language

    Apparently, the average med student learns about 13,000 new words in the first year alone.  Not sure how many in the second but it definitely keeps increasing.  The words get longer and more complex with their connotations, too.  Try saying 'Membranoproliferative Glomerulonephritis' 10 times.  And not content to leave it alone, pathologists had to identify two different forms so that there is a Type I and a Type II.  And then you have to know the inferred clinical signs because in addition to being nephritic, is also also nephrotic.  I think I'm beginning to forget simple words like 'cat' and 'dog' to be able to remember this gobbledygook.

crazy

General advice from the clinical instructor (an internal medicine doc) of my last group.

     "Anyone entering oncology needs to have a psychotherapist.  No, I'm serious.  Even though you may be normal, the clinical world in which you inhabit is not.  Take care of yourself."

slave

     My uncle recently wrote on my dad's blog what it felt like to try to be the stem cell donor and have it fail.  They spent 35 days down here, flew from Michigan to Houston twice, made multiple 70 mile round trips back and forth between MD Anderson and here, spent numerous hours in the waiting room, been poked and prodded and in all manner of ways..........and came up empty.  He will not be the donor.
     My response?  Welcome to cancer.  You bust your ass, give all you've got and then find a way to give even more, you never stop trying, battle the disease 24/7, hold onto that ridiculous yet enticing word 'hope'............and still come up short.  That's cancer in a nutshell.  Don't get me wrong.  It's not that I'm not appreciative or grateful for his effort.  I am.  But what he experienced in that condensed episode is what my brother fought against for 15 months and what my dad continues to fight against for 10 months day in and day out.  Yeah, cancer sucks and welcome to its world because it owns you.

the problem with hope

     I hate the word 'hope'.  It's a cruel and bitter emotion that won't leave you alone.  In meditation, one is taught to 'let go' of attachments to emotions.  I can often do that with anger and grief and anxiety.  In fact, I've gotten pretty adept at it.  But not hope.  I despise it because even if I let it go, it never lets go of me, along with its cousin of disappointment.  'Hope springs eternal in the human breast' and all that jazz.  A three hundred year poet wrestled with it then as I wrestle with it now.  Some things never change.
     This morning right before class, I get a phone call from my dad.  MDACC has already initiated the search for an unrelated donor.  "They got over 900 potential hits initially.  They want to narrow it down to 3 people and that should take about 2 weeks," my dad tells me.  His voice is filled with hope.  As a consequence, my ears are also filled with hope.  But does it penetrate down and do I allow my heart to dare hope?  Can we find a 10 out of 10 match in just a few short weeks?  Is that possible?  More importantly, is it probable and likely?  Do I dare get my hopes up????

Know then thyself, presume not God to scan
The proper study of Mankind is Man.
Placed on this isthmus of a middle state,
A Being darkly wise, and rudely great:
With too much knowledge for the Sceptic side,
With too much weakness for the Stoic's pride,
He hangs between; in doubt to act, or rest;
In doubt to deem himself a God, or Beast;
In doubt his mind or body to prefer;
Born but to die, and reas'ning but to err;
Alike in ignorance, his reason such,
Whether he thinks too little, or too much;
Chaos of Thought and Passion, all confus'd;
Still by himself, abus'd or disabus'd;
Created half to rise and half to fall;
Great Lord of all things, yet a prey to all,
Sole judge of truth, in endless error hurl'd;
The glory, jest and riddle of the world.

Go, wondrous creature! mount where science guides,
Go, measure earth, weigh air, and state the tides;
Instruct the planets in what orbs to run,
Correct old time, and regulate the sun;
Go, soar with Plato to th’ empyreal sphere,
To the first good, first perfect, and first fair;
Or tread the mazy round his followers trod,
And quitting sense call imitating God;
As Eastern priests in giddy circles run,
And turn their heads to imitate the sun.
Go, teach Eternal Wisdom how to rule—
Then drop into thyself, and be a fool!

 - alexander pope from an essay on man

do this in remembrance of me

     My dreams have been troubled of late.  Often my brother is in them.  Always with cancer, never healthy.  Death is also present, too.  They're not pleasant dreams.  Pot pies have been on my menu a lot lately.  And not just any pot pie.  "They've gotta be the cheap Banquet ones," as my brother would say.  And he was right.  And still is right (can he still be right now that he's dead?).  The banquet ones trump all.  I didn't even realize I was eating them so often because of him until my mom mentioned she and my dad had some one night in honor of him.
     And I think back.  Why pot pies?  They're some cheap frozen meal that can't possibly be real food.  But wh am I addicted to them?  When we first moved to Texas, I was only 9.  Both parents worked and so during that first summer, my brother was forced to baby sit me.  We had this ritual where we'd conjur up our lunch time meals.  Iggy's Grub, we called our kitchen.  Nothing fancy, always frozen or canned but it got the job done.  Three meals, specifically I remember.  Dinty Moore's beef stew.  As we got older, we both considered this on par with dog food.  It fell out of favor.  Chicken Chow Mein, though, I don't remember him liking this one.  How I wish I could shoot him an email and ask him.  "Was that one we ate at Iggy's Grub?"  Nevermore.  And Banquet Chicken Pot Pies.  This one stayed with both of us through our adult lives.  Why, I don't know.  But I remember reminiscing with him at MD Anderson about them.  It's so bizarre how a 69 cent item is the cause of such pain and tears for me now.  As I write this, I've got two in the oven cooking.  And I'm going to eat them and remember both that summer when were kids and the time at MD Anderson.  Memories are all I have of him now.

tally

Grades are finally in and the tally is:

• Epidemiology/Evidence Based Medicine - honors on the one and only exam and honors in the class.
• Genetics - just a pass on the one and only exam and high pass in the class overall.  Both these classes are now done.  Now on to the continuing classes.
• Behavior - high pass on the exam
• Fundamentals of Clinical Medicine - only a pass.  This class is presented very differently than the other classes and I dramatically underestimated the difficulty.  Need to rectify that.
• Pathology - high pass but they set the cutoff of honors at 93% so that's a hard target to hit.
• Pharmacology - ditto for this one.  There were a couple math problems I just couldn't figure which probably kept me at high pass.
• Integrative Clinical Experience/Problem Based Learning - pure clinical based on cases we work through.  Knocked this one out of the park with a straight up 100.  We're also graded by the group facilitator on how we do in the group work.  He told me I could've taught this class (it was mostly cardiovascular so I'd hope I could teach that after my years in industry) so needless to say I've got honors for this one.

Not too shabby for an old dude.

tails

     We called 'heads' on that flip of a coin.  It seems to have come up 'tails'.  My uncle donated his stem cells but the count only hit somewhere in the neighborhood of 200,000.  That number needed to be closer to 1 to 2 million so we're way off.  They're going to try some last ditch efforts to see if there isn't some way to get the cells produced but I'm not holding my breath.  It seems we're headed to the national registry so I will again make this plea. 
     If you feel motivated to impact someone's life (possibly my dad's but more likely someone else's) in a very big way with very little impact on you, I would urge you to register at bethematch.org.  You fill out the request online and they mail you some q-tip types of swabs.  You swab the inside of your cheek and mail it back.  That's all it takes for the initial steps.  They then contact you if you match anyone down the road. 
     And I'm sure my dad wouldn't mind hearing directly from any of y'all to encourage him in his battle.  Fighting day after day after day in the face of continual losses gets more than a bit disheartening.  Cancer sucks, after all.

flip of a coin

     Have you ever had a moment in life where your very survival was distilled down to two very real and very different possibilities?  I can think of one instant in my life.  I had climbed Mt. Kenya and while coming down at the very end of the trip when things are supposed to be safe and triumphant, I came face to face with a cape buffalo.  I was five feet away from him and if the bull charged, there was little chance I'd survive.  My climbing guide had lost his dad to a cape buffalo so it wasn't a trivial thing.  For what seemed like an eternity but in reality only lasted a second or two, my existence was called into question.  Fortunately, the bull didn't feel much like goring me and gave a warning snort and wave of the horns that I promptly honored.  I imagine that's what life must be like for my dad right now.  His brother, the donor, is down at MD Anderson again.  He's in the apheresis unit again.  They've given him shots to stimulate his stem cells again.  And they're collecting his blood again.  All to see if he's able to produce the stem cells.  If he is, then my dad gets a very good chance at life.  If not, and that proverbial bull rushes, who knows what will happen - will we find an unrelated donor, how good of a match will they be, how long will it take, how many complications?  It seems as fickle as the flip of a coin.

pain

     The proctors shuffle sideways through the tight rows and begin to pass out the exams.  The last one, which is actually a two-fer-one test.  A total of four versions for the test, each person gets a random version to lessen the likelihood of cheating off your neighbor.  Even the earplugs are supplied by the school to prevent any earpieces that could allow for cheating.  I thought the school was just being nice. 
     I roll up the earplug and shove it down into my ear canal.  As the spongy material decompresses against my ear canal, it's a bit like walking into a tunnel.  All extraneous sounds, and thoughts, fade away into the background as my mind approaches a zen-like state.  Except one sensation.  There's pain in my left ear radiating up from my jaw.  Right before exams started I had a tooth flare up.  Bad.  No time for dental appointments, I numbed it up with vicodin.  I discovered that while I could NOT study while in pain, I COULD break through the fog of opiates with enough caffeine and enough will power.  So each day, I'd wake up in a haze and start pouring tea into my body by the gallons, hoping that by the time the exam rolled around I'd still have enough pain relief on board while simultaneously having enough caffeine to counteract the mental fog.
     I know, I know.  It was less than ideal but when your back is up against the wall, you do what you gotta do.  All those rules and guidelines about not self medicating go right out the window when it's three am, you have exams, and you're in severe pain that laughs at the notion of ibuprofen controlling it.  The memories of my brother were quick to haunt me, too.  How many times had I watched him wait for the pain meds to kick in...waiting....waiting....waiting....ahhhh, relief.  It always took about 30-40 minutes.  So at three am, I'm frantically digging through our house looking for pain meds.  I got them for my hiking first aid kit.  They must be there.  Nope.  Medicine cabinet?  Nope.  After a half hour finally breaking out in a cold sweat due to the pain, I finally find them, pop them, and then plop myself onto the couch in front of the tv.  It takes two South Park episodes on Netflix for them to kick in.  Waiting....waiting....waiting...ahhh, relief.  44 minutes, just like my brother.
     Blissfully, I can fall back asleep hoping that my brain will begin to function on a higher plane by exam time at 1 pm.  And so I repeat this ritual for 7 exams over 10 days and amazingly, it works.  I am able to study.  I am even able to drive, much to my wife's consternation and worries.  And to top it all, I am able to do well on exams.  I wouldn't recommend it and if I had the chance to do it all over again, well, there wasn't a lot I could do.  But I can say that being visited by the specter of my brother's pain at three am is a powerful teaching moment.  If I didn't already have enough appreciation for patients with pain that is not well controlled, I now have another personal level of empathy and understanding.  Opiates get a bad rap because of some bad people but for the majority of patients who really have pain, they are a life saver.  I don't know what I would've done without them.  They got me through my first round of exams and made me a more caring doctor on top of it.

pause

My third exam is done and in the bag.  100 questions over genetic diseases and all the esoteric minutia that goes along with them.  I'm going to go out on a limb here and say that with a few exceptions, I will not see most of this tested material in my career.  Ever.  Expanding repeats, unbalanced translocations, calculating the risk of birth defects in inbred cajuns.  Ain't gonna happen.  Lots of grumbling about this class throughout my class.  Keep in mind that med students are a bunch of hypercompetitive braniacs so grumbling is the norm.  They're not used to being wrong.  But in this instance, I think there's some legitimacy to the grumbling.  Oh, well.  Don't care.  Exam is done.  And like the class yesterday, this whole class is done.  This was the one and only exam worth ~70% of the grade.  Good riddance.

I did get my score back on my first exam, which was Behavior.  Squeeked by with an honors grade by 0.4 points.  Sweet.  Not expecting honors on the next two.  But as I said, don't care.  Pass is all that matters for those.  They are done and will factor minimally in the board exams.

I'm taking the evening off, instead choosing to spend it with wine, barbeque, and South Park.  Tomorrow begins the studying for the real exams.  The heavy weights are next week.  Monday is Pathology (the 800 pound gorilla), Wednesday is Pharmacology (lots of memorization), and Friday is a tag team of a two class exam that really amounts to assimilating everything from every class and seeing how it applies to imaginary patients.  It's bizarre.  They only had 5 lectures in this class but it's probably the hardest and most expansive class that we have.  The diverse topics range from anemia of chronic disease to fever of unknown origin to heart failure to my personal favorite, EKG interpretation.  The other difference is the test is written by a pure clinician, not a PhD.  I'm hoping that balances in my favor but we'll see.

ruminations & anxieties

     Even though he lives just a few miles away, I've hardly seen my dad lately.  Exams and the lead up to them have been brutal and I've had to compartmentalize.  I still try to call him at least every two or three days but even that has become more difficult.  I typically would call when I'm making that hour long drive to-and-from the med center.  But even that time is now packed with listening to lectures in the car.  Besides, it's hard to gauge over the phone how he's doing with the waiting.  First, the manic rush to stem cell followed by the brick wall of a poor collection.  And now playing the waiting game. 
      So I honestly do not know how he's doing.  But I have a decent imagination.  He hates inactivity and waiting.  I'm sure his mind is running through endless scenarios of "what it, what if, what it?"  I know mine has.  And my mine isn't content to just ask the question.  It has to answer them.  In the back of mind where I still have a bit of reserve brain power, I've begun to wonder, 'what about that new clinical trial with genetically engineering the patient's own T-cells?'  Before, it was a moot point since we had a perfect donor match.  It wasn't necessary.  Hopefully, that still holds true.  But now?  I don't put much stock in hope.  I tend to put my stock in Plan B, just in case.

Second test done.  It was only 56 questions.  It was mostly over stats and who doesn't enjoy being tested over stats?  The only good thing I can say is that this class is over.  It was a short class with only one exam worth 70% of our grade.  Good riddance.

first

104 questions over behavior and my first exam is in the bag.  Not sure how I did other than I passed and that's good enough for now.  Line'em up and knock'em down.

highs

     Tight with strain, my eyes easily glaze over at any chance they get.  Subsisting on fast food, I've abandoned exercise for a bit, and in all likelihood am drinking too much.  Check that.  I told my wife, "yes, I know I'm drinking too much.  If I'm still doing it in 10 days, then you have cause to be concerned." 
     And yet I emailed my wife just the other day, "in some weird, twisted strange way, I'm almost enjoying myself."  I started with real patients last week and this week marks the finish of the first leg of a sprint begun in August.  It's exam time.  The first of four this school year.  And they don't mess around.  Seven exams in ten days, probably in the neighborhood of 600ish questions in total.  I'm not sure I'd ever want to do this whole training gig again but I must admit that I am thrilled at the opportunity.  I do not regret it one bit.  I vary between thoughts of "oh shit, I don't know anything, I'm screwed" to delusions of "meh, it won't be that hard."  It ain't easy.  And nevermind all the obvious emotional associations of what I'm studying being being inextricably wrapped up with my brother and dad.   But despite it all, I love the fact that I'm doing this.  I feel alive.