This was a stream-of-consciousness rant written by Karl in the summer of 2007.

There are a number of things that annoy me in this world. I’m sure sometimes there are more than I would like to admit. Some things like the violence in the Middle East or Africa, hell why even go that far? Let’s talk about the violence in New York City; a little closer to home in more ways than one. But none of that is going to change anytime soon. Of course, that fact doesn’t seem to make me feel any better or make me any less annoyed at it, but perhaps that comes back to my perpetual lack of understanding with how someone could kill another. I digress… other than the plethora of things that are outside my control, there are then the things which I can control, from one point of view, which is by my proximity to them. By that I mean I can possibly control them because I choose to be in contact with them. For instance, there are certain characteristics inherent in medicine. They will never change because they have been ingrained so deep over hundreds of years. Would these factors that I come in contact with everyday, perhaps we could say subject myself to everyday, still annoy me if I was no longer a part of medicine? They would still exist. Medicine would still exist, and it sure wouldn’t miss me. Would they still annoy me though? Because in the back of my mind I would still know that they are there. This becomes confusing, and an example is required…

A few of the hospitals that I have been at wouldn’t necessarily receive exemplary marks in the teaching category. I guess that’s a nice way to say they don’t really teach students very well. Perhaps that is overly critical. Perhaps it wasn’t my style of teaching. I will be the first to admit I have a very specific ways that I like to be taught. Perhaps some would say overly high expectations. I guess it comes from being fourth in a family of five. I’ve always been pushed whether I wanted to be or not, and somewhere along the way it has become inherent in me that I learn best when pushed just ever so slightly. And therein lays the problem. Medicine only understands extremes. On one end of the spectrum there are the hospitals that I have heard of; continuous pressure, pimping, pushing, driving, and overall hard-liners. These are the stereotypical US hospitals. Supposedly the best in the world according to their own biased opinions and statistics. And with every spectrum, there lies the other side. This is the side that I have seen more often than not; a lack of care, compassion, or skill. Everyone seems jaded and just pushes to get through the day.

This, of course, does not lend itself to teaching. Although, some would argue, myself included, that neither does the other end of the spectrum. There don’t seem to be shades of grey where students can choose the method of teaching that works for them. In college you can pick your professors, but here you can’t really pick which attendings you get stuck with. But it doesn’t stop there. If it was just that there are attendings and residents that can’t teach very well, that wouldn’t be a problem. After all, not everyone in the world is a teacher for a very specific reason. The thing that continues to haunt me everywhere I turn is the apathy associated with the programs. Not a single person I have worked with has the charisma, motivation, confidence, resilience, or care to improve the program that they are apart of. And at the point that people don’t want to even put forth the effort to improve the situation that they are in the middle of, the rest is lost is the sound of a flushing toilet.

I have confidence when others have confidence in me. My self-esteem is not usually at an all-time high, but especially comes into question when others start to question me. I would love it if everyone saw it as modesty. It’s really self-doubt and low self-esteem. This becomes painfully obvious in the clinic or on rounds when the attending isn’t even sure that med students should be there. Because once doubt enters the psyche of one, it spreads like a virus throughout the room to everyone including and most especially the patient. The patient then becomes unsure, and the downward spiral ensues usually ending with the medical student leaving the room. Attendings and residents that give an air of confidence when they say that we are apart of their team permeate the room with a sense of calm, and consequently students stay in the end. This conundrum becomes even more apparent when certain anatomy comes into play. If attendings or residents are uncomfortable with a vaginal or rectal exam, it becomes projected on the medical student that they should leave. Not because they haven’t seen plenty of these tests, but because then the attending uses their power to send the med student away to build their own confidence. Perhaps the patient will feel more at ease with less people in the room, but I would continue to argue that this still comes back to the attending exhibiting confidence in the first place to rectify that situation.

Then we arrive on the pervasive overriding difference between medicine and myself. I differ from people in medicine. I do not fit the mold. If there was a lineup of doctors, I would probably be the “one that is not like the others.” I yearn to be in a relaxed and chill environment. It took me six years to get out of a mold that I built for myself. It took six long years and changing locations three times to get to a point where people didn’t see the brain cloud that obscured my vision. And now, a short two years later, I feel it returning. Not to the point that people have started mentioning it. Perhaps they just aren’t comfortable yet, but deep down somewhere I can feel it trying to rise back to the surface. Clawing and scrambling out of the deep, dark, depths that blonde hair, travel, and vitamins helped me bury it. I don’t want it to take a hold again. I don’t enjoy the dark shadow it casts after I remove my sunglasses. But medicine has an effect that I have a difficult time controlling; an anger that rises in me from the hierarchy, the politics, the pimping, the competition, the learning styles that aren’t my own. Should I be put off guard because I am unable to think quickly on my feet? Because it takes me time to work through the renin-angiotensin path or any number of endocrine disorders? Perhaps it shouldn’t, but it does. It stresses me out, and as hard as I try to not let it effect me; it does. And people will say “you should learn how to control your feelings.” And perhaps I should, but in the meantime as I try to meditate, the water gets closer to being over my head. And once you start to drown, it’s that much more difficult to get to shore.

And while we are on the soapbox about people in the medical field, one other wonderful characteristic of medical professionals is their inability to remember what life was like before they got to where they are. Perhaps they remember what it was like and, back to the apathy for the current state of affairs, don’t care. I once had a resident tell me: “I hated medical school, but I did it, and now you guys have to do it.” What do you say to that? Your life sucked and now it makes you feel better to try and make other peoples’ lives suck? That’s borderline sadism. But so is medicine. Because people want others to go through exactly what they went through in order to make it into the brotherhood of the shield. Maybe just so that others appreciate the struggle, even though everyone that makes it through to the other side knows how useless it really is.

But if it were just the people that put me on edge perhaps I could learn to tolerate it. Somehow learn to tune them out, and return to my own terms. Of course, it’s more than that. I could drive myself to think quickly; work through systems and disorders and diseases as quickly as any student from the states. But I can’t bring myself to miss out on life experiences in the name of medicine. People in this field are already two-dimensional and one-track minded. They rarely know current events, other cultures, or anything that isn’t written in their book. This is probably because they were on call last night. And if they weren’t on call they were sleeping because they were post call. You can always tell when medical professionals are in a conversation. Sometimes it doesn’t even require more than one, but surely if there is more than one, the conversation will always, inevitably, weave its way toward medicine. Like a car accident that is about to happen in front of your eyes; there just isn’t enough that you can do to stop it. Missing out on having friends in town just because the boards are coming up; missing comedy shows, art exhibits, or nightclubs in New York; skipping out on the culture of western Europe; none of these are acceptable losses to me just to learn a little more medicine.

So of course if my secret was let out of the bag to the world of medicine I would be shunned into the corner because not wanting to work 12 hours a day and then studying another 6 before sleeping 4 to get up and do it all over again is frowned upon. Not just frowned upon, looked down upon like looking for the bottom of an empty well. Looked down upon in order to make you feel inferior that you don’t know something and aren’t willing to give up life in order to learn it. And looking down on someone else is so much easier from the high road. Statistics are quoted on patient morbidity and mortality to somehow guilt you into working and studying more and giving up more of the freedom you already don’t have much of.

Now don’t get me wrong, I’ll work just as hard as anyone. Not only does it give a sense of fulfillment getting a lot done, it passes time quickly. When I am at the hospital, I will go straight for 12 hours and try not to complain. Among medical students this work ethic is either minimal at best or nonexistent. I’m not sure how they manage to hide the fact that they don’t like learning in order to get good evaluations, but they do it well. They manage to appear at exactly the same time as the attending and disappear on cue just as quickly. I don’t need to be accusatory or point fingers. Even if they did want to be there to learn, I still differ from them. I find it awkward to not be helping. I have a pervasive desire to feel needed and not like an extra burden. Standing around watching only keeps me awake for so long, and so I watch to try and anticipate what they will need next. Sometimes it works, and most of the time it doesn’t. In Guatemala, I asked what they needed me to do, not what I wanted to do, and I lucked out that someone appreciated that. However, in the hospital when you ask what they need you to do; you are told to do secretarial work, do busy work, or leave. Because that is what is easiest for them; because learning and teaching are not helpful. It doesn’t allow anything to go smoother, and it becomes a burden on those forced by the medical profession to do it.

And continuing the soapbox about the difference between students and myself, let’s talk about the vast difference between how students view the patient they are learning on. I have started thinking that if a student expects to learn a procedure on a patient, that student should be willing to allow other students to perform that procedure on them. If a student wants to learn how to do an LP, fine. I have no problem with students learning complex procedures usually saved for residents and attendings, but the question arises when students are asked if they needed an LP, would they allow another student to do it? Immediate, unhesitant, and emphatic is the response. No. Perhaps it’s the communist in me or maybe the affinity for the underdog, but when those who know medicine only allow the best and the highest ranked to perform procedures on them or their loved ones, that leaves the ignorant, the poor, and the destitute to “practice” upon. These are the people that don’t understand the system and can be easily misguided by consenting to allow the medical student to “assist” with a procedure. But that is the reality of the profession, and the most disheartening part about it is that nobody sees a problem with it.

And where does all of this put me? In some strange form of irony, it puts me in the spot of being tempted to return to the simple life. The life that I once thought was stagnating. I was nearly the most educated employee and returning with an MD would secure that title. The life where people are relaxed, chill, and yet when work needs to get done can step up and speak into the microphone. Of course it is just a matter of time until the feeling of stagnation creeps back over me. Because traveling in one to two month increments is not going to help anyone except those looking for multi-vitamins.

So with two ways of getting to never never land we look a bit further into the future and determine what exactly we are looking for out of this career path that we have chosen. I have become interested in social systems. An interest toward the everlasting debates of waiting times versus high prices; universal coverage versus insurance coverage; and taxes versus individuals. Perhaps this makes people think of politics and governments, but I can’t handle the meetings and the talks and the lack of action. And who besides anthropology would be able to see the social systems without the burden of bias. Who would be able to evaluate through the hearsay and the personal stories and anecdotes. Truly manage to get to the heart of the matter; to find out exactly what the real story is and exactly how many people the system helps. With knowledge such as this, would it be possible to set up social systems from the ground up without meetings and politics? Is it possible to make such an effect without the talks and the planning and the time-wasting “proper channels?” But through the burning desire to affect health care over a larger span, there is still the primal feeling of just wanting to help those in need. To be able to see the look on patient’s faces when they realize you have saved their life. The “thank you” from family members who realize more than anyone how close they came to losing a loved one. Is it possible to merge these two dreams into one cohesive plan that embodies the best of both worlds? Would things work out they way I eternally hope? Would trying to do too much cause nothing to work? These questions won’t be answered anytime soon, but still deserve appreciation because they should direct the choices of direction that I go.

“If you give in, they will win” was the last line of the email that he sent. Besides the fact that I resented my choice of lifestyle being compared to a competition, I didn’t care if they “won.” Why should I ruin the rest of my life doing something I don’t want to just because there are some people that will continue what they are doing? And at the point that we say fixing a broken system is more important than the happiness in my life, than that is when we have a problem. Because at the point that you are not happy fixing the broken system, than you will not be as effective. And in the end the system won’t have changed and you won’t have succeeded. How much pride should play a part in not averting (diverting?) from your goals? Because this would be the reason if someone said that they would continue to do something they didn’t want to so that some nebulous people won’t “win.”

There are other options of course. Although there probably isn’t enough work to keep two people busy, Elk Rapids I am sure could use a resident 4th year med student to do something. I could go and see people I haven’t seen in a long time. Jenn and Darren, Sue and Will, Danny, Che… Talk to them and see what they think. Bounce ideas off of people and see if something appears out of the shadows of a direction to go in. Somewhere that allows me to walk the line that I want to walk. And continue to be who I want to be in the location that I want to be in. Figure out how a person can be naively idealistic and pessimistic at the same time. Relax and recharge after the hard push for the last three years. And of course, the side effect, possibly stagnant as well…

Or there is always the option of pressing on full speed ahead. Continue in the direction that I have been sailing and pushing toward with all my effort for the past three years. Although if things continue in the manner they have been, than a very real possibility is the idea of burning out. Getting to a point where I can no longer handle being around the people that personify medicine and have to leave. For good. Probably never to deal with medicine again, and then what will happen to these ever elusive dreams? But I admit that just as clinical medicine is a lot about luck and time and place, so probably will residency be. If I can manage to swing a global health residency with good people that want to do the same thing that I want to, then perhaps we can ward off the funk that I have been in and turn the corner to promise of better days ahead and attaining what I have dreamt of attaining ever since my days underneath the Guatemalan sun…

“Everybody has been wondering where you’ve been, and now that we know what happened, we’re all wondering where you are. And even though we feel bad we won’t be seeing you around anymore, we want you to know, we feel better we won’t have to worry anymore. We know your only worry now is you worrying about us worrying about you. And even though we stopped worrying, that doesn’t mean we’re not still sad. And we’re happy to let you know that we always will be.”