Amanda Dave – Graduation 2018

Amanda graduated medical school from Creighton University in May 2018. She will be a pediatrics resident in Omaha, NE.

Both families came to Omaha. So proud of my wife!

My workout routine

I haven’t posted about lifting in a while, but a conversation with my cousin Rishi prompted me to make this post. I stick to 2 different workouts, a push day and a pull day. I usually take about 2-3 min between sets for rest.

• Pull day (back + biceps)
  • Weighted chin-ups
    • 15 sets
    • Bodyweight + 45 + 45 + 25 x 3
    • BW + 45 + 45 x 3
    • BW + 45 + 25 x 5
    • BW + 45 x 10
    • BW + 25 x 11
    • BW x 20
    • BW x 10
  • Machine row, horizontal
    • 4-5 sets
  • Bicep curls
    • 4-5 sets
    • Superset with leg raises and crunches
  • Pull-downs
    • 3 sets
• Push day (chest + triceps)
  • Incline DB bench
    • 5 sets
    • Max: 105×3
  • BW dips
    • 4 sets
    • With assist in last sets
  • Triceps pushdown
    • 3-4 sets
    • Superset with leg raises
  • Lateral raises
    • 4 sets
    • Superset with shrugs
  • Occasionally, I do 3-5 sets of squats on this day also

I’ve been doing this split for the last 2 years.

The Proposal

After much waiting and anticipation, I asked probably the most important question in my life (thus far) to the woman I love a few weeks ago. The answer was a resounding yes. After much thought and deliberation as how to actually propose, I came to the conclusion that I wanted to (1) surprise her, (2) make it a special moment between the two of us, and (3) make it emphatic.

I think I accomplished all three of these things in my approach. I did it on a Friday, with Amanda expecting me around 8pm. I drove up 3 hours early, set up champagne at the post-proposal restaurant, and set up 2 bunches of 36-inch sparklers on either side of the stairway leading up to her house. After confirming her location with a trusted third party none other than her roommate, Aleah, I wait for the sun to set. The staircase shimmering, I ran up the stairs, ran back down, and watched as she stepped through with elation as she realized what was taking place.

Just the two of us in that brisk February air, the low blaze of the fireworks, I knelt down and asked her.

Future wife

What followed was a great weekend. We spent some time with her friends and enjoyed a romantic dinner at Lot 2 later that evening. The following day, we knocked out some work in the morning, went to the gym, and got Chipotle and relaxed. On Valentine’s we checked out the Joslyn art museum.

Dinner and Ring

All in all, as weekends come, pretty much a perfect one.

Obstetrics and Gynecology: Of birthing, surgery, and nights

Whew, I just finished my OB/Gyn rotation. After those two months of medical exposure, I truly feel like I have only begun the marathon that is MS3/MS4. Both months were challenging in their own ways.

In November, I was introduced to the revered O.R. My inauguration was brief, and much of the mystique and wonder I had built up dissipated within the first week of my month of gynecological surgery. The surgeons and residents I was privileged to work with were focused and skilled, and I have the utmost respect for their craft. Surgery, I found, was demanding in ways I had not anticipated. The focus, diligence, and dynamic coordination required for the routine tasks of surgery was largely new to me in a medical setting. Internal medicine, to contrast, was steeped in speed, intellectual fastidiousness, and static coordination. The O.R. is the here and now; the floor is what was and what will be. The distinction is dramatic, and after experiencing both I can begin to understand the schism between the two disciplines. Moreover, I also can appreciate that while IM is more of a science (to some extent), surgery is an art. The control of every decision in IM guided by evidence cannot readily be replicated in the nuanced motions and subtleties of incisions, cautery, and knots.

“We are all fixing what is broken. It is the task of a lifetime. We’ll leave much unfinished for the next generation.”

Part of me finds dissatisfaction in this. There is an inner desire for certainty in the actions I take. The certainty in art of surgery stems from lifetimes of experience, against which my 25-year old self has comparatively paltry assuredness. And, really it’s a cop out. At its essence, I’m saying there are too many variables in surgery. That’s tantamount to saying there are too many variables in life. There are infinite aspects of in any situation, not simply surgery. I think it’s my engineering background that gives me this aspiration for an ideal action or solution at every turn.  Does medicine simplify many variables into digestible forms that are more interpretable? Blood pressure? Temperature? Possibly. I am not able to determine that. Maybe no one is.

In December, I was exposed to the practice of Obstetrics. In line with the discussion above, the field of OB has similarly a handful of cardinal variables that are critical to its practice – cervical thickness, dilation, contraction frequency, etc. Once mastered, the decision trees are fairly intuitive. Anyways, I was really tested on this rotation. Half of my month of OB was nights, one of the most demanding experiences I have had in medical school thus far. The nights were mixed – some were action packed, some were slow, some haphazard. The adjustment to a nocturnal lifestyle was not smooth, and I found myself craving sleep at times. The best part and the worst part of the rotation was its unabashed spontaneity – at moment’s notice, a C-section case could (and did, many times) step through the door. That readiness required was daunting, and often times, I found myself dreading action towards the end of my shift.

This dread stemmed from a very concrete (and mildly embarrassing) experience I had while on my first week of nights. A patient required a C-section at around 3AM and the team was notified. I had about an hour of sleep at that point, and also had not eaten dinner. I had a vasovagal episode and had to sit down on the floor of the OR in the middle of the case (in the middle of the night), later to be wheeled out against my requests. The ignominy of that event was replayed when the resident reenacted the scene in clinic.

As an aside: one particularly sad part of OB was being part of unsuccessful pregnancies. Intra-uterine fetal demise was unsettling and I cannot begin to fathom the feelings of the patients I saw that underwent such an ordeal.

This rotation was the one I learned the most from during the rotation. My basic science curriculum did not address the nuances of the management of pregnancy; I knew little of pregnancy and its clinical aspects. The hands-on experience I was afforded bridged much of that gap in my knowledge base, and I can say I appreciated it.

 

The Warrior of Light remembers a passage from John Bunyan, adapted by Paulo Coelho:

Although I have been through all that I have, I do not regret the many hardships I met, because it was they who brought me to the place I wished to reach. Now all I have is this sword and I give it to whomever wishes to continue his pilgrimage. I carry with me the marks and scars of battles- they are the witnesses of what I suffered and the rewards of what I conquered.

These are the beloved marks and scars that will open the gates of Paradise to me. There was a time when I used to listen to tales of bravery. There was a time when I lived only because I needed to live. But now I live because I am a warrior and because I wish one day to be in the company of Him for whom I have fought so hard

Original text from The Pilgrim’s Progess:

And though with great difficulty I have got hither, yet now I do not repent me of all the trouble I have been at to arrive where I am. My sword I give to him that shall succeed me in my pilgrimage, and my courage and skill to him that can get it. My marks and scars I carry with me, to be a witness for me that I have fought His battles who will now be my rewarderd

The conclusion of my time on-isle

On Wednesday, December 3, 2014, I took the exit examination at Saba University School of Medicine, also known as the NBME Comprehensive Basic Science Shelf.

The last 4 months were spent preparing for both the exit and the USMLE Step 1. Now that the exit exam is done and I’ve successfully passed, I can take the Step. I was pleased with the mark I received on the exit, and I know if I put in another month and a half of work I can really sharpen my knowledge base.

In completing the exit exam, I finished my 5^th and final academic semester in the basic science portion of my medical education. My next week will be spent packing up the last 19 months of my life and flying back home to Louisiana.

There are many places and sources of advice on how to prepare for such a colossal exam, so I’ll keep mine brief. Firstly, you need to know yourself. Only on an existential level do you know what you know and what you don’t. After that, it’s simple: systematically address your weaknesses until you have as few as possible.

Personally, I knew I was a variable test taker. I knocked the socks off the SAT but did average on the MCAT. This was my personal weakness. So, every day, I tried to simulate testing conditions and pressures so that I could increase my capacity for focus. This was rough, but I am very proud of myself for the improvements I made. Every morning, at the same time, was the same ritual, the same breakfast, the same pre-question formula sheet, the same number of questions.

Every Saturday (except for when we had exams), I would do 4 blocks of questions. The first time I did this, I was mentally fried after the questions. I couldn’t do anything else that day. By the time around, I was able to review some of the questions the same day of the test. Eventually, I was able to focus for the whole exam, do well, and review all the questions in a single day, albeit from 8AM to 5PM.

The sources I used varied, but I liked:

• First Aid 2014
• Kaplan CV Physiology
• BRS Path, Physio, Pharm
• DIT
• Sketchy Micro
• Slides from courses (best if profound review needed)

Without a doubt, the bulk of my studying came from questions; thus far I’ve finished both the Kaplan question bank and the USMLE-Rx bank. I’m saving UWorld for when I get back home.

So that’s that. Now for a long awaited break.

At the cusp

Before I was actually a medical student, I was asked a very pointed series of questions in an interview for medical school. I like to think of myself as a good interviewee, and rarely do I get a question that leaves me at a loss. Since I am nearing the end of my basic science curriculum portion of my medical education, I thought it might be relevant to share my thoughts.

The questions were in this line of thought, about two-thirds of the way through the interview:

Interviewer: You are starting medical school, and after the first quarter, you find yourself in the bottom 10% of your class. How would you proceed?

Me: I would look at my study strategies and try to find a method better suited to my strengths.

Interviewer: Good. So let’s continue this scenario. You change your study habits for the next quarter. Time passes and at the end of the quarter you again find yourself at the bottom 10%. What would you do?

Me: Again, I’d look at my performance and assess what I did this quarter and compare it to the first quarter. After that I’d try and find a study method outside of these first two approaches I took and apply it to hopefully better my scores.

Interviewer: Ok, so you try that. Again, the quarter passes and you’re in the lower 10%. How would you approach the next quarter?

Me: (at this point I’m stuck. I can’t say the same thing for a third time. I’m sitting there and I know he’s looking for something, but I just don’t know what. I can’t leave too big of a pause, though, because that’s just awkward.) Well, again, I’d reassess and figure ou-

Interviewer: You tried that. Is there anything else you’d do or think in our scenario?

Me: (I know I missed it, but I have to say something) I think it’s important to learn from the mistakes I made and try new things until I figure something out.

Interviewer: Yes, very true. (moves to another topic)

It’s not something I think about every day, but from time to time I remember that scenario. Now that I’m at the end of my basic sciences and have mulled it over enough, I think I understand what he was getting at.

I think he was trying to make a broader point about having the wisdom to tell the difference between things you can and cannot change. The ideal third response in that interview, I’m pretty sure, would have been something like: “Well, if I’m trying my hardest and am still in the bottom 10%, maybe I should continue working hard and be happy that I’m passing.”

The point being made by the interviewer was that it’s important to be happy that you’ve passed rather than to be happy that you’re in a certain standard deviation of performance on a test. In other words, be happy about getting through medical school rather that beating other people at a numerical game. The metric you choose to measure yourself against should be internal, not external. External metrics can be references to what is possible; internal metrics are those you are aiming to beat.

I think my time in the basic science curriculum at SUSOM certainly made me realize that, and I am better for it. As my time on the island is swiftly coming to an end, I have been focusing my hardest on overcoming my personal limitations when it comes to test taking. Specifically, I’ve been building my stamina of focus so I can be as sharp as I can throughout a 5-6 hour testing period. I definitely notice improvements. Anyway, as far as preparation for the USMLE1 and NBME Basic Science SHELF ago, I’ll have a separate post after outlining what I did and what I learned.

Saba’s second peak

Every morning on Saba, the skyline that greets me is the sea, the sky, and the ragged, looming peaks that frame my view from the Bottom. And every time I see those peaks, I ask myself how it might be to climb them and look at the island from on high.

Today was the day I finally climbed the slopes of Paris hill and it’s Whale Tale; it made for a memorable adventure. When Amanda visited me a few weeks ago, we tried the hike, but didn’t manage to find the right trail and ended up scrambling up through the jungle unguided. This time guidance was welcomed.

I set out with friends from my class, Neil and Cirous, around 10 am from behind the stairs of the medical facility. I chose to bring a bottle of water, my trusty knife, my paracord bracelet (which, thankfully, was not needed), sunglasses, and gloves. The gloves were the most useful of these items, and I had a keener grip when climbing.

After an initial upward trail that took about 15 minutes, we came to a field of gigantic boulders covered in lichen that gave the next portion of our venture a primordial feel. We grappled, leaped, shimmied, and bouldered up the various rock formations for a good hour before getting to the top.

Some easy bouldering

There were a few telling moments in our climb where careful planning was required to overcome the arduous incline of the terraces of stone and the occasional treachery of the trail; on many instances, branches that were trusted gave way and alternate routes up were used.

The peak was glorious; a touch of gossamer clouds hung the sky was bright, and the was a gentle breeze that soothed as I glanced down on the red rooftops of the Bottom from my new vantage point. It is always a poignant moment when you look at something you’ve seen a thousand times in a different light.

As we made our descent, we were unable to find the same path that brought us up. We warily made our way through the brush and shrubbery, following the music of the Caribbean Carnival, to find ourselves across the street from our anatomy professor’s home.

Near the peak of Paris Hill

From a technical point of view: the combination of boulders and generous grip availability made this hike extremely enjoyable. Easily the best hike I’ve done on Saba – very little danger for an amateur climber. I will note that some of the flora on that hike is very unforgiving – all three of us suffered minor cuts and scrapes from the green plants that somehow grow in rock.

13.1 miles in, warmed up and steady

I’ve reached a symbolic midway point in the basic sciences portion of my medical education; three of five blocks in this semester are done, with this being the third of five semesters.

The work of men who died generations ago. From here, it looks like an achievement.

I have developed reservations about the whole process of school, but nevertheless, the fact remains that time has passed and I have learned. Is it an achievement? That’s a very subjective question. In old posts I spoke of what I considered two different types of achievement: personal and existential. In fact, I explicitly said that education was always a personal achievement rather than an existential one, and my opinion on the matter remains so. Over the last ten months, I have understood the machinations and theories of other men, not created my own. This is the key flaw to such an education; however, there is nothing worth doing to change it. Shortly, I will be gone from this place, and the island will be another memory of my past.

That said, the material we’re covering is the most clinically relevant stuff we’ve learned so far. Various pathogens, the complex function of the immune system, and very circuitous (but applicable) neuroscience. The current block for microbiology is a survey of virology, which is a very interesting subject despite the droning lectures we receive.

I am looking forward to starting rotations in a little more over a year, finally seeing things in full color and form. It’s a strange question to ask myself – now that I’m here, halfway, would I start over and do it all again? This question doesn’t really represent the process that will be the other half of my education. In the first half, I developed the capacity to handle large swathes of material and study habits that will assist me for the rest of my life.

---

Someone wise once asked me:

How do you make a test for someone smarter than yourself?

At the time, I didn’t fully appreciate the answer to the question. I was in high school, and academic achievement tests were a joke. They were timed, difficult, and represented the perfect opportunity to prove my intelligence to others without; the tests were a pure ego-flexing opportunity to have a numerical value to rank me against my peers. The point the question made, nonetheless, was that to make any test harder, you shorten the amount of time allotted to take the test.

Take this notion and supersize it from a test to an entire curriculum, and you have medical school. The material is not hard, the volume is just incredible. It is manageable, though, and begets a transformative experience. While I initially disliked the lack of creativity, the courses I am taking have become more and more detailed, which is to my liking; the purpose is to serve as a survey rather than canvas.

Achievements

As I understand it, there are two types of achievements.

The first type of achievement is personal. I think this is the type of thing most people, myself included, strive for on a daily basis. These are things like getting perfect marks on exams, excelling physically, improving your body composition, getting a degree, etc. These things are methods of bettering ourselves as individuals. Most successful people in society proceed by excelling at personal achievements and going forwards from there. For instance, a medical student excels in his or her coursework and knows the proper physiology and anatomy of the human body well enough to become a practicing surgeon. For some, that in itself is a personal achievement.

The second type of achievement is more lasting. It isn’t a personal achievement, but, it is a sort of existential achievement. This requires broad vision and drive. I am having a hard time describing how it is different (but not opposite) from a personal achievement, so I will give examples. Establishing a library or a hospital or a school in a severely impoverished place in the world. Doing pro bono work with your advanced degree. Modifying a staple crop to make it more vitamin-rich, preventing blindness in millions of children. Bridging the gap of private and governmental space flight programs. This sort of achievement affects many, many people. It is the kind of achievement that can take the help of hundreds for the sake of one resounding goal.

While the two achievement types are different, they can have some overlap. Many (if not most) people spend their lives working for organizations with such broad oversight. I would include hospitals in the list of such organizations, and many doctors have larger goals to help as many people as possible. They provide a necessary service, but the pace at which they change the world is necessarily slow and personal. Often times, public health policies can have a larger impact on the face of a populace, but not always greater.

I guess the main difference is that personal achievements mean something to the achiever, whereas the other types mean something to others. I don’t want to make out pursuit of personal achievement as selfish; self-mastery is an important part of being an individual and life. Ideally, one can strive for both simultaneously and harmonize the two.

Personally, I am trying to accomplish both. I want to become a physician, which I think had feet in both territories. I want to participate in research that will come to fruition and affect medicine and quality of life globally. I want a stronger, leaner body. I am actively pursuing these goals; with time I will accomplish them.