I'M SO EXCITED! I JUST CAN'T HIDE IT! dada-dada-dada-dada-da-doodoo.

supposed to be studying. and am getting some stuff done. going through review questions and taking notes on things i need to make myself remember. reviewing all the 'buzz' words that lead you to a diagnosis....auer rods/philadephia chromosome/ca-125/reed-steinberg/thompson test/thomas test/homan sign...etc, etc. somehow i've kept all this stuff more or less categorized in my head and so just going back over it now is hopefully cementing it in place. it does alarm me, though, that in 5 years time i have to re-certify and that then i'll be YEARS out of school and away from all these memory games that i play....that will be rough. but for now i think that my tricks will work. tricks such as: the Philadelphia chromosome reminds me of a philly cheese steak and what's on a philly cheese steak? why that would be: Cheese, Mayo, and Lettuce.....therefore bringing me to the correct diagnosis of CML (chronic myelogenous leukemia). i have millions of those. i really do. some of them kind of naughty, if you must know. someone asked me the other day how i was able to learn all that i know in the short time i had to learn it. i told them memory tricks to get it down initially, but then once you've seen it on a real life patient, it just sticks with you. OR if you totally blew it when a preceptor asked you a question ('pimped' you) you'll remember those, too. i even remember the questions that my FRIENDS totally blew and then came crying to me. there is some merit in being publicly humiliated.

ANYway...

so yes, i'm studying, but....mostly i've been preparing for and thinking about my upcoming vacation. we are going to eat really well on the trip. and since food is such an important part of my life, i will share with you all the amazing meals that i have. and, since we're doing a bunch of wine tastings and such, i plan to become a genuine wine snob and say pompous things like, "i do detect a slight cherry, oak, prune, caramel aftertaste and, if my nose does not deceive me (which it NEVER does), i believe this harvest was in september and that the grape picker's name was raul and that he wears a red, no wait...a dark fuchsia hat while pruning the vines." and as i speak i'll wave my hands around grandly and say things like "RATHER" and "oh, indubitably, i do agree."

that's my plan. in reality, i'll probably look like i just fell off the bus and landed in sophisticated places where i don't belong. i just hope i don't do anything too stupid to embarrass my family like ask for a straw while wine tasting or pull an eliza doolittle and rave loudly about what "good shit" i'm eating.

these concerns are not without precedence. when my parents graciously took me to england for high school graduation, i had just taken an honors english course where we talked a lot about the history of shakespeare and whether the author of all those plays was in fact the man we think he was, or instead an earl or someone else of royalty... so....when we were at westminster abbey, i very earnestly asked the stodgy (but good humored, mostly) tour guide where the "real" shakespeare was buried. i think i even had a conspiracy theory name of some aristocrat and was looking for his headstone. needless to say, we were almost kicked off the island.

cheerio!

Too Cool for School

so the last few days have been my last in the PA program. i'm now a graduated physician assistant and am one boards exam away from being licensed. all year i've been saying that i'm "practically a doctor, practically"....very soon (and for the rest of my days) i will simply be "practically a doctor." i'm good with that.

thursday night we had a party at a fun sports bar with all the students and our spouses and all the professors and theirs. it was nice to celebrate with everyone. emotional, thinking that these are the last occasions we'll ever have to all be together. i have a lot of great memories from working with and learning from my peers, and of course, my professors. but we ate and drank a lot and were generally very merry.

friday night was graduation. it was really nice. the speakers said many kind words about our class and were optimistic about our expected success as PA's. they're already begging money from us, since we're now alumni....which was mostly more funny than annoying....you'd think they would wait until we actually started paying off our debt we accrued from their exorbitant academic costs before hitting us up for cash, but alas.....i learned that we are the 800th graduates from our prestigious program (i wonder if all those alum are donating to the school?)...so there's an army of us out there- look out.

i got my official long white coat meaning that i'm not a student goofus anymore but a full grown real deal goofus. that's a major relief. i've been waiting a long time to have the backs of my knees covered. it's a nice coat, too. many pockets and a waist cinch thing. very high class. but it's a whole lot of blank white canvas... so i'm thinking about airbrushing a unicorn or something on the back. good idea? i thought so. and have i mentioned yet that i get to wear scrubs everyday in my new job?? i will only actually wear said coat when i'm rounding on patients on the floor, so most of my days it will be hanging in the PA surgical office fraternizing with the other coats.

my whole huge family and a bunch of friends came over/down/up from where they live to see me graduate-we had a little pre-grad party at the house with appetizers and my special super secret famous drink , then cake and champagne following the ceremony at school- then came back to my house for pizza after all that. so we did not starve. i have a wonderful family- both mine i was born to, and my husband's who adopted me. very supportive and loving, and generous. i got some amazing gifts- lots of financial assistance, but also chocolates-to-die-for, champagne, PA paraphernalia, beautiful jewelery...all kinds of good stuff. i told them i will just keep getting more degrees if this is the kind of loot i'm going to pull when i graduate. my husband did not find that amusing. i think he's really ready for me to have a normal schedule, normal routine, and a PAYCHECK. i couldn't agree more. he's been really gracious about me being a crabby, busy, ungrateful mooch- but i'm ready to be a little more functional member of our family.

so then all weekend i partied with friends who stayed in town following graduation....and today i hit the books. i have 4 days this week to study for the boards before my parents, my husband, and i leave for san fransisco and nappa valley next weekend. woo!! we'll be gone for 10 full days. so excited. then when i get back, i'll have 4 more days to study then i take the exam. it will be fine and i'll have plenty of time to get in all the review i plan on doing, but it's feeling a little closer and scarier now.

i think i'm going to try to blog while on vacation- so if you're interested in all the awesome wines and foods and beautiful destinations that san fran/napa has to offer, stay tuned.

Again with the Debbie Downer

it's 10:00am and i'm in my pajamas, drinking a cafe au lait and watching "golden girls" reruns right now, like any good summer break morning should be. and last night i was all zen after i did yoga. i left the gym totally relaxed and thinking world peace thoughts. as i walked to my car, i glanced over at a rotund couple walking into the ice cream store (right next to the gym, how cruel is that?) and actually thought, "you don't want to go in there, you want to turn around and go home and drink some green tea." and then i laughed at myself, because somewhere in my mind i actually believed for a second that my jedi mind power would work.

so clearly, i'm doing my best to feel relaxed and celebratory this week. but i was up much of the night tossing and turning. yes, my exams are over, but they were pretty intense and i still don't have my results, so there's a chance that i'll have to redo one or a few of them. which means, there's always a chance that at this late date, a few short days from graduation, i won't make it through the program. all that work, all that money, all that stress- can be wiped away in a moment's failure. and i'm afraid i may have failed. and if i do get through and graduate, there's always the impending licensing exam for which i have to frantically hit the books. a 6 hour painfully difficult exam that can keep me from practicing. and immediately after that, i start the new job where they expect me to know stuff and be able to practice at a proficient level. i'm pretty terrified about that. all of that.

so, as per my M.O., i have found a way to make this most awesome of times of celebration and success into an uncertain and daunting time. ugh.

so i'm going to go lay out in the sun and finish reading "mount misery" by samuel shem. it's been depressing the last few chapters, but is starting to look up, so i'm hopeful that it too will help pull me out of my mood. (by the way- whoever commented on samuel shem- are any of the other books a little brighter? is there a new one out this summer? this one has been much darker, less hopeful than "house of God" and i've struggled to get through it).

addendum: watch how quickly i can swing moods. ready? so i just got my final grades and i PASSED EVERYTHING! the one exam i was pretty sure i'd really blown, i received the lowest grade necessary to pass, meaning that I PASSED! and i finished reading "mount misery" which ended really profoundly and beautifully with a lot of hope (and my tears). so now i'm feeling all yippppppppeeeeeeee!!!! guess what? i'm graduating, graduating, gradu-gradu-graduating!!

Them's Were The Days

flashbacks a plenty as a group of fellow students came over yesterday to study for our upcoming practical exam. my house being centrally located and us not having any kids to worry about interfering with their lives, mine was usually the place in which we all met to study last year during our didactic classes. being all back together, getting ready for this next big exam (tomorrow/monday, big practical exam where we demonstrate our exam/diagnostic/treatment skills on fake patients while being graded by professors), reminded me of the frantic days of studying last year. it was bittersweet thinking that this would be the last time we would gather en mass at my house.

one of my bestest school friends lives way out in the middle of nowhereville and so, for studying convenience, he stayed w/ us on many a weekend last year. he came and hung out before and after our study session yesterday, and it felt just like old times. sigh. i'll miss that.

and we sat around and ate that beautiful cake and laughed until our stomachs hurt, sharing stories about how our lives were last year when we studied/panicked all the time, and how our lives were this year as PA students in the real world.

as far as last year goes- the program i attend is pretty cut throat. not just to get in, but once you're in, many people didn't make it through...it is set up so that on each exam that you take, failing out of the program is always just a few points away. so...we had many rituals to our study. we were an extremely superstitious bunch. in the days leading up to our big exams we all had certain dietary restrictions (a few people admitted that they had to eat on the morn of every big exam the same food they happened to eat on the morning of the FIRST exam), sleep restrictions, places to visit/avoid (one of my study buddies and i sweated bullets when we changed from our regular coffee shop to a restaurant elsewhere), people we had to talk to/avoid, loving we had to have/avoid, even our bowel functions were tightly controlled around exam time...we actually accumulated these into a list and presented them on video to this year's incoming class as a warning of the neurosis that would develop in their lives during that stressful year.

regarding this year...we regaled each other w/ stories from our antics in clinicals. we heard a similar story to mine of erupting cysts- but covering HIS cheek and neck instead of the doc's he was with. another took a needle full of valium in the back of his neck, from a clumsy student nurse. other people had lost things, said dumb things, given the wrong patient the wrong advice, etc, etc, etc. it was comforting to know i wasn't the only buffoon pretending to know what i was doing this year. it felt really good to have everyone together. and everyone is both ecstatic to no longer be students and to wear the official 'long white coat' that means we're PA's, but also terrified of messing up, harming patients, not knowing enough. we're all in the same boat on this.

one of the students is a marine, and he compares the brutal challenges and discipline it took to get through this program to that which he faced in service. that may be a bit of a stretch, but we were definitely put through our paces this last 2 years. and the bond created by surviving something like this together is very strong. we're all different people from widely different backgrounds and heading in different directions, but no matter where we started or will end up, we know we have a few dozen people out there in the world who understand. the PA world is still a small one, even in this relatively large metropolitan area...so i suspect that we'll cross paths again professionally, and of course will do our best to maintain social relationships. i feel a lot more ties to this education than i do to my undergrad one- which is unusual, i think. even though this is a master's program and we're 'graduate students in a highly esteemed clinical program' (herumph!), i kind of wish we had yearbooks or class rings or something to commemorate this.

so...one last major exam tomorrow (will we make? don't know! better eat my ritual pig's heart and call my 2nd cousin twice removed at exactly 10:42pm for luck!), big party with all us students thursday night, then graduation with friends and families on friday.

i'll keep you posted on all the tears, fears, and cheers.

I Can't Believe It's Over

so for weeks i've been feeling burned out and tired and desperately wanting a week without thinking about medicine. completely without thoughts of - is that drug excreted by the liver or kidneys? -could this thing on the patient's skin be a carbuncle or a pile? (i like those words and make it a practice of thinking/saying them, even though there are actual official names for them).

i've just been worn out. unhealthy in my head, my body. drinking caffeine all day long- even in my water a few days ago (eck!), eating unhealthy food...and watching TV instead of studying/spending time outside. and let's not forget flat, stone-cold broke! it's been great that all year we've managed to keep a little something in savings for a rainy day despite my not working (for things like flooded basement/broken car exhaust system/mission trips, etc). but because of events like these, we are now depleted. i know we'll be fine (this is NOT a plea to my family/friends to send us cash, it's really not). it's just that i like having a little cushion (the MONEY kind, not the kind that develops from my sitting around watching TV and eating junk food). i'll be so glad to actually get paid...i keep trying to remind myself, things might be tight now, but very soon we'll be very comfy. and we are so blessed. we've never really wanted for anything, even on the one income over these last few expensive years of school. and we "own" a house (as in, have paid off something like 4 percent of our house- i think we own the sink in the upstairs bathroom outright...maybe).

so all that whining is to say that i'm feeling really sad that this is my last day. it feels so final. no longer a student. leaving the MD and his staff who i've spent 3 months with over this year and the hospital in which i spent 5 months...i had to drop my badge off today...and say goodbye to the nurses and docs i've gotten close to. i spent the last $2.72 of my starbucks gift card today on an iced latte in the starbucks in the hospital. cleaning out that reliable account seemed like an official end. (by the way, this IS a plea to my family/friends to send starbucks money-i'm not too proud to beg).

so i'm emotional. excited, but a bit sad. one more exam on monday and then graduation next friday (the 15th)- assuming all goes well. i have to say that last part. it's like a superstitious thing- and you couldn't see me, but i just "tsu tsu" spit on the floor to keep me safe from curses. :)

i have a request. i am going on vacation between graduation and the time i take my boards exam in september. (leaving myself a week on each side to study). i want to read some totally non-medical books while on vacation. i mean, i don't want a hospital in site of the setting of the book and the characters should not have as much as alopecia or halitosis. if anyone can recommend something well-written, fun, maybe funny...that would be awesome. i'd appreciate it.

and now i must go drown my sorrows in this cake. this is not a picture i pulled off the interweb. this is actually the cake that the staff at the MD's office gave me as a going away present. amazing. it's about 10 inches tall and so decadent! the pics probably don't do it justice. and it had a little confectionery sign on the top that wished me good luck. i already ate that through sugary tears. :)

I Will Cut You.

i'm not sure if the general public is aware of this, but there's a sort of rivalry/respect game thing between surgery and medical folks. it's something like the surgeons think they're rock stars that cut and dig and sew things back together to save lives and the medicine docs think they understand pathophysiology, diagnostics, and treatments of life threatening conditions better, so that they can more sophisticatedly and less boorishly save lives. surgeons stereotypically are very skilled with their hands, seeing what they do as a fine craft, and want to make the problem in front of them go away, and then move on to the next....they tend to view time outside of the OR as boring...and aren't notorious for their excellent bedside manner. medicine docs, stereotypically, conduct long interviews with their patients, don't do much hands on examining/ treating, but will follow their patients' hypertension, heart disease, diabetes, etc over their lifetimes. there's definitely a difference between the two philosophies and everyone is subconsciously aware of it. as far as how i look at things, i'm somewhere in the middle. i like medicine- i like taking the time to think through a spiked temp about all the possible culprits that could be causing it...and I LOVE mannering at the bedside, but i also like actually examining, opening up and taking out the problem. and it's not like i won't be practicing medicine as a surgery PA- i will follow patients post-operatively and do admissions pre-operatively for them...

...but i guess i do kind of like the incising and draining of a cyst and figuring out the appropriate antibiotic coverage more than pontificating about what underlying autoimmune disorder might be causing the patient to be more susceptible to cysts and speculating as to whether it will recur.

but that's the great thing about my training- PA school is such a complete, general education that i do have, in the back of my mind, an idea of the big picture of what might be happening with a patient, even though i'm just cutting or squeezing on something.

it's been eye-opening, though, over the last few days that when i tell people at the hospital (all internal medicine people) that i took a surgical job, i hear a lot of, "oh, well. that should be fun" or "even though you're not going into medicine...let's talk about heart failure...you should know a little something about it..." as if they expect that when i start surgery, i'll turn my brain off and forget everything i know. i assure you, that won't be the case. i won't worry just about the incision site and whether or not the patient is moving his bowels, i'll consider all his ailments and meds and how they might be playing a role in his presentation. i will. i really will. and if i forget everything i know and instead occupy my brain with the names of the ligaments of the knee or the 13 types of forceps, i can always consult medicine. :)

booya.


by the way- a friend asked just what a PA does in surgery: here's what i told her, in case you're wondering the same thing...

what PA's do in surgery is assist the surgeons. but not like the nurses or techs or anesthesiologists assist the surgeons, but actually scrubbed in, across the table from the surgeon, cutting, holding, sewing, suctioning, cauterizing, etc along with the surgeon. if it's a laparoscopic surgery- we move the internal camera so the doc can identify and cut out whatever he's taking- gall bladder, appendix, or sewing up a hernia hole, etc. so i'll be used in this capacity for any surgeries that require 2 people (this is wide ranging- abdominal surgeries, vascular, cardiovascular (some open heart), neuro (spine/some brain), gyn (hysterectomies mostly), plastic (boob jobs, face/tummy tucks, etc), ortho (hip/knee/shoulder replacements, amputations, etc)). and then i'll follow patients post-operatively as they heal in a hospital room, taking care of their wounds and pain, diet, and all that.

there you have it. :)

The Human Race: Take It or Leave It?

so i was having a discussion the other day with a group of friends on whether human nature is fundamentally good or bad. there are easy and hard arguments for both. i've always inclined toward glass half-full when it comes to people as a species, and am of the opinion that, although we certainly can do horrible things, one-on-one, we basically don't have ill will toward others and will show some kindness when put to the test. but this week has been a test of my faith in human beans. and in my own humanity.

in my own small world i'm still all tra-la happy joy joy over my new job. but it's been nuts to the wall busy at the hospital where i'm finishing up my final preceptorship rotation. completely insanely busy. like i can't believe i'm doing all this work for free- busy. and it's getting frustrating that i can't write my own orders, can't make decisions on my own. i feel like a puppet where i'm pulling my own strings but someone else is getting all the glory and laughs. and internal medicine is so tedious in many ways. i write the same note on virtually every patient we have, since they all seem to be in with renal/cardiac failure. and it's kind of a cluster-badword working with all the consultants...

like "did so-and-so order the transfusion? i don't know-what did he say? can you read his note?" absolutely not. ever. "did so-and-so show up yet and make a decision on what to do about ambulation/diet? well, his resident came by and they said...." absolutely nothing. ever. "did so-and-so remember that putting the 400lb patient on a 1500 calorie /day diet (when he's used to eating, probably, 4,000/day) but not adjusting his massive amounts of insulin might put him into a coma?" not so much. like i said in an earlier post, doing internal medicine is like being the ring leader. but it's a lot to juggle. and it's getting pretty old.

so i've been crabby about that. and also, patients and their families can be very frustrating. much of health care is about customer service...but that can be challenging when there are impatient 'customers' bitching about every little thing. it seems some people have no idea that they're not the only patient in the hospital and that sometimes their priorities and that of the rest of the world don't match. every once in a while i'll come across a patient/family member who thinks that shouting/whining/threatening is the best way to make sure you remember they exist. it usually has the opposite effect.

and news this week (i check cnn.com every morning for a pick me up w/ my coffee) has been devastating to my people-are-good theory. examples of horrible, twisted murders- 16 and 17 year old kids beating to death a Mexican immigrant, several pregnant military women killed by baby daddies and the revelation that some 40% of women in the US military have been sexually assaulted while in the service, the anthrax killer scientist's suicide, the list goes on and on. awful things people are capable of. it can be so disheartening. and maybe these incidences and, of course, the larger scale human tragedies we've seen across history, trump the small anecdotal evidence i've collected to prove that people are good.

but i still have to stick by the astonishing human spirit i see in patients. for all the pain and fear and anger people experience while suffering in the hospital, most are amazingly generous and kind. patients who haven't gotten to take as much of a sip of water in a week and are being fed through their noses, those in unfathomable pain, those getting zero answers and only more tests, tests, tests, some who are in the process of dying....they will still smile and laugh with me. will still reach out to their family members and worry about their needs. they'll even worry about their roommate or the patient down the hall that they hear crying out.

and we had a patient recently in the ICU who was in terrible shape- on the ventilator, being dialyzed, jaundiced, swollen all over, every system shutting down...and her wonderful husband kept coming in every day, not just holding her hand and talking to her in her non responsive state, but also teasing the nurses, bringing cookies to the staff...he somehow still built people up while going through this most awful situation. and you can tell they've impacted others-- apparently she and her husband (married 64 years, he proudly told me- he called her his "princess") had for years gone to mcdonald's every morning for senior coffee. when the staff there noticed that she wasn't coming in with him, they asked about her...and mcdonald's sent a HUGE bouquet of beautiful flowers up to the hospital for her. you can't tell me they're trying to keep their reliable $0.60/day customers happy- that's just kindness. love to virtual strangers. goodness.

i found that really touching. and for that example and many others, i'm not changing my theory that people are loving and good. i don't know how we effect change so that people won't do awful things...it's pretty apparent that we humans all have the capability to be awesome or awful....other than to show them kindness and grace and hope they figure it out. when i'm angry and fed up with whiny patients or devastated by the stories in the news, i try to remember that i can only control my own interactions with people and hope that how i do will effect the world at large. i've certainly seen examples of how to be humble, gracious, and thankful from my patients, and i'm really trying. if you have any ideas on how to go about any of this, let me know.

so that's where i stand and what i've been thinking about these last few days. sorry i'm kind of a downer today.

"there are good people and bad people in this world....the ones who start the fires and the ones who put them out." - meryl streep as 'aunt josephine' in "lemony snicket's a series of unfortunate events"

"people are bastard-coated bastards with bastard filling!"- dr. bob kelso, "scrubs"