I Have Been Neutered!

Each year the University of Texas Health Science Center at San Antonio (UTHSCSA) solicits its new fourth year medical student class for words of advice for the beginning third year medical students as they start their first year of clinical rotations. The ensuing publication, appropriately titled Letters to a Third Year, is then shared with everyone who's willing to take one home with them. As I had a good deal of time and a message I felt that needed to be shared with the world I wrote my own letter. Attached below is how it reads in the book:

Dearest, Largely Unknown Third Years,

You have all probably heard now from various friends, family, and faculty about the joys and perils awaiting you in your third year of medicine: the stress, the excitement, the lack of sleep, the novelty, etc. etc. etc. You’ve probably also heard now about how third year will affect you as a person. How you’ll learn so much finally practical knowledge. How you’ll begin to develop confidence in yourself as a novice clinician. How you’ll develop a taste of the variety that medicine has to offer. How you’ll run faster and jump higher. All this is true, and I don’t mean to detract from any of it. What I felt was not conveyed to us – or to me at the very least – was something completely different.

Somewhere near the end of your first clinical year – or earlier if you’re particularly introspective – you’ll look at yourself and you’ll realize, “medical school has changed me.” Despite your best efforts to remain a caring and ethical medical student – volunteering a little bit here, resisting those accursedly friendly drug reps there – it’s a challenging battle. There’s just too much change, too much stress, too many demands, and, simply, too much to adjust to. Perhaps some may resist this inevitable decline, but even if you deal in a healthy and positive manner to what comes at you, not regressing, splitting, or repressing, you’ll change in many ways for the worse.

This is not to say that third year will totally change you. Hopefully the medical school application process successfully filtered all those types out, but you will certainly be a little bit more “short-tempered.” You’ll find yourself a little more inpatient in the car, a little less graceful with the errors of others, a little less generous with what you have, a little less inclined to call back a friend if its no big thing, and a little more likely to put yourself ahead of those you care about. Not only in stressful situations does this apply. Yes you’ll be irritable after a long night of scrubbing debris out of the wounds of an unconscious patient in the ER, but everyone knows that, accepts that, and it’s nothing particularly telling of one’s character.

All of this said, I do not mean to be a negative. Go out eat, drink, and be merry. Even during the worst of times – even during the controlled chaos of general surgery – you’ll still be able to find time to enjoy yourselves and still remain much the same charming person you always were. Instead I’d like only to issue a small advisory. Like all of life third year will have its ups and downs, and for some it may even means new highs and new lows. Some of you will do just fine, and some of you, despite my melodramatic introduction, will even likely with little effort become better human beings. The majority, however, I’d be willing to bet will be made just a little worse for wear. Use this then as an opportunity. The injury to character obviously need not be a lasting thing. Instead it can be the first uncomfortable stages of durable personal change – a forge, a crucible, a whetstone, whatever metaphor you want to use. Sometimes to become better we must first identify what is especially in need of improvement. The first step in this process often involves insight, however, and so I write you all briefly to encourage self-reflection. To those unobservant, such as myself, these changes can go unnoticed till you have to work to undo what’s been done, but with a little bit of honesty and vigilance a rough year can be made a stepping stone for greater personal development.

Go Spurs Go,
Scott Crabtree
MS3

Sucks doesn't it? Yep, pretty crappy. I think the word "change" occurs 20 different times there. They also apparently had enough time to switch out most my adjectives with the first synonym that came to mind but not enough time to edit my "MS3" which was obviously a mistake as all the letters were supposed to be written by fourth years. Some changes, as you'll shortly see, I truly didn't even understand. Seems the guy began to simply eliminate any words that didn't fit his fancy. Here's how it originally read:

Dearest, Largely Unknown Third Years,

You have all probably heard now from various friends, family, and faculty about the joys and perils awaiting you in your third year of medicine: the stress, the excitement, the lack of sleep, the novelty, etc. etc. etc. You’ve probably also heard now about how third year will affect you as a person. How you’ll learn so much finally practical knowledge. How you’ll begin to develop confidence in yourself as a novice clinician. How you’ll develop a taste of the variety that medicine has to offer. How you’ll run faster and jump higher. All this is true, and I don’t mean to detract from any of it. What I felt was not conveyed to us – or to me at the very least – was something completely different. It seems to me that while the third year of medicine changes you in a lot of ways, it also makes you more of a jerk.

Somewhere near the end of your first clinical year – or earlier if you’re particularly introspective – you’ll look at yourself and you’ll realize, “medical school has ruined me.” Despite your best efforts to remain a caring and ethical medical student drone – volunteering a little bit here, resisting those accursedly friendly drug reps there – it’s a losing battle. There’s just too much change, too much stress, too many demands, and, simply, too much to adjust to. Perhaps some may resist this inevitable decline, but even if you deal in a healthy and positive manner to what comes at you, not regressing, splitting, or repressing, you’ll change in many ways for the worse.

This is not to say that third year will make you into a jerk, hopefully the medical school application process successfully filtered all those types out, but you will certainly be a little bit more “jerkish.” You’ll find yourself a little more inpatient in the car, a little less graceful with the errors of others, a little less generous with what you have, a little less inclined to call back a friend if its no big thing, and a little more likely to put yourself ahead of those you care about. Not only in stressful situations does this apply, mind you. Yes you’ll be irritable after a long night of scrubbing debris out of the wounds of an unconscious patient in the ER, but everyone knows that, accepts that, and it’s nothing particularly telling of one’s character. This change is deeper as even fully rested after a short day reclining on the inpatient psych wards you’ll still not be quite the humanitarian you used to be.

All of this said, I do not mean to be a Debbie Downer. Go out eat, drink, and be merry. Even during the worst of times – even during the controlled chaos and narcissism of general surgery – you’ll still be able to find time to enjoy yourselves and still remain much the same charming person you always were. Instead I’d like only to issue a small advisory. Like all of life third year will have its ups and downs, and for some it may even means new highs and new lows, but it will also be very subtly abrasive. Some of you will do just fine nevertheless, and some of you, despite my melodramatic introduction, will even likely with little effort become better human beings. The majority, however, I’d be willing to bet will be made just a little worse for wear. Use this then as an opportunity. The injury to character obviously need not be a lasting thing. Instead it can be the first uncomfortable stages of durable personal change – a forge, a crucible, a whetstone, whatever metaphor you want to use. Sometimes to become better we must first identify what is especially in need of improvement. The first step in this process often involves insight, however, and so I write you all briefly to encourage self-reflection. To those unobservant, such as myself, these changes can go unnoticed till you have to work to undo what’s been done, but with a little bit of honesty and vigilance a perhaps unavoidably rough year can be made a stepping stone for greater personal development.

Go Spurs Go,
Scott Crabtree

Obviously not a stellar work of fiction in its original state either, but certainly a whole lot better than the piece of garbage currently with my name attached now in the hands of a few hundred people. Thankfully I'd gamble 90% don't bother to read more than an entry or two, but regardless, what the heck UTHSCSA? In the age of medical ethics and informed consent could you not even consent me to your terrible neutering of my entry? Argh. I emailed one of the many deans who headed this up to complain and advise they not follow the same algorithm for strangling the style and character in their letters next year so we shall see how it goes. I imagine, like so many things in school and life, that I am simply wasting my time.

Fight the Power!

Liberation's Lost its Fun

It's been a couple of years now since Iraq has been liberated, and the Iraqis themselves are everywhere enjoying the spoils of freedom. The collapse of the Hussein regime has been met with a brief round of applause followed now by a not so brief round of looting, violence, and sectarian politics. Currently, questions of troop levels and our future actions in the region are hot topics for discussion everywhere. Any yahoo with a 10th grade knowledge of the region and the ability to watch CNN or FOX news for 20 minutes a week can interject with their simple yet effective solutions for dealing with the situation. Being a self-respecting yahoo myself -- and the convenient owner of this here site -- I have felt compelled to enter the fray. And, heck, with all this EKG self study going on I'm running out of things to occupy my time with anyway. Now in as few words as possible, my answer to everything to do with Iraq:

Screw 'em. No I am neither a defeatist nor a Democrat. I do not think leaving the conflict will somehow solve it. In fact, I think abandoning the Iraqis to their own devises will likely lead to greater bloodshed then what we are seeing now. Moreover I feel there is even a small but real chance that such a deterioration in the situation could lead to the involvement of neighboring states like Iran and, especially, Turkey (our only real hope for a secular Islamic state in the region.) I also feel that by abandoning a war which we, at the very least, indirectly helped create we are committing a serious moral dereliction of duty. Most of all, however, I feel that we have little other choice.

The surge in Iraq, in as much as it was a surge*, has yielded few identifiable successes so far. Portions of the country are safer, but no region is truly peaceful. Fighting continues in Anbar and attacks still sporadically occur in Kirkuk and the Kurdistan north. Coalition forces continue to depart with the British leaving Basra only a short couple of weeks ago. The police force continues to remain infiltrated by militias and the politicians -- despite the fact that they can easily draft bills tackling immunity for our mercenary-lights in only a matter of weeks when they want to -- have been unable to decide on what to do with Iraq's oil wealth or any other essential topic. Even if we were to conclude that overall Iraq is safer and more stable than it was half a year ago there is little indication the Iraqi people or the Iraqi government have done anything with this change.

A bleak assessment does not a withdrawal make, however. Iraq may be in for tough times ahead, but this does not mean success is not possible. Indeed General Petraeus and many other high-ranking military officials seem to feel very strongly this way. With all due respect to them, however, the problems have always only been partially military-related. Beyond the political and security related issues mentioned previously (1) our military is taxed and consistently falling short of recruitment goals, (2) our other war is currently anything but a poster child for success**, and (3) the majority of American people care only enough to chitter chatter about it amongst themselves. In light of all this a decision to continue fighting in Iraq is not simply a question of keeping 100,000 combat troops or 60,000 combat troops, or 130,000 combats troops in the region. Rather it is a question of how to best divide the limited resources the American public has devoted to the cause of fighting its wars. There is good reason to believe another year in Iraq will only mean another couple thousand dead, wounded, and maimed American soldiers, another tens of thousands of dead, wounded, and maimed innocent Iraqis, and no more of a brighter future for a country that cannot properly conceive of its future than the the year previous. And, just as importantly, there is good reason to believe all we will have to show for it outside of Iraq is a dispirited and broken military, ever-deepening national debt, and a floundering Afghanistan.

In light of these realities a strategic retreat may be in order. Abandon Iraq to their own devises (figuratively speaking), secure Afghanistan, and, when our military has recovered, our reputation is on the mend, and the Iraqi partisans have had their fill of bloodshed we can reengage and properly, hopefully, fix the wound that is Iraq. A complete withdrawal is not necessary or even advisable. Intelligent planning on force reduction and the rescue of pro-Coalition Iraqi refugees can be achieved. This is certainly not a great idea, but, unfortunately, it very well may be the best. Unless the Iraqis begin to show they are willing to do anything but squabble and unless the American public is willing to invest any more to the cause than idle chatter our choices are few and poor. As we learned in the Pacific theatre in World War II and on the Korean Peninsula in the opening volleys of the Cold War sometimes the best strategy is the strategy of temporary retreat. In our current Global War on Terrorism if we are unwilling to fight harder than we must certainly fight smarter.

*Iraq is larger than California which is larger than Japan which, after world WWII, was occupied initially by some 350,000 US soldiers and marines; there have been roughly 170,000 military personnel in Iraq according to the more generous estimates and even including an additional 126,000 American and foreign contractors to the equation still yields only 296,000 in comparison.

** Attacks in Southern Afghanistan continue to increase while repair and reconstruction projects and funding continue to decrease. Although many NATO nations have responded to requests for further troops (Poland, the Netherlands, Denmark, the Anglo states) others can barely maintain public support for current levels (Germany, Spain, Norway, Turkey) and others have actually slightly reduced their contributions (France.) Moreover it should be noted that non-Anglo states provide only a fraction of the NATO force in Afghanistan and many have rules against active engagement except for in extraordinary circumstances. If the amount of drug production in a nation is any degree of its strength or stability, the country's record opium crop this year (the largest also in the world by far) should not be very encouraging.

There. I've talked about both Iraq and Paris Hilton now. My blogging obligations are over. Seacrest out.

Saving Lives, For Profit

Leaving the office last Friday after four weeks of outpatient medicine at a local private practice I felt as if I had been liberated. Not necessarily from the work as the work was not terribly difficult or demanding, but rather from the commitment. Although I was allowed to sleep in to a rather late 7:15 in the morning every day, I usually did not return home from work till about 7:00 at night. I may not have minded the job, but I minded the fact that all I did was my job. For almost 28 days I felt like I was less enjoying life and more listening to senior citizens tell me in as ambiguous terms as possible their various minor ailments. I am told once you hit your career days you are no longer supposed to enjoy life, and to an extent I acknowledge that that's true, but nevertheless I'd like to live in sweet denial for as long as possible.

Aside from the fact that 60% of my patients were 70 year old men and women telling me about their terrible shoulder pain which they hadn't even bothered to take any tylenol or aspirin for, I have other grievances. For one, my physician had me research a new topic every evening thereby limiting the little free time I had even less. For another, the man had not the worst handwriting ever, but easily the 5th or 6th. Since he still had paper charts that meant that I either had to try and tweeze out a coherent history from my half-senile elderly patients or desperately try and put together an idea of what happened from the studies he'd ordered and the correspondence of other physicians he'd sent the patient to. Of course those other physicians remembered to send copies of their notes only... oh... 40% of the time. The rapidity of the encounters at not only this clinic but many clinics I have been to either as a patient or a student have also convinced me the average American probably gets only mediocre care at best. There are certainly some great physicians there who actually devote enough time to a patient to provide great care as well, but I am pretty sure they are anything but the rule.

Though I like to complain there were some good sides too. My physician was, generally speaking, a fairly nice guy and easy man to work for. His nightly assignments, though painful, -- especially when they consisted of diseases that don't exist like "hand and foot fungus" -- were moderately educational. His office staff were also a friendly bunch. The patients were as a whole very grateful, and aside from a few Spanish speakers who mumbled their speech, I enjoyed most my visits. Though I have no desire to return, I do not consider it a bad rotation. Just a not very fun one.

One last thing I noticed was that with such rapidity of care the work up of patients becomes less well-thought out consideration of the applicable science and more the following of whatever whim or algorithmic pattern the particular physician seems to have acquired at some point through whatever means. I would imagine -- and so it seemed at this clinic -- that this makes such physicians ripe for the picking by anyone willing to provide a little bit of already digested, helpful medical advice. And of course since few things in life are truly free, this educational charity work is largely done by pharmaceutical representatives. Perhaps such industrial parasites are a necessary evil, but judging by the drugs prescribed the pharmaceutical industry does well by sending out their drones. All their blahbety blah blah aside, though, the drones did usually provide pretty delicious lunches. (Except for Crestor, I will never prescribed Crestor to my patients -- even if they need it. They're jerks.)

As a final note: a public service announcement. Beware the small tubes at Schlitterbahn. They may look like fun, but from first hand experience last weekend I can confidently say they only lead to bruised elbows and cervical spine injuries.

Oh and here's an unrelated photo from my previous stay at the Delevan homestead....

Gone Shootin'

If you'll remember, my loyal readers, my dear friend Tyler has a family house outside Austin on Lake Travis. It is awesome, and up until this year I was completely unaware of it. Likewise, it turns out, my dear friend Adam also has a family house. His, however, is outside Fredericksburg near Enchanted Rock. It too is awesome, and, likewise, I was once again completely unaware of its existence. Who else has a luxurious beach house or mountain home? I can't say, but I certainly hope to find out soon. All that aside, two weeks ago we went out to Fredericksburg for a weekend of relaxing, hiking, and shooting stuff.

Despite my illustrious military career which, my loyal readers, you'll recall has so far consisted of playing dress up, I have fired a firearm only once before -- and that guy deserved what was coming to him. Actually I only shot a rubber duck decoy, but if ever a duck decoy deserved it.... Regardless, that weekend I was given intense training in the loading and use of a twelve-gauge shotgun and 22 caliber pea shooter. The shotgun was cool because I could explode gently thrown clays with it while the glorified rifle was cool because it had a scope on it with which we tore up various soda cans. Though I probably fired a couple dozen rounds of both guns and only shot one legitimately thrown clay, I feel now that I am finally, officially an Army of One. Unfortunately the Army's changed its slogan to Go Team or Sea the World or something like that now, and the Air Force doesn't seem to use shotguns all too much, but at least when I do finally see a gun before deployment some years from now I will at least know what that I am in fact a terrible shot.

Of course all of our time wasn't spent shooting because no trip to Enchanted Rock is complete without a trip to the cave. Neither Adam nor Kate had been before and it was a joy and a privilege to take them there. Despite my outstanding record of being a generally great guy, my motivation in leading them through the caverns of E-Rock was not entirely benevolent, however, as when they exited through the birth canal at the end of the cave complex we were ready for them with cameras in hand. There are few sites more heart warming or completely hilarious than Moleman Adam struggling to exit to the light of day. We looked at the pictures and laughed. Later we thought about the pictures and laughed some more. Even two weeks later the thought of the pictures make me smile. Amazing that one moleman can bring so much joy into so many peoples lives.

Anyways, we also hung out at Adam's family's place which was beautiful despite being under the constant threat of scorpion attack, the jerky burgers we had Saturday night were fantastically salty as well, and affixing a headlamp to an akathisia burdened Bella (one of Adam and Kate's dogs) was worth at least 30 minutes of entertainment. What's important, though, are the photos. Those glorious molemen photos:

Pictures!

Ode to Ashlee

Few realize that in addition to my giant brain I am also in possession of an equally giant heart and the soul of a poet. I was saving this for their wedding day, but recent events have compelled me to share it earlier. My brother is marrying one Ashlee Hilliard and, after meeting her, let me say, in all sincerity, he is a lucky guy.

Ashlee, oh Ashlee

Forgive me if I act brashly,

But truly you are

A princess

A gem

A peach

A princess

A catch

A princess

A prize

A unicorn

Ashlee, oh Ashlee

Forgive me if I act brashly,

But truly you are the best sister-in-law I've ever had.

.

Rocky Mountain Majesty

It’s almost a week since I’ve returned from saving Mother Earth and I still feel that she wasn’t worth saving. In many ways I enjoyed the trip – the Sangre de Cristos are a beautiful mountain range and I loved being outside – but the overwhelming feeling is a feeling of futility. The majority of the time was spent working and the majority of the work seemed inefficient or ineffective. Whether it was laboring to slowly build up a trail so that, after some 200 cumulative man hours, it looked slightly more like a trail rather than a scrambled jumble of rocks or it was digging up parts of the hill side to fill in holes in other parts of the hillside it just seemed like we were fighting a losing battle. People were still hiking off trail. Many of the transplants likely died. I still don’t have any idea why we moved half of the rocks we did. The alpine environment was simply too fragile and mankind is simply too determined to enjoy it for our work to have any lasting significance I feel. Plus, especially in pertaining to our reconstruction efforts, it seems like we just despoiled one area of land in a desperate attempt to reclaim another previously despoiled area of land. Oh wells, let us not lament such things. They don’t make for very good stories. Marmots, on the other hand, make for great protagonists.

Marmots, for those not in the know, are essentially big, friendly mountain beavers that make sounds eerily similar to the sounds of an electronic pager. Their significantly smaller and more skittish friends the pica make noises exactly like electronic pagers. I am fairly confident they use this chorus of sound to coordinate their raids on our camp as they came to visit whenever they had the chance. Our leaders said it was because they’d eat anything and everything if given the opportunity, but I like to think they were just saying hello – saying hello by eating our stuff and licking up our urine that is. They never touched my gear, though, and for that I am grateful. I’d say I have a Planeteer like ability to bond with animals, but we all know no one liked Ma-Ti.

Marmots aside, the rest of the trip was for the most part enjoyable. Certainly met some interesting people and interesting personalities. From amicable old, nuclear plant workers who called me “doc;” to young, naïve Anglican-Tibetan Buddhists who could not stop talking; to extroverted, amateur snowboarding occupational therapists; and to a variety of people of all ages a little too in touch with nature and perhaps not in touch enough with the rest of the world it was an eclectic group. I am now also familiar with the term “cougar” as well so all the kids will respect my street kred once again. And I am now familiar with what congestive heart failure must feel like as physical exertion at 12,000 feet is essentially the shortest path to shortness of breath. There were mornings when I woke up and loathed getting out of bed, but, to be corny, I never regretted doing so.

I cannot let the account end here, however, as there was certainly much more to be experienced.

The Wag system, for example, was a unique treat. Although defecating in a glorified bucket was easy to get accustomed to, pooping out in the open with a frozen mountain wind blowing through your shorts was not. I never had to clean the Wag, but I can easily say I will not miss it.

The hike atop Crestone Peak was a joy and considerably easier than I was expecting. I may not be able to carry a pack worthy my salt, but I can certainly climb like a monkey when necessary. To be able to see the Great Sand Dunes National Park from atop a mountain was also an amazing opportunity.

And finally, jumping into an alpine lake was an experience I will never forget and hopefully never repeat. I had never felt uncontrolled reactive physiology before, but after jumping into that lake there was little I could do to stop myself from breathing 30 times a minute. My first and only instinct was to gasp for air as frequently and as strongly as I could. That and scream. Interestingly enough, however, the experience of getting out of the water was remarkably enjoyable and satisfying. Despite the air around the lake being relatively chilly itself as well, removing myself from the pool was profoundly calming and warming. With just a shirt and some pants on I felt great. Relaxed and rejuvenated even. My heart may have been a little worse for wear, but there’s a satisfying feeling that comes after experiencing nature’s stress test. I had absolutely no desire to jump in again at that moment, but one of the best moments was walking back to camp, damp from the lake, and headed to some hot chocolate and a couple dozen rounds of Speed.

My pictures....
Ben's pictures....
Jay's pictures....