Just Because

     In adherence with the anesthesia board re-certification process and maintenance of my medical license, I've been taking an online, self-study continuing medical education (CME) exam. In all honesty, I've been avoiding it for the last six months. Since the 30 hours of credit expire on December 31, 2012, and I've already paid $300 for the exam, I figured I may as well suck it up and get 'er done over the holidays. The questions range from absurdly easy ones like this (the answer is "Duh!"):

  Which of the following is most likely to occur in rhabdomyolysis?

1. Hyperkalemia
2. Metabolic alkalosis
3. Hypercalcemia
4. Hypophosphatemia

to redonkulously obscure ones like this (eliciting a head-scratching, hair-twisting "Huh?!"):

   In which of the following situations would a paired t-test be the MOST appropriate statistical test?

1. Determining the neurologic outcome (graded as "intact," "neurologic compromise," or "dead") in patients with subarachnoid hemorrhage due to intracranial aneurysm
2. The presence of headache following donation of autologous blood in 50 subjects, each of whom donates 2 units of blood--once with a fluid bolus and once without
3. Heart rate change from baseline measured in the same individual given neostigmine with glycopyrrolate
4. Blood pressure changes with propofol versus thiopental for induction of anesthesia in 1000 patients

    To obtain CME credit, I had to answer all 100 questions correctly. As much as I'd like to say I got them all right on my first attempt, I had to go back and reset the responses on more than just a few, after taking time to read through the scholarly discussion provided with each question. The discussions are actually pretty awesome. For me, doing lots of practice tests is the smartest way to study for a written exam. It's no secret that exams don't exclusively test knowledge: they measure how well you take a test. By studying a multitude of questions and answers, you gain an understanding of how they're structured, and even if you don't know the answer off the top of your head, you can usually eliminate at least two choices based on wording alone. "Always, " "only," and "never" are pretty reliable red flags. When you've got it narrowed down to two choices, but you're still unsure, an educated guess will typically produce the correct response. Wrong answers are usually A) the result of not reading the question or answers thoroughly OR reading too much into them, B) a knowledge deficit, C) failure to apply existing knowledge logically, or D) ignoring gut feelings and changing your original answer. Never change an answer unless you're absolutely sure you got it wrong! If you happen to guess wrong, the discussions provide a brief review of the basic science or clinical pathways involved, walking you through a dissection of each scenario so you can determine for yourself why there is only one BEST response. Before I'm even halfway through a discussion, it's already evident why the correct answer is cut and dried. 

    After finally getting through the exam, I re-read the questions, and the answers seemed so simple and straightforward.  None of the material was new to me: I've seen it all before. In fact, I knew it all like the back of my hand when I took my initial written and oral boards in 2006, so it's more like assimilated information that's on hiatus...gone, but not forgotten, absorbed and committed to what I consider an even loftier level of knowledge: intuition. Much of my decision-making in anesthesia practice has its basis in what feels right, which is also how I live my life. I've never been one of those who can recite studies or regurgitate factoids when I'm being pimped onstage, which is probably why I despise the Socratic method of teaching. Real life patients and scenarios aren't textbook. Rarely (if ever) cut and dried, an evolving situation is nuanced, complex, and dynamic in nature, and it won't stand still while you're busy crunching data. Relying solely on logic and reason is myopic at best, eliminating the very real possibility that sometimes, shit just happens. That's when you just have to trust your gut and act accordingly.

     What is it that we think we know and how do we know we know it? Where exactly do we get all of our facts? Aren't there things we know just because--instinctual, intuitive knowledge that defies explanation or justification? Is something spontaneous and fundamental lost in translation when we know that we know, when we start thinking about thinking? In continuity with the universe, we beat our own hearts and breathe our own breaths. We don't have to think about these processes, we just automatically do them: they are central to our existence. It's only when we start thinking about these things that we feel anxious. Self-awareness leaves us wondering if there's something we've missed, ignoring the obvious because we're driven to complicate what's basic and simple, effectively permitting minutiae to supersede experience itself. Does how and why we breathe really matter as long as we're spontaneously breathing? Can all questions be answered at a molecular level, and do our answers always warrant a defense? Although the mechanics and physiology of automaticity have been fully elucidated, they still fail to explain the basic question: what is it that makes our hearts beat in the first place? Why isn't "because we're alive" enough of an answer? It's when "just because" becomes unacceptable that we separate ourselves from nature, and become dispassionate observers, victimized by existence, instead of engaged participants who are too busy enjoying now to worry about what's going to happen next. Here's the thing. I am my body and my body is me. I'm marvelously self-contained, a symptom of nature, a unique expression of the cosmos. I am my existence, not a victim of it. I am just because.

The Upside of Emptiness

     Naked and robustly feminine, libidinous and carefree, I wandered through a dreamscape of random yet intimate encounters--some sexual in nature--consolidating primal me, briefly merging and coming away absolutely galvanized, with no sense of shame or guilt. It was intensely familiar, a dream I'd never dreamed before, but remembered so well. Some dreams are as simple as reality.
     What kind of person do I think I am? How do I see myself? Ineffable. Wild at heart, with the heart of an artist. Fiercely non-cynical. Resilient. Irreverent. Courageous. Self-effacing. Unapologetically brilliant. Humbly accomplished...I've already lassoed the moon and coralled the stars, and now, I'm giving them back. Complexly simple. Deeply sensual. Love, personified. Happy that I still haven't turned into a boring old grown up. I'm a true original...the mold wasn't broken after me; I broke it myself.
     My mirror isn't selective, and it never lies. It reflects my image without bias, but when I step away, not only do I disappear, it's as if I'd never stood before it. It sees without filters, but remembers nothing. No preconceived notions, no self-criticism, no fear, no regrets. Perhaps that's the upside of emptiness, of having a mind like a sieve instead of a steel trap. Go, primal me.

--Inspired by last night's wonderful dream, and this aphorism by Marty Rubin aka nothingprofound: "Once upon a time there was a parrot that kept repeating 'happiness, happiness, happiness.' I am that parrot."

Goodness, Deconstructed (As Good As It Gets)

     Last night, Spartacus and I attended a Christmas party thrown by the gastroenterology group I work with. Thanks to Atlanta's impossible traffic situation, we arrived an hour and fifteen minutes late to the feast already in progress, both of us starving after our grueling pre-party workouts. Had either of us anticipated that treacherous bottleneck on I-20 eastbound, I would've brought a few snacks for the road. Yeah, I get a little bitchy when I'm hungry. Relieved that we'd finally made it there after our harrowing backroad detour, we loaded up our plates, grabbed a glass of wine, and engaged in pleasant chatter with the folks sitting at our table. I couldn't help but notice that we all clean up very nicely. At work, we spend our days running around in non-descript, formless scrubs, so when I see colleagues dressed in their street clothes, it sometimes takes me a moment to recognize them. It was great seeing everyone so happy and relaxed. Women of all ages were wearing updos and party dresses and sequined sleeveless tops, some on the conservative side, some downright sexy, but they all shared one thing in common: a burning desire to shake their booties on the dance floor.  Needless to say, the air of dance-ticipation was pretty thick.

     As the dinner plates were cleared away, the DJ eased from mealtime muzak into disco, dance rock and good old country, the urgent question on everyone's minds being "Who's going to get up and boogie first?" Glancing about the room, I could see boyfriends and husbands--including my own--bracing themselves, hoping to ward off their respective dancing queens' attempts to drag them from the security of their chairs into the encroaching disco inferno. I assumed the hot young chicks in stilettos and satin mini dresses, priming themselves with shots of Cuervo over by the bar, would be the ones to get this party started. I'd been hearing legendary tales of their dancing prowess for the past several weeks, so I thought they were a safe bet. Surprisingly, and somewhat endearingly, the first rug-cutter was a young newlywed guy. Obviously obliviated and observedly oblivious, he wielded his Bud Light like a homing beacon, solitarily tripping the light fantastic for a few moments before being joined by his laughing bride. Their spontaneity and uncensored delight in one another set the tone for the evening. It wasn't long before a decent-sized--albeit mostly female--crowd accumulated, expertly kicking out The Electric Slide in unison. Hell, I even got out there and busted out a few of my trademark awkward-white-girl moves to Baby's Got Back, and I didn't even have to twist Spartacus's arm to slow dance with me during "Unchained Melody."

     We left shortly before the party ended, our post-prandial sleepiness a welcome promise of sweet, uninterrupted sleep to come. As we made the rounds, saying our goodbyes and thank yous, one of the nurses I work with pointed out an attractive young woman who was clearly enjoying herself on the dance floor. "See that girl? Her mama's one of our co-workers, and she's a real upright holy roller. She's gotta be cringing, watching her daughter dance like that!" The woman looked to be in her mid to late 20s. She was dressed modestly in a long-sleeved white sweater, slim black pants, and open-toed pumps, and although she was swaying energetically to the beat of the music, she certainly didn't appear to be trying to draw attention to herself. She was only having fun. "Good for her for getting out there and dancing!," I replied, supposing aloud that Mama probably believes Jesus didn't dance or drink wine, and then adding, "Morality is what happens when goodness has failed." My friend nodded, "Uh-huh," in agreement, but the perplexity furrowing her brow conveyed an ascending note of misapprehension. "How can goodness fail?"

     Perhaps the better question is what's so good about goodness? And, where do our ideas about goodness come from? From the moment we're born, our goodness is vigorously reinforced. Good boys don't cry. Good girls sit with their knees together.  Good babies sleep through the night; after all, children are best seen, but not heard. Are babies even capable of being good or bad? The easy answer is "no," but what if babies are true goodness personified? If morality is the by-product of faulty goodness, then what came before goodness, true or otherwise? Goodness, it seems, stems from desire. Newborns aren't desirous of attention when they cry, they're simply reacting to hunger or discomfort. They're just being. Through ongoing behavioral conditioning and reinforcement, babies eventually learn that certain cries will elicit predictable responses from their parents, heralding the genesis of self-awareness from which all goodness emanates. Because goodness seeks approval, it is never fully satisfied. Being somewhat of a micromanager, goodness wants what's right, but doesn't trust others to do the right thing. So, maybe goodness is what happens when we cease to be, when life's mysterious, marvelous flow is ignored in favor of duty, expectation, and control. Goodness, deconstructed, doesn't sound so good after all. Still, we're in love with the idea that true goodness exists, and that goodness is good.

     Much like the young woman dancing last night, true goodness doesn't call attention to itself. It just does its own thing. As I stood there watching her, I noticed another one of the nurses I work with, a preacher's wife, dancing alongside her. Aside from being gorgeous and bubbly, Crystal has a wicked sense of humor and a really firm grip on acceptance: she's one of the least judgmental people I've ever met. She's a genuine "live and let live" kind of gal, someone who doesn't pretend to holiness or piety. It was fun seeing the two of them getting their groove on. There's something so primal and spontaneous and human about dancing...even when it's bad, it's still pretty darn good. Goodness like that can't be improved upon. It's as good as it gets.

     Fast forward to 2:19 to see me, shakin' my groove thang...

     

The More Of Less

     The sky's pink hue this morning is at once beautiful and unsettling, its radiance irritating me into a simmering inertia that refuses to budge, even after I've had my coffee. I am five years old again. For reasons unknown to me, my beloved red maple tree, the one that stood bravely among the blue spruces and elms and birches in our backyard, is being felled, and I am watching helplessly. The world seems just as crazy now as it did then, deluded by progress and productivity. Has the business of living killed the business of being alive?
     The less I work, the less I want to work. Coming from a physician, that's nothing short of blasphemy. After all, the moment I stepped into anatomy lab, I traded my personal life for a life of personal sacrifices, the clichéd "I am my work" axiom in which I've been assured that running on fumes somehow begets sensitivity and compassion, and that the reward for denying all of my own needs is the immense satisfaction that comes from tirelessly attending to the needs of others. One really has to question the ethos behind this flavor of altruism: it's more like a contagious societal disease.
     I see evidence of infection everywhere, from parents whose lives revolve around their children's sports to volunteers who can never say "no" to my own husband, who's averaging thirteen hour days at his networking job, containing the fallout of a security breach that occurred before he even accepted the position, sometimes going in to work at three o'clock in the morning and not returning until 7:30 at night. Many of his colleagues are working 20 hours a day. Yesterday afternoon, he noticed one of his co-workers, a brilliant senior systems architect, looking uncharacteristically dazed and disheveled, walking with a slight limp, and in desperate need of a bath. "Are you all right, man?," Spartacus asked him. "I've been up for 36 hours. I just got my third wind, so I'm feeling pretty good. I'm ready to go," the poor bastard answered, wearing his glassy-eyed funk proudly, like a badge of honor. A year ago, that was me.
     I'm surrendering to the more of less, sacrificing nothing for a return that's unquantifiable. Because work is no longer working me, I like my job again. Even though I work in a fast-paced ambulatory setting, the pressure to produce is offset by my overall change in perspective, sort of a happy medium. I feel like a consultant in anesthesia again, not a warm body. Maybe what I really mean to say is that the less I work, the less it feels like work. The sense of dread I used to wake up with has vanished. Now, there's plenty of room in my life to do the things I want to do. I actually have time for living. It's funny, because in talking with my physician friends, many of them seem to envy my downward mobility, viewing it as a bravely conducted rage against the machine. Sometimes, it takes a little rage to get the courage flowing. Like that red maple tree, I haven't always blended in with the crowd, but I don't live in fear of my demise. I've just found a way to fly under the radar.