 8:45 opening (I'm not sure I'm correctly recalling all of these specific times, but the chronology is fairly close) of human resources. Once they opened, we read tons of sheets of paper (auto-orientation), signed even more, and took a rather laughable cultural competency test. Following that, they herded us to security so that we could have new ID pictures taken - and then we were free. Actually, before leaving, we spoke with one of the head docs, who explained to us the imminence of universal care and medical-student-professionalism. At first, he seemed a little gruff, but it quickly became apparent that he loved teaching, and wanted to see us all succeed.

Since we were finished early (they actually didn't tell us when the orientation would end, but Nicole and I were prepared for an all-day affair), we decided to go and locate the clinic where we'd be stationed for the rest of the week. So, I whipped out my little brown book (which is, in actuality, only a wal-mart approximation of a mole-skin journal), opened it to my page of directions, freshly copied from Google maps, and we were on our way (the head doctor we'd spoken with, upon hearing where we were placed, told us how to get there, but I figured we'd better follow the directions). So we drove, and did our best to follow the lefts and rights and slight rights, eventually finding ourselves hopelessly turned around in an area full of farms and citrus trees that looked much more like deep south Texas than Florida. We eventually found the road that this clinic was supposed to be on, and followed it - until the road ended. You know something's wrong with your directions when you hit a "private road" sign. I called the clinic (which is actually closed on Mondays) and was switched over to the urgent care hotline. When I read off the address to them, they replied with a simple "Yup - that's where they are" - and that was that. We burned a bit more gas, circling the area to see if maybe we'd missed the clinic - maybe it was tucked in between....I dunno.....trees, or something.

Finally, we decided to just drive the other way down the street, and hope for better luck. And so we drove. You know, street numbers can be remarkably hard to figure out in non-residential areas of town - no simple mailboxes or numbers on the doors. We continued to the other end of this road, finally finding the clinic right where the road ended. *sigh of relief* As we headed back down the turnpike, what the doctor had said now made perfect sense - the exit he'd named was exactly the right one. Thanks, Google. I think we stopped and had lunch at Chili's - so much aimless wandering and bad directions had made me very cranky, and for that, coffee is the only cure. Coffee and margarita grilled chicken (no, there were no margaritas. Shame, that.).

So, the next day, we set out bright and early with all of the essentials - our neatly pressed white coats, fully stocked doctor's bags, notebooks, and a fistful of dollars (for the ubiquitous toll booths - theory about that in a minute). We got on the now-familiar expressway and were making great time, when traffic started to slow, just as we were getting up to the first toll plaza. Since Nicole's driving, she was very kind and let people move over in front of her when the lanes narrowed down from 4, to 3, to 2, to 1. Up ahead, the turnpike was entirely empty, and all traffic was being diverted off the nearest exit.

I glanced at the clock - we had to be there at 8:30, and it was probably 7:30 at this point, so I figured we'd just be able to hop back on the turnpike and still make it in good time (little did I know). We followed the traffic as best we could, figuring that the big semi-trucks in front of us would be getting back on the highway at the first available opportunity.

Red light. Inch forward. Red light. Inch Forward. Red light. Inch forward. By now, there was a growing sense of panic, more for Nicole than for myself, as we watched the minutes tick away. Being the positive person that I am, I told her not to worry, and that we'd get back on, and make it with time to spare. Red light. Inch forward. Red light. Inch forward. Red light. I promised her that if we weren't back on the turnpike by 8am, I'd call in to Ross and the doctor's office. Luckily, we had the Black Eye Peas new album, The End, to listen to. It's not as good as the first two.

As we moved along, it became more apparent that folks were driving a little aggressively - I've come to the theory concerning the way things work down here: you see, to get to where we were hopefully going, it was going to cost us $4.50 in tolls - every day. That's a lot of money when you consider how many cars are going through each and every day - highway robbery, if you will. However, because of this, I don't think there's such a value placed on speeding tickets. This is readily obvious - Nicole's a stickler for the speed limit, but we get passed like we're standing still - often by the cops themselves. The driving aggression is more than a theory, though - it's a fact; Miami has the second most aggressive drivers in the country. Add to that the fact that the roads resemble a map created by a slightly autistic 4 year old - what with the avenues, streets, courts, places, ways, and lanes that at times have no numerical relationship to each other whatsoever - and you get a frustrating driving experience. Especially if the turnpike is shut down. Especially if you're supposed to be starting a rotation that day.

Red light. Inch forward. Serious panic was setting in, as the little CHF-mobile (that's what we call the rented dodge charger - it sounds like an old guy whose struggling to breathe) putted along, and the minutes unmercifully drained away. I called the doctor's office, but they weren't open until 8:30 - the possibility getting there early to make a good impression was dissipating like morning fog. I called the Ross office - no answer. It was roundabout here that we remembered Nicole's new phone has a yellow-pages GPS capability - and so we began plotting our way once more.

We turned off one of the main road, following the traffic, which was finally picking up. Soon we were moving nicely, following the GPS-charted course that would hopefully bring us from our current destination to the clinic. All the while, I was still hoping that we could make it a few minutes early. We kept on driving (thank God I'd filled the tank the day before), cycling through the radio stations to see if there was any traffic update - any explanation I could feed back to Ross and the doctor concerning our predicament. We continued following the directions until we ran into another hope-dashing snag. Ahead, to our left, was another entrance to the turnpike - the one the GPS had been directing us towards - which was blocked off by a police cruiser.

So we kept on heading down the road, trying to decipher the best way to get to this place that we'd already had a hell of a time finding. The GPS thing updated the directions based on our currently location (and didn't yell at us when we got it wrong, like a Tom-Tom or Garmin). Beyond the reach of the turnpike, I eventually managed to plot out a course to our destination, which is no easy feat on a 1X1.5 inch screen; it's a trade off between actually seeing where you're going, and being able to read the street names. As 8:30 came and went, I was finally able to call and speak with the medical director at the clinic, and let him know that the turnpike was shut down, and we were on our way.

45 minutes later, we pulled into the parking lot, not knowing whether or not this doctor would be benevolent and understanding, or an old-school "yell-at-med-students-to-relieve-them-of-pesky-self-esteem" dragon. We headed into the clinic, and began profusely apologizing to the medical director - who told us not to worry, that the doctor was easy-going, and that, if ever again they shut down the turnpike, to just hop on US-1. Finally the doctor came out - more apologies - and she told us what she expected of us, and what had been her general experience with med students. *WHEW*. Unfortunately, I later found out that the reason for the turnpike closure was that an officer lost his life in a car accident.

The first patient we saw was a middle-aged woman with pulmonary nodules -who didn't speak any English. This being a community clinic, it attracted a lower socio-economic class, and many of them were Spanish speakers. So we sat in for a while, interviewing this woman, trying to remember Spanish words for things like "have you ever" and "lightheadedness". After a while, the doctor came in, spoke with the woman, and examined her. Then, she sent the woman on her way, and we moved on to the next patient. Even though I don't want to go into family medicine, I'm enjoying this rotation - I'm looking forward to going back next week. I enjoy talking with the patients, I enjoy how they open up when they see that I'm concerned (and some of them certainly just want someone to listen), and I enjoy the physical exams. Hearts are fun - I haven't heard any abnormal ones yet, but the retinas are cool - it's still new to me, and I'm trying to squeeze an eye exam into the visit of every diabetic or hypertensive patient. It can be a relatively quick one, and since the doctor is still trying to run a business, she's suggested that following our history, we try one (or two) physical exams with each patient.

I really like this doctor-she's very patient (with us), taking the time for teaching points. I have to get better about presenting cases, but with each patient, I learn (1) a new Spanish word or phrase, graciously volunteered by the patient as he or she realizes what exactly I'm flounderinginly trying to translate and (2) another significant question I should have asked, given the patient's presentation, as I relate the details of the case to the doctor.

We haven't seen anything terribly interesting so far, but I did manage to determine a case of drug-seeking behavior - in Spanish! While Nicole and the doc were off with another patient, I was sent in to do an interview. There sat before me a weepy, heavy-set woman, whose lower lip was trembling ever-so-slightly. I introduced myself, told her that I was a medical student working with the doctor who would be in to see her shortly, and asked if I could ask her a few questions. She agreed, and we got down to it. She was a walk-in, who had complained of a sore throat. Before going in the room, I'd learned that she was now reporting that she' fallen the previous week, and was in some pain. I went through all of the questions about the cold - since when, where does it hurt, runny nose, associated symptoms, what makes it better and worse, etc. etc, and finally got to her fall. She was sitting there in such obvious pain, that I reassured her the doctor was coming. This woman appeared to be very stably set on the verge of tears; tremble as her lower lip might, it never changed, and though she blotted her eyes with a tissue, I never saw the dams burst, like I was expecting. She told me about her fall, and how the tylenol hadn't made it better, but that her son had given her some..."what was it? Oxy....oxy something?" Oxycodone, I volunteered. "Yes - that's it". BIG red flag.

Generally, unless patients have drug-seeking behavior or chronic pain, they don't ask for serious narcotic pain meds by name. It didn't strike me as funny at the time - I firmly believed that she was in pain, but it was still very strange that this was specifically what she'd asked for. When the doctor and Nicole came in, I gave them a brief rundown, and watched the doctor's eyebrows elevate in surprise as I relayed the request. She then proceeded to examine the woman's throat and lymph nodes, and sure enough, she had some pharyngitis - the doctor said she'd give her something for it. As she turned away, the woman's lower lip began trembling anew, and she called out in a whiny little girl's voice. "Doctor....."

She then retold her tragic fall, and how nothing had cut the pain but the big guns - to which the doctor replied "No, you don't need that - I'll give you something else". And after only the smallest protest, that was that. Did she really have a cold? Sure - I'll buy that one. Did she fall? I'll buy that too. Was she in serious pain? I have no trouble believing that one - I'm not so jaded yet. So sure - she the pain was real -but I agree with the doc; she didn't need narcotics for a fall. I'm looking forward to going back next week.

On to other things - when I was first applying to med school, and even years before, I had it in my mind that I was going to be a psychiatrist. I had a somewhat difficult time choosing a major in undergrad, staying far away from the sciences (despite premed prereqs) and settling on anthropology. It wasn't until my junior year that I realized I cared nothing for pots or bones, and that everything I loved about the classes had to do with psychology. Thus, I switched my major and dove headlong into personality and abnormal psych (the really fun stuff), the history of psychiatry, doing brain surgery on rats, and rounded out my undergraduate education with a senior essay on exercise and motivation. One of the things I enjoyed most was my "psychiatry in the community" class, in which I spent time every week with severely emotionally disturbed adolescents living in a group home, journaling and researching about them all the while. After graduating, I took some time to speak with a psychiatrist/family friend, seeking to gain more insight into what it really meant to be a psychiatrist. I loved the idea of the human mind being capable of genius and madness, and of the oftentimes tenuous line between the two. I was fascinated by the power of a person's psyche to shape their reality, to morph and wall off parts of itself, and, despite advances in neuroscience, to continually deny explanation. However, like all red-hot love affairs, it was not meant to be; it was based on fantasy, and not reality.

The first hint that perhaps psych wasn't for me came when I was working for the health insurance company. I read several books about psychiatry - some of them resident level - and just had a blast with it. I like to say that I read psychiatric case-studies like other people read romance novels; they give me the warm-fuzzies. I soon learned, though, that psychiatry today is little more than drug management; the insurance companies pay the Ph.D counselors to do the talk therapy, cognitive behavioral therapy, and the like - while the psychiatrists are only paid to manage medications and avert emergencies.

That realization shattered the romanticism I'd built up around the idea of helping people wade through their mental illnesses to triumphantly burst forth on the other side, stepping out into fully-realized, stable mental health. The next blow came when I first began studying in the anatomy lab on the island. There was something so visceral and so exciting about the dissections, that I knew that whatever it was I chose to work with, I'd have to do something with my hands. I wasn't as gung-ho about the idea of surgery (as I may be becoming), but I think that was the death knell for my love affair with psych.

There have, however, been various little sparks of the former love - minor flings, I suppose. We went through behavioral science in my third semester, and one of the professors we learned from was a clinical psychologist - his outgoing, somewhat unorthodox though incredibly disciplined approach brought back all of the feelings I'd tucked neatly away. I was more mature, though - instead of thinking it might work this time around, I knew to just enjoy the fling for what it was, take my pleasure, and turn my attention back to pathology and pharmacology.

Now, I must make a distinction between two professors. I will identify neither of course, and I will attempt to pass no judgments - all I will do is tell you how I feel about my old flame when they're professing.

Professor B really doesn't seem to care. I get the impression that he sort of fell in with psychiatry, because no other girl would go out with him - because he couldn't match into any other specialty. I could be wrong, but hearing him talk about psychiatry is like listening to a public service announcement. In fact, his lectures are very similar - stay away from "crazy people - but if you encounter them on a test question, here's how you should answer". They're presented almost as if they're a bother; he holds no fascination for those with mental illness, as I once did. Of course, he knows far more than I, and far better understands the subtle nuances of the fracturing and warping of the mind. Why, then, is he not bursting with enthusiasm on one hand, or shuddering at the near-horrifying implications on the other? His lectures are not that interesting - they're the bare bones. How can someone make personality disorders boring? I suppose anything can be made boring, but I'm surprised that this professor is able to make something I once considered the goal of my life - into tedium.

Professor A does not treat patients - he treats people. His lectures are punctuated with empathy, as he tells us how difficult life is for these suffering people and their families, and how success stories still keep in touch with him. He is genuinely excited about psychiatry, and obviously cares for the people he treats. Rather than "taking what he can get", it seems that psychiatry is his first love, and his enthusiasm is always infectious. Hours of his lectures pass like minutes as I fondly recall why I was first excited about mental health - and the longer I listen to him, the more I begin looking for loopholes...maybe I'd settle for psych and neuro, and could then have the best of both worlds, like Oliver Sachs. The details feel like desiderata, rather than detritus. How can two such highly trained professionals approach their career - what should be their passion - so differently?

I don't know. I can theorize, but I can't know. No one knows a man but himself. I, for one, am still excited about medicine, and couldn't see myself doing anything else. Clerkships will be difficult, residency will be draining, and beauracracy will be frustrating, but hopefully I will never lose that sense of wonder and awe. This is medicine - it's not just a job.