One year.  A sand in the passage of time.  A period of time dominated by love and pain.  Watching my brother breathe his last breath seems an experience both long, long ago and yet as recent as watching the sun rise this morning (grief necessitates the acceptance of paradoxes).  Perhaps the heavier the emotion, the greater the ability to distort our perception of time.  I'm not entirely sure where I am at with my grief, nor am I sure where I am supposed to be with it.
     I have spent the last year of my life living the motto, first, to endure.  Merely surviving the jumbled pieces of my life seemed a lofty enough goal.  It's been a good strategy for me and in all honesty, has served me well.  There is, however, a small part of me that grows daily by the smallest of margins but inexorably gains nonetheless.  It wants to move on.  It wants to enter into the clinical phase of my training fully engaged.  It no longer wants to be troubled nor governed by loss or the threat of more grief.  It wants to live life amongst the living again.  To find some measure of peace and joy. 
     You can imagine that grief might have something to say about that.  The loss and pain will not be brushed aside so easily.  So I am negotiating with grief, not that I have any negotiating power.  Grief holds all the cards.  But I've struck a bit of a truce, if you will.  Grief will allow that tiny flicker of a flame to continue to burn and be fed daily.  In exchange, whenever another wave of grief comes, I will not try to overshadow it with light.  I will allow it to wash over me as it has countless times in this past year and in all likelihood will follow me the rest of my life.  I will do so with the knowledge that after the wave has receded, the light will remain unextinguished and that I remain more than the sum total of my grief.

     Ding, ding my phone chimed.  In what's become a reflex, my wife chimes "Helen!"  I only have a few people I text and by orders of magnitude, my cousin accounts for the bulk of my text messaging.  I pick up my phone and read the text message.  "How are you doing?"  I can almost hear the emphasis in her voice that she would place on the word 'you' if she were in person.  She's my cousin whom a little more than a year ago, I wouldn't have recognized walking down the street.  But her and her sister came down about a year ago when the end was rapidly approaching for my brother.  I lost a brother but gained two sisters.  I hate to think in those terms but I can't really help it.
     I didn't really know how to answer her question because the simple fact was that I do not know how I was doing.  It's a time of great transitions for me right now which also means it's a time of reflection and looking backwards seeing from whence I've come.  I have my first licensing exam in about 6 weeks.  The tenure of my classroom learning officially ends.  Now I enter the clinical world for hands on experience 24/7.  Actually, call is 28-hours long so it's really more 28/7, if you can figure the math on that one.  My son is learning how to drive.  My dad is transitioning into his role as retired cancer battler.  (Notice I don't use the word 'survivor' yet.  We don't know if it will stay in remission.)  And the 1 year anniversary of my brother's death is nearly here.  I have no clue how to feel.  Am I supposed to feel proud?  Have I turned a corner?  Relieved?  Have I turned enough corners?  Stressed?  Sad?  Angry?  None or all of the above?
     I didn't begin to unravel the answer to my cousin's question until I took a day off and puttered in my garden.  Shortly after my brother passed, I planted a tree in memory of him in my back yard.  In the confusion and hastiness of my grief, I planted the tree in entirely the wrong place.  I considered leaving it where it was.  It would serve as a tribute that life sometimes sucks.  It often doesn't work out the way we plan.  Besides, the thermometer is already approaching the mid 90s here and so it ain't exactly the best time to be transplanting trees.  But that really wasn't the memory that I wanted for the tree.  So on my day off, I moved it, dripping both sweat and tears. 
     I listened to music as I trudged through my task and I found that I finally got a song that has perplexed me for years (and of course, it's one of my wife's favorite songs proving that I'll never understand her).  It's an allusion to Icarus and his legendary flight of getting too close to the sun and perishing in the process.

If we burn our wings
Flying too close to the sun
If the moment of glory
Is over before it's begun
If the dream is won
Though everything is lost
We will pay the price
But we will not count the cost

When the dust has cleared
And victory denied
A summit too lofty
River a little too wide
If we keep our pride
Though paradise is lost
We will pay the price
But we will not count the cost

And if the music stops
There's only the sound of the rain
All the hope and glory
All the sacrifice in vain
And If love remains
Though everything is lost
We will pay the price
But we will not count the cost
bravado by n. peart

     I never understood the last four lines of each stanza.  How it contrasts gaining a dream while losing everything, keeping our pride while losing paradise, holding onto love but losing everything.  And then final two lines about paying the price but failing to count the cost perplexed me to no end.  Well, I get it now.  I can now answer my cousin's question with satisfaction, albeit grimly.  I am dimly yet acutely becoming cognizant of the magnitude of the cost of the past year of my life.  The price is far from trivial.  I wanted to become a doctor, to realize a dream, but not like this.  Learning pain managment from your dying brother?  Learning the extent of what it means to be a difficult patient from your dad?  And given that cancer is the second leading cause of death and spans every organ system, you'd be surprised at how often it comes up in lectures whether it's pathology, pharmacology, radiology or even ethics.
     THIS is why they tell us never to treat our family or friends.  Hell, it might even be illegal here in Texas.  We can't remain objective, conflict of interests, blah, blah, blah.  What in the hell would you do if your dying brother begged of you, "make the pain stop"?  You pay the price and try not to think about the cost.

Done.  Over 900 questions spanning 10 exams.  Brain...is....shutting....down.

never enough

See?  It's never enough.  Like this question.  Again, a supposedly "easy" one though only 28% got it right. 

      I correctly identified the disease - chronic bronchitis.  And I narrowed it down to two answer choices.  Then I made an educated guess that chronic bronchitis would probably have similarities with asthma.  Asthma involves eosinophils so I chose B.  WRONG.  Apparently, chronic bronchitis is not similar to asthma from a pathological point of view.  The correct answer is C.  Cram another thing into my already bursting at the seams memory tank.  And so I close my eyes and say it out loud.  "Chronic bronchitis differs from asthma in that the infiltrate are mostly CD8+ lymphocytes, NOT eosinophils like in asthma."

when is it enough?

     You can never be done studying.  The amount to learn is near infinite in its quality.  So for me, I study until I'm done.  There's no objective criteria.  I'm just done and that's when I stop.  And as I plow through thousands of questions for review, I wonder, if I were to pull 100 random docs, how many could answer some of these basic science questions?  Unless the doc is a pathologist or nephrologist, I wonder how many would know the answer to this question?

     In my question bank, I can select from Easy, Medium or Hard.  This falls under the Easy category.  And notice that only 48% of the respondents got the answer right.  Easy, right?  I knew it but that's just because I reviewed this subject for a brutal test yesterday written by a nephrologist. 
     And do you know how I remember it?  Let me walk you through it.  A kid comes in with dark urine.  A kid peeing coke would freak out most parents, right?  Through history, you find he had an infection a couple of weeks back.  That's a pretty easy reflexive association that I talked about in a previous post.  It's Post Infectious Glomerulonephritis (or post streptoccous GN).  Thankfully, some pathologist with common sense named the disease in a descriptive manner that tells you exactly what it is.  And what's the acronym of that?  PIGN.  Pigeon.  Pigeons leave lumps and bumps of shit all over my driveway when they eat my fallen mulberries on the ground.  The pathology looks like lumps, bumps or humps.  I can never remember if they're subepithelial or not but the answer choices only have one hump choice.  All that just to remember one disease.  And you don't even need treatment.  It resolves on its own.  Like I said, I just study until I'm done. 

reflex

     When faced with massive amounts of information, we docs-in-training learn to pick up on patterns pretty quickly.  Unless you're some kind of savant, it's impossible to remember every detail about every disease and therapy.  So you pick out little gems and regurgitate the answer before you even have time to think about it.  It's a reflex.  Like this question.

Any question, any time, any test, that has a question about an African American woman with some sort of funky lung issue ALWAYS has an answer related to sarcoid.  Period.  End of story.  I've yet to see one come up where it's atypical pneumonia or something.  Obviously, that's not going to be always be true in clinical practice and therein lies some of the difficulty in translating test taking knowledge with real world doc skills.

Waiting

I've reviewed so much information, I feel as if I have forgotten more than I've learned. Like a sponge that is too full, it begins to drip moisture back out. So I found a new place to hang out before the exams. Right near the med center is a large park. And in it is a Japanese zen garden that I had never seen before. If I'm going to forget stuff before the exam, this seems as nice a place to do it as any.