Top Ten: The ones I keep coming back to.

When I woke up Saturday morning, I did the normal early Saturday things. I made some coffee and pulled together some breakfast . The television came on and I listened to the boom-boom-pow of Saturday cartoons. Mean-mommy me puts the kibosh on television and electronics Monday through Friday so Saturday mornings are pretty much dedicated to both. I'm cool with that since I simultaneously find it a perfect time to nestle down at the kitchen table in front of my own "electronics."

The laptop opens. On a lot of mornings I wake up knowing what I want to write about. My hands are itching for the keys and I can't wait to go into my own world of writing. There are other days where instead of writing I just sit and read. Usually it's a combination of other blogs and, dare I even admit it? My own blog. It probably sounds a bit narcissistic but I hope not.

I've said many times over that the reason I started writing my blog was so that I could read it. It's been an archive of moments and lessons that I wanted to keep. Writing them down makes those stories and memories come alive. . . and stay alive. On the days I need to a pick-me-up or when I just need a swift kick in the pants, I find the stories that help me to do that. Sometimes I just want a good hearty laugh or a luscious ugly cry. I have my go-to posts for that, too.

Even pictures I've posted here remind me of things. Like these MacBook photobooth shots of Zachary and me are from this day when we were watching the video to REM's "Losing My Religion." The song had been playing on my mental iPod and I'd written a post that had this song at the end. Zachary came and sat on my lap (as he often does when I'm writing) and went into a trance while hearing that mandolin wailing and seeing the REM frontman Michael Stipe flapping his arms all about dancing.

"Play it again," he kept saying. So I would. And I did. And we talked about it and asked each other what we thought was happening in the video. I ended up writing about that, too. And if I want to relive that tiny little moment with my son, I can.

So I do that often. Sit and read. Sometimes it's a post that I remember every single detail about. Other times when I'm reading it, it feels like I'm reading it for the very first time. Many, many times I'm moved to tears by your thoughtful comments. I reflect on the unexpected community that has come to rally around these ideas and how many of those same people welcome me onto their own porches to sit and read and think and reflect.

I love it. I really do. It makes the world feel smaller and less lonely. It makes me feel -- no know -- that we are so much more alike than different. You show me that. I show myself that, too. So for that reason this is therapy, really. Anything that makes you more okay with yourself and the world you live in counts as therapy if you ask me.

Anywho.

This morning, I've been just sitting here at my kitchen table with a hot cup of coffee doing just that. Rereading and reliving. Doing that gave me an idea.Thought I'd try my hand at creating a top ten of the posts I go back to the most--and why. Quickly I ran through a list in my head and realized that it would surely exceed ten. I figured I could still call it top ten still to rope y'all in. Bwwwaaaaah! Ha! Haaaaah!

Ah hem. I wrote a little top ten (okay fifteen) about it!

Like to hear it? Here it go!

THE TOP TEN (OKAY FIFTEEN)  BLOG POSTS THAT I RETURN TO REREAD, RE-REFLECT UPON, AND RELIVE ON THE LITTLE BLOG THAT COULD (AKA THIS-HERE BLOG.)

And let me just give the disclaimer that I am already feeling some tinge of anxiety at the idea of trying to do this. It sort of feels like I'm picking out a favorite child out of many or like I'm thanking people on a stage and am about to forget someone very, very important.

Very corny, I know.

You're probably thinking, what about the archive list on the right side of the blog? Why not put them there? Well, first of all, I don't update that too often. Second, I can't say it fully reflects the ones I go back to the most often. And third, oh. There is no third. Yes there is! I thought it would be a fun exercise to reflect on my reflections.

Even cornier, I know.

Hey! For those newer here, it could provide some insight. For those who've been down since I had less than ten followers, it might feel like a walk through an old neighborhood. And for those who are bored to death by all of this and see it similar to a rerun or when Tyra Banks does the hodgepodge episode on Top Model, please, please come on back here later, ya hear?

Warning: This will take some time to digest. Especially if you are new here. Take your time, bookmark it and come back to have another bite. Those who read here often, you'll remember most of these so no pressure for YOU to reread just because I do.

Wow. These disclaimers and warnings are getting neurotic.

And away we go!

#15  OH NO,  I SAID TOO MUCH.

*note that the pictures all link to the post of reference.

This was the post I was referring to above. Though I've written specifically about that song, Losing My Religion, the original post where I linked that song was about a patient asking me if I believed in God. I loved the discussion that followed in the comments.

My student-friend-mentee Cathy M. posted this weekend about her thoughts on keeping her faith-cards close to her chest. I know that people all along the faith spectrum are a part of this community. Believers in humankind only to those who said "L'shanah tovah!" often in the past few days to ones who fasted during one of the hottest months of Ramadan ever all the way to the ones who specifically believe in Jesus (and even that is a whoooole 'nother humongous spectrum.)

Anyways, I dipped my toe into that topic. I wondered if the post was too much or if it would offend somebody. As I was writing, I kept hearing Stipe on a loop. . .bleating into my ear. . . "Oh no, I said too much. . ."

What I learned was that I didn't. I go back to that post to feel this community and to also think about faith questions in the work place. Now I know that it's okay to do that and it's not really too much if you respect the space of others while owning your own.

#14 LA PROFESORA.

This was the post written after I'd visited the University of Pittsburgh Medical Center as a visiting professor. I go to that entry often because it makes me thing about friendship between women. My friend Shanta Z. was the one who invited me up there and is such an amazing friend and colleague. I loved my visit there and continue to be glad that I wrote about that experience very shortly after it happened.

I often refer to Shanta as "the profesora in Pittsburgh." She is a wonderful champion for medical students and residents, a strong leader, and someone who gets me. She also inspired a poem that I posted a few months ago about teaching medical students and residents that I read often. Her mantra is "back to the bedside." I hear it in my own head every single time I am attending on the ward.


#13  PANIC! AT THE NICU.

First of all, I always smile at my witty play on words with that title. Then that smile becomes a laugh when realize that my most faithful readers like my mama have no idea who the band "Panic! At the Disco" is so it actually isn't so witty at all.

That story was one that I had wanted to get out of my head and into written form for years. It felt so very therapeutic to write it and it continues to feel that way when I read it. The comments moved me to tears in ways that are hard to describe. What's funny is . . .if there was ever a post that I wrote for me, it was that one. I needed to process that experience. What I learned is that others needed to process some related feelings, too.

And I'm glad.

#12  THE BEST MATCH DAY EVER.

This was the post written after Small Group Alpha (my first group of medical student advisees) had their residency Match Day in March of 2011. It was probably one of the proudest moments of my entire career. In fact, I'm sure of it. On days that I feel overwhelmed by teaching and mentoring medical students, I go to this post. It recharges me and gets me shadow-boxing again because the reward is so, so great.

And since I mentioned Small Group Alpha and their Match Day, that always leads to me rereading the fun day I had with Ant, the sole survivor of SG Alpha, on her last day of medical school. That was special, too.

#11 ONE MOMENT IN TIME

Well. I can't read this one too often because I end up thinking about that whole journey with a previously anonymous medical student. That leads to an ugly cry like no other. Like, super-duper-somebody-slap-me-to-get-a-hold-of-myself ugly.

But when I am in the right mindset, I read that post. I love that entire story because it is a testimony and reminds me that good things can happen if we pay attention to one another. So many people paid attention. The pieces came together and the result was . . . .  literally, a dream come true.

If you put "one moment in time" in the search engine or click that label, you can read the entire story.

#10  WHEN HARRY MET KIMBERLY: YOU HAD ME AT OHIO.

Oh, how do I love thee? Let me, like, count the ways!

Aaaah. You guys know how much I love the BHE. Oh, that man. He is just . . . the best husband ever. Don't believe me? How about even more pictures to make you gag on how much I have a crush on this man!

The post about when Harry met Kimberly (witty again and bet Mom does get this play on words!) I don't know what was going on with me that day--oh yeah! Yes, I do. It was Harry's birthday, I think. Anyway, I put fingertips to laptop and wrote about the entire story of the day the we met. Whenever I am having a Harry love-fest (which is often, often, often) I read this for a smile.

I was never, ever lucky in love. Like, ever. So reading that makes me feel encouraged that every single dream can just be one moment away. It makes me hope that someone reading believes that, too.

I also like knowing that my boys will be able to read that story one day. The real, true story of "how I met your mother."

If you are interested in gagging repeatedly, please go straight to "The BHE" as a label. I do that often and fall in love all over again. It sort of embarrasses him that I so effusively profess my love for him here. But it mostly touches him.

#9  TEENAGE MUTANT TARGET CHECKOUT CHICK.

Man. This post just makes me laugh out loud. Every single time I read it. No matter what.

Part of it is imagining my sister JoLai or my friend Psonya saying, "Aww hell naaaw!" while reading it. Or knowing how much it would tickle my friend Lesley M. She always shares the funniest ones with her husband who, like her, is an avid reader. Something about that makes me feel proud of the funny ones.

For whatever reason when this happened, I thought of all of you! I couldn't wait to write about it and hear your thoughts. It felt like I was standing on the corner talking to my homegirls about some mundane ridiculousness--and all of you were those homegirls. Ha. Sure, it had nothing to do with medicine but seeing as forty two percent of my life is spent in Target, it seemed reasonable to write about it.

I can't tell you how many times I've revisited this post just for a pick-me-up on heavy days. Laughter is an excellent panacea for icky days.

#8  I WON'T COMPLAIN.

Something about this image I found of a young Bob Dylan singing in the deepest parts of the south during the epicenter of the civil rights movement moved me this morning. It also made me think of what was probably one of the greatest and most memorable moments I have ever experienced at Grady Hospital.

This is the post about that moment. I reread it often. I think it's my Poopdeck's favorite post of all time. (Poopdeck is my dad, but most of you know that already.)

Most of the stories I significantly modify to protect anonymity. The reason I love that story is because not one single drop of the details were changed in any way. I reported it exactly as it happened and, since it didn't involve patient care, it was okay to do so.

I loved this moment. It embodied every drop of every thing I love about Grady and underscores my complete awe and respect for the Grady elders.

That picture was one that I thought would make my friend Sister Moon smile. She (and the rest of our blog community-of-writers) is one of the best parts of starting this blog. We have really all become friends and it's so wonderful.

I mean that.

#7  LITTLE MAMA.

This post about a young mother crossing the street was supposed to be nothing but an exercise in simple observation. What I learned is that this can make for some of the most powerful imagery. I reread this post often. I recall closing my eyes and trying to think of words to bring that moment to life.  Funny. I had no idea where I was going with it. Once I reached a destination I was surprised at the emotion it evoked. It wasn't supposed to be that kind of post.

But it was.

#6  I THINK I KNOW YOU.

I just reread this post again this morning and it made me cry. I wrote this after running into an old acquaintance in the hospital. Someone I'd known from college whose life had taken a few sharp turns that landed him in a clinic room at Grady Hospital.

I loved the way he owned his space. Despite the obstacles or the little voice it was obvious that he was alright with himself. It immediately made me feel comfortable and made me want to emulate that quality.

More than anything, I learned that you don't know anyone like you think you do. Pretty much ever.


#5  THE HAIR POSTS.

Okay. Not all of them. But a few of them.

The F.P.

The first is the one about my favorite patient (F.P.) whose hair was coming out after chemotherapy. She was an amazing human being and one that I think of very, very often. I didn't know her for long but she had a tremendous impact on me. The very last thing she ever said to me was, "Love you." I will always remember that and hold it close.

Though not her real name, I gave her the name Mrs. Zebedee in the story. I'm not sure what made me pick that name but it's probably no accident that I chose a biblical one for her.  In the bible, "Zebedee" was the father of James and John. I imagine that he was quite wise. My Mrs. Zebedee was, too.

FOX-y Lady

This was the one about a patient calling to the hospital after an appearance I'd had on our local FOX affiliate. Hilarious.

The Hair Mane-ifesto

My homage to black hair and all that goes into it. What prompted me to do this? Well. Blame it on the Surgeon General of the United States. Sister-Doctor Benjamin said that sisters not exercising because of their hair concerns is a public health issue. While I neither support or refute this statement, I will say that I get why some women might be deterred by sweating if they have hair of the kinky-curly variety. Once I started writing about it, I couldn't stop.

One of my good friends (who does not happen to have hair of the kinky-curly variety) said that it was "truly educational and eye-opening." Something about that makes me wish I had a book cover to put that on the backside of.

Ever wondered about black hair? Read that post.

#4  WE LOVE HER MORE.

This was the post written after my mother's sixty fifth birthday. It was a day of new beginnings. I was reminded of what is truly, truly important. I have read that post and watched the video clip of my brother and I more times than I can even count.

Ever had misunderstandings with family members? Read that post and be reminded that life is too short to let them fester.

#3 THE NOD.

A modified version of this post is now published in JAMA. It is accompanied by an author reading. If you go to www.jama.com and either search or click on the multimedia page, you'll find an author reading of the full text version.

 I get "the nod" from people at least ten times every day.


#2  MY SO-CALLED LIFE OUTSIDE OF GRADY

This is exemplified through this small handful of posts about things that happened away from Grady. Technically, Teenage Mutant Target Checkout Chick and the one about my mom's birthday should be there, but they deserved their own place since I read them so very often. I know I'm cheating by not listing an individual post. But oh well, what can you do? I truly do read these often, so I figured I'd share.

The Puppy Mafia.

This entire saga makes me laugh out loud. But the very first installment makes me laugh the most. It's so ridiculous yet so true. I am laughing just thinking about it. So ridiculous and very much the embodiment of "my so-called life outside Grady."

The Lady in the Airport.

I kid you not, that's what happened. I go to this post for a hearty chuckle. And a reminder to have a little bit of chutzpah and cojones.

The Unexpected Isaiah Car Conversations on Race Relations.

This post was about a surprisingly heavy conversation that I had with Isaiah in the car one day--all revolving around The Green Lantern.

And this one was about the day that Isaiah relayed what a friend had told him about black people.


#1 -- ACUTE-ON-CHRONIC PARENTAL PRIDE

This post was written right after I had the surprise of winning the Evangeline Papageorge Teaching Award at The Emory University School of Medicine Commencement this year. I really, really considered not writing about it. But then I realized how bummed I'd be if I wanted to come back to that moment someday and had neglected to write about it while it was fresh.

I'm so glad that I did.

Every time I look at that last picture of my father, I cry. It makes me remember how I felt when I saw him standing there patting his eyes in that chapel. It reminds me of how acutely proud I made my mother and my father that day -- on top of their already chronic pride.



Whelp. Now that I have sufficiently eaten up your entire day, you may return to your regularly scheduled life. Ha ha ha.

There are others that I reread but I realized that I had to narrow it down. Remember, this blog is therapy and like Toni Morrison said after writing The Bluest Eye-- it was written "so I could read it." And I guess the point is. . . .I actually do.

Which makes me wonder--do any of the other blogger-writers out there do this? Or am I just a cornball who reads her own writing? I always hear artists and television/movie personalities saying they don't listen to their own music for leisure and that they've only watched their own movies/TV shows once. Is that just the cool thing to say or is that, like, how it really is with most people?

Hmmmm.

Sometimes I read things on my friends' blogs and wish I could remember the title or label so that I could go back to it. That may or may not be me nudging you to do a version of this, too.

My mom says that she is going to make a guest post here with her top ten posts from her daughter's blog. And by her daughter I mean me. Stay tuned for that. It could be as soon as next week or next year. I've learned not to rush the sixty-five year old version of my mama. You shouldn't either. Just saying.

Antywho.

I'd love to know which posts, if any, have resonated the most with you. Do you like the student posts? The mommy-hood ones? The patient stories? The ridiculous Target encounters? I'm curious. Feel free to delurk to share. Or just share. Think of it like feedback on Amazon.

But without the mean comments and star system.

***
Happy Weekend, my friends. And thank you so, so much for returning over and over to read the little blog that could aka this-here blog.

Trials and errors.

I was talking to a patient the recently. The conversation was easy and fluid, just like doctors like discussions with patients to be. A blood pressure was too high so we needed to do something about it. Two medicines needed to become three. Because even though she was taking the two, her blood pressure was still uncontrolled.

I listened to the amazingly competent resident physician as he unfolded her medical history in front of me like a linen napkin. Stage two essential hypertension. Currently on a thiazide diuretic. Next came a calcium channel blocker. Now he wanted to add another medication because the pressure was still too high.

He gave me a clear explanation for his choices of medications. That resident cited all sorts of clinical trials with funny acronyms that spell out words like ACCOMPLISH and MERIT-hf and provided evidence for why each potential drug combination was or was not the best for this patient. I marveled at how well he knew the fine points of so many intricate medical studies and how effortlessly he applied them to his practice.

Honestly? He was all over that plan. So much so that I had nothing much to add. Who could argue with clinical trials?

"Is she taking all of her medicines?" I had to ask at least a couple of questions.

"Yes. She's very motivated and is taking them all. She brought her bottles in and everything."

Then he assured me that she was taking her medications, exercising, and watching her salt intake. So a third medicine it would be.

Admittedly, this resident had memorized more medical evidence than I had. I knew the rules and what to do, but when it came to calling out the names of each study and those fine details like, "3100 adult white males were randomized to this medicine versus placebo." Me? I tend to mostly know the impact of the study and what it means to patient care.

But I'm always super impressed by others who can recite the details.

So after my less-than-probing queries, we went to see the patient.

I exchanged pleasantries and explained that we were concerned about her blood pressure. That's when we launched into that easy-like-Sunday-morning chat about her hypertension and she seemed quite amenable to all of the things we were saying. I then thanked her for bringing in her pill bottles and asked if she'd minded showing them to me again.

"That's no problem," she answered and pulled out her medications as prescribed during our last visit and also during a recent  ER visit.

He was right. This lady seemed to have it together. Greying hair in a tight chignon. A careful application of lipstick. And a fancy blouse with ruffles along the front. All accessorized with a warm demeanor--the very best kind of "together."

My resident launched into a discussion about our plan to add another medicine. How she should take it. What side effects to look out for. All of that.

I kind of zoned out while he was talking. I read the labels on her bottles and made sure they matched the amounts recorded in her chart. Everything was spot on and the resident was nearly done with the encounter.

That's when I let my eyes do what they habitually do. Check the fill date and estimate the number of pills remaining in the bottle.

Fill date: July 20, 2012.
Quantity dispensed: Thirty pills for each prescription.
Amount in each bottle: Easily twenty.

Rut roh.

"Is this the last bottle you had filled?" I asked her.

"Yes ma'am."

I twirled the bottle over in my hand and pressed my lips together. My brow knitted and then unknitted; I didn't want to alarm her. "Do you ever . . . .sometimes. . . forget pills?"

"No, ma'am. I take my pills every day." She kept her eyes carefully fixed on my own.

"Okay. I was just wondering because this bottle should have run out at last month around the eighteenth of August. Are you sure you always remember?"

She dropped her head and sighed. "I be forgetting. A lot."

I looked up at the resident and then back at the patient.

"You do? Did you take them today?"

And she shrugged.

We probed some more and found out that this "really together" patient with the stage 2 hypertension mostly took her medicines on a "as needed" basis. Because on the other days she often forgot. The day her head hurt, yes. If her urine was dark yellow, definitely. And in those next moments we uncovered a surprising amount of things that she didn't understand about her medical problems and couldn't remember in her life. It became clear that she had some pretty significant cognitive impairment.

"I live by myself. I don't be wanting to bother nobody and don't want nobody thinking something wrong with me."

"Something like what?" I asked.

"Like the old-timers setting in. You know. My daddy, he got the old-timers disease real bad before he passed on. It started with him forgetting stuff."

Aaah. She was afraid that she, too, might be developing some Alzheimer's dementia.

So we talked some more and arranged for her to see our neurologists in the "Memory Clinic" -- a session devoted to early cognitive impairment. The resident doctor spoke to her son on the phone who agreed to regularly check in on her and to get other family members to help him. Lastly, we spoke with our social worker and pharmacist to arrange some other interventions to assist her in managing her health.

It wasn't clear what this all meant. Was she on her way to developing severe dementia? Had those daily crossword puzzles and sudoku grids betrayed her? We didn't exactly know. All of this had been masked so well.

Finally we discharged her home with the same exact medications with which she'd arrived. Two medications instead of three.

"I'm going to worry about her," the resident told me. "I know I am."

"Me, too," I whispered.

He shook his head and stared out of a nearby window. "You do all this reading, you know? But for some things there's just no textbook."

And I got what he meant by that. He was right. Sometimes medicine isn't about knowing the clinical trials  off the top of your head. Sometimes it's just about trials and errors.

Yeah.

But the other part that isn't in the books is that it also involves worrying. . .  long after the patient has left your sight and just before your head hits the pillow.

***

Random goodness.

"What is it you think you see when you see me?"

~ Mary Mary

_____________________________

Well.

I can't say I have the energy to type the story that's in the queue of my mind. Promise to get to that soon. In the meantime, here's a little bit of random goodness.

Let me start with this:

I was in clinic on Monday and a patient that I have been seeing for several years came in to be seen. I mostly see patients with the residents and for this patient, we'd together seen two trainees from internship to board eligible graduation. Now seeing her third resident primary care doctor, we felt like the seasoned camp counselors returning year after year as constants in an ever-changing system. Instead of the doctors showing this patient all of the ropes, she knew Grady so well now that she schooled them.

It had been a while since i'd seen her. As a matter of fact, it had been well over six months considering all of her medical problems were under such great control. On this day, everything was still in great shape, so the encounter was easy and familiar. After the resident saw her, I came in and socialized more than anything else. I examined her briefly and then jumped straight to the pleasantries. It was great.

But then, she reached into her purse and handed me something. It appeared to be some kind of card and I could tell she wanted me open it right then and there.

So I did.

A birthday card. With my actual date of birth on it. My mouth fell open.

"I remembered from one year that I was here in clinic and it was your birthday. I always remembered that it was on September 7 after that."

I was speechless.

"I wanted to bring it sooner but I knew this appointment was coming up. So happy belated birthday, Dr. Manning."

But by the time she said that, I was getting choked up. Reading this card with my date of birth on the front that this patient with all of her medical problems and life issues had remembered.

Here is what it said:

"You're such a cheerful giver, Dr. Manning. You give of your spirit. Thank you for blessing me with that gift."

Come on, y'all. Now you know what happened next. And if you think I didn't do it right there in front of her, you haven't been reading this blog very long. Yep. Cried right then and there. Didn't even try to front like I wasn't moved to tears.

She gave me a meaningful hug, hand tight on my back. And I was tired that day, too. So reading that card and feeling her hand pressing between my shoulder blades made my soul just open right up.

She pulled back from the hug and looked at me. With a chuckle, she said, "You know? This isn't the first time I've seen you cry, Dr. Manning. And I love that about you."

And well. What do you say to that? Especially on a day when you're tired and you really, really needed something like that?

"Thank you. You have no idea what this means to me."

"I do. This is why when I saw that card, I knew I had to get it for you. "

And that was that.

Can I just say this? I have done some cool things in my career. Like, I've been on really high profile television shows talking medicine and taught some amazing students and have received some really unbelievable awards, too.  And hand over heart, I appreciate every last experience and accolade. But these moments? These one-on-one pivotal moments with real people are the ones that tell me the most about who I am and what I've accomplished.

Yeah.

Someone at Grady Hospital felt like I was a cheerful giver--of my spirit. My spirit, y'all. This? This is making me cry right now because this is what I want to do in my life more than anything else.

Whew. Let me lighten things up with a change of subject.

The hair salon was great today. Nobody was selling peach cobblers or talking about Mrs. Obama, but two of my good friends had appointments today so that was awesome. And we weren't expecting it, so that made it even better.

Joy, one of my besties and college sorority line-sisters, was there. We caught up and agreed that we should coordinate our appointments more often.  That's Joy on the left.

Isn't she gorgeous?

Yolanda, my med school classmate, was there with her daughter, Ryan, who is turning six next week. Ryan had the appointment--not Yolanda.

Yolanda and me, both medicine nerds

Her first press and curl? Chile please!


This is a milestone, people. We all applauded Ryan as her little afro puffs slowly took on another form. And this is not saying that we have any issues with afro puffs. Or the darling braids and twists she normally wears. No, we do not. I'm just saying that there's something about getting your hair straightened as a kid that feels like a big deal. I know you couldn't tell me NOTHING (yes, I meant to say nothing instead of "anything") when I got my hair pressed out as a kid.

Don't believe me? Here's one of my very first press and curls. Clearly that sidewalk in front of our house was a runway. And clearly I was FIERCE. (Can't you see me smizing?) JoLai was ready to take up the runway next.

You betta work, honey! (That's Top Model lingo for those unfamiliar.)

Whaaaat?

There's her mom, Yolanda, standing in the background. I took out my phone and said, "Girl! This is a milestone! Why ain't you snapping pictures?"

And yes. I said "ain't" and not "aren't" because that's just me being honest.

I can say for certain that I did NOT have an iPad to keep me company when I got my first press and curl. Furthermore, I was not in a salon but in a kitchen. And I was not sitting in a fancy chair but on three to five phone books.

I'm just saying.

You can't really see it in this light, but one thing that hasn't changed:

You couldn't tell Ryan NOTHING when she strutted out of there. That baby almost broke her neck from swinging her hair. And yes, the parking lot was a runway.

Sashay, Shante! You beta work, Ryan!

That made me think of this, listen to this, and pause from this post to "sashay, Shante!"



First press and curl? Been there. Sho nuff done that.

What else?

Walked to campus today for my meetings. How gorgeous was it? A fall teaser of a day, I tell you.

I snapped these shots while strolling along and humming a song.

Here's another shot from another meeting I had downtown. I just liked the view.

Purty, huh?

What else do I have? Oh this:

Isaiah had a family tree project due this week. He really worked hard on it and got into the whole process. I loved seeing his face light up with ideas. When I'd try to redirect him, he'd say, "It's my project, Mom." To which I'd say, "That it is."

He was very proud of his finished product.

"This is awesome, Mom, right?"

"That it is."

***
Happy Wednesday-pretty much-Thursday.

Now playing on my mental iPod. . . .

Oke-rees.

oke-rees

You know how I love the elders. Lord knows I do.

Sigh.

Today I was leaving Kroger and this sweet elderly gentleman in front of me in line commenced to strike up a conversation. The man was surely about to knock 90 down if he hadn't already and he definitely put some fear in my heart as he pulled out his car keys to approach his car. Because he was about to drive.

Mmmm hmmm.

I made the mistake of smiling at him too warmly because that opened up the floor for him to get his full, unfiltered and unabbreviated chit-chat on.

I wan't you to know: I am currently typing this while beheaded. Because that man TALKED. MY. HEAD. OFF.

Do you hear me?

I walked out toward my car at approximately 6 PM. And I just got home five minutes ago. For real. Okay, maybe I got home a little bit sooner than that but, for real, he was skipping from topic to topic like rocks on a lake.

Lawd.

"Do you eat oke-rees? I like your cross neck-a-lace. I see you got that Er-bama on your car. Are you in college? My son had double majors when he went to college. Is that a stick shift? Some folks can't even drive a stick shift. Do you drive stick shifts? Seem like prune juice don't work like it use-ta. Was your peaches sweet this season? I puts oke-rees in my black-eyed peas. You eat peas? What you put in 'em? I like a piece a salt pork. Seem like pork get a bad rap. You know they letcha buy wine on a Sunday now? That's a shame. I like your cross neck-a-lace. Why you got Er-bama on your car and a cross neck-a-lace? I saw two ladies in broad day light kissing on the mouth. You have children? My wife deceased but she liked H.W. Bush. I liked him okay. Seem like a damn shame to get some beer on a Sunday. This is Georgia, you know? I got a grandson in college. He real smart but otherwise he ain't no count. Did you know them oke-rees was on sale? Do you eat oke-rees? My son he'll eat anything but some oke-rees. Seem like it's getting dark already. Hey. . .what you think of that Er-bama anyway? He's alright with them girls kissing each other you know--smack dab on the mouth! And them was some pretty little ladies, too. Broad day light. Did you know that it's poisons in them fabric softener sheets you got there?"

LAWD.

He WOULD. NOT. STOP.

I. COULD. NOT. GET. AWAY.

Multiply that paragraph by seven hundred and you have the number of tangents he went on.

Seriously.

I love the elders. Lord knows I do. But this one. . . . sigh. . . bless his heart. WOW he was chatty. I feel so bad that I had to just finally walk away in the middle of his sentence. Literally. So terrible, I know.

What would y'all have done? I'm real scared that he still might be out there talking. . . .

Dat'll do.

*Names, details, and all that stuff that folks worry about have been modified.

Piedmont Park on a Saturday, Atlanta

Last patient of the day on a sunny afternoon. This was back when our Urgent Care center was open on weekends and, no matter how much you love Grady Hospital, being there on a sparkling Saturday is not exactly ideal. So yeah, that's where I was but on this day I was trucking. Running three rooms, working seamlessly with the nurses, and stamping out disease one urgent complaint at a time.

I'd grabbed his chart and read the complaint. "Recurrent hemorrhoids and constipation." Age: twenty-something.

Now. If you are a doctor who has ever worked in a super-busy clinic--especially a super-busy inner-city clinic--you can totally understand why those two words "hemorrhoids and constipation" would make me do the happy dance. Especially at 4:45 P.M. on a weekend when I really wanted to be in Piedmont Park.

I nodded my head smugly and pointed at my colleague who was feverishly charting on his second to last patient of the day. "Yeaaaaah baby!"

"What? A toothache?" he asked. We both knew that a toothache was the motherlode of complaints that were in-and-out for us. As internists, there wasn't much more that we could do other than getting the patient to an area dentist or oral surgeon. Antibiotics in the interim and pain control could be written on a script quicker than you could say "Rumpelstiltskin." Next best thing? Hemorrhoids. Especially recurrent ones.

"Hemorrhoids. And constipation. Recurrent." I smiled a big wide smile.

He squinted his eyes at me and groaned. "I have someone with a headache and a pretty elevated blood pressure. At four forty-five. Awesome." He held up the other chart in his hand. "And this patient needs some stat labs."

"Ouch."

"I know, right? So much for finishing up early. But I guess we signed up for this, right?"

"Claro que si," I replied while sifting through the computer to see if my young patient had any old lab work. "No labs or prior visits to the Gradys." I stood up, propped hands on the desk and leaned over toward the window like a tripod. I was looking forward to feeling that sun on my face.

"Rub it in, why don't you!" my colleague teased. I raised my eyebrows and smiled again. Then he offered me a playful warning. "Hey Kim. . . . . nothing is ever as straightforward as it seems."

"Especially at four forty-five on a Saturday!"  I pushed the door open and chuckled again. Quickly I made my way to my last patient of the day.

After a knock on the door I stepped in and introduced myself. "Hey there, sir! My name is Dr. Manning and I'll be seeing you today. You are . . .Mr. Cole?"

"Yes ma'am," he replied while firmly shaking my hand. That handshake was deliberate and masculine. "It's okay if you call me Quentin, though."

"Is that your preference?"

"Sure. That's cool. I mean, yes ma'am, that's what I'm most comfortable with."

I liked the way he autocorrected himself when speaking to me. Almost like he could hear some grandmama in his ear saying, Is that how you speak to people? The Grady elders call that home-training. I could tell he had plenty of it -- from his neatly groomed hair and clothes to the straightness of his spine as he sat. No slack jeans or mumbling voice. He clearly had some quality home-training.

"Okay, Quentin. So . . .are you a student here in Atlanta?"  I couldn't help but ask since he was wearing a t-shirt with big block letters from his university on it. The baseball cap and drawstring nylon bag in the same color palette gave it away. That and his young face. "I see you representing your school with all the paraphernalia!"

He nodded proudly. "Yes ma'am. Proud of it, too!"

"Good stuff," I continued. "What are you studying?"

"Finance. And I'm on an athletic scholarship. Football."

"Nice."  And I said that because I meant that. It was nice that this kid with the home-training was in an excellent four-year institution on a scholarship. I looked back down at his chart and was reminded of his chief complaint. I knew it would be more awkward for him than it was for me  so I did my best to keep things light but formal. "So I see that you have a problem that isn't a new one for you. How about you tell me what's going on?"

"It's kind of embarrassing. But yeah, it's hemorrhoids. And since they are kind of uncomfortable, I think I've been avoiding doing. . . .you know. . . number two."

"Got it." I jotted that down and glanced back up. "Hemorrhoids are so super common. They can be pretty uncomfortable, too."

"Yes, ma'am." He seemed to appreciate that normalizing statement.

"You've had hemorrhoids in the past?"

"Yes, ma'am."

I stared at him for a beat and thought about why a twenty-something year old man would have recurrent hemorrhoids. Most of the time they come from straining--pushing out hard bowel movements, pushing out big babies and pushing through some heavy lifting. Heavy lifting? Aaaah. Yes.

"Do you lift a lot of weights for football? Like squats and stuff like that?" I knew that answer before he could even open his mouth. His percentage of body fat wasn't the kind you get from recreational work outs. He had that two-a-day practice kind of definition clear down to his calf muscles.

"Yes ma'am," he chuckled, seemingly relieved that we had an easy explanation for all of this.

I was relieved, too. Relieved that this was as straightforward as I'd hoped it would be, but also that I was sitting in front of a really charming young person who knew how to talk to other adults. His caramel complexion was almost identical to my own and his facial features even looked like those of people related to me. Something about that made me well with pride. I was glad to be seeing him.

"Is this similar to when you had hemorrhoids before?"

"Pretty much. They hurt a little more last time. Now they're mostly irritating." A wave of embarrassment came over his face. "I'm sorry. This is so weird to be talking about."

"Totally understand."

"I was hoping to get some of the foam and the medicine they gave me last time."

"That shouldn't be an issue."  I wrote down a few more things and then asked him some more obligatory questions. Like, what are you allergic to and do you smoke? Are you sexually active and have you tried any kind of drug? Do you drink and what medical problems besides this have you had in the past? His answers were predictable. No allergies, yuck to smoking, yes ma'am to sex and no ma'am to drugs. A little bit of asthma that he thinks he grew out of. Otherwise uneventful. Yes, this was all very straightforward.

Hallelujah.

I also asked a little bit more about the constipation and reviewed his diet. Typical crappy college fare, full of refined sugars and fats with a paucity of fiber. Duh.

Next was the physical examination. Habitually, I started with his eyes and oropharynx which didn't yield much of anything. Ears had not even a trace of wax and other than being hidden inside of an uber-ripped container his lungs, heart, and abdomen were pristine.  And then I paused.

Shit. He needs a rectal exam.

I could see his face pleading with me. It was saying, Please, ma'am. Just take my word for this. Please don't ask me to drop trow right here, right now. And you know? I strongly, strongly considered obliging him.

First of all, it meant I'd need to get a nurse to stand in as a chaperone. Since it was late in the shift, we were low on nurses so that would make the whole thing take longer. And seriously? This guy was a good historian with good home-training. Why wouldn't he just tell me like it was? Everything else about him had been easy-peasy. Was it really necessary for me to make this poor guy show this lady doctor his nether region?

I started coming up with arguments in my head. Telling myself that if this were some swanky private practice that this whole encounter could have been a call in to the nurse and that, sure, a prescription could be phoned directly to his local CVS. Or Rite Aid. Or whatever he so chooses.

But that isn't what this was. It was an urgent care visit. With a complaint involving the rectum. What kind of doctor would see someone for a complaint in an ear and not look at it? Grrrr. I could hear my dad in my ear. He calls that being a "dat'll do" kind of person. The kind that cuts corners just because they think they can.  I knew I had to look.

"Well let me just step out and grab a nurse, okay? Go ahead and undress from the waist down and cover your lap with this sheet. I'll be right back."

"Excuse me, Dr. Manning--umm. . . . is it possible to just make the prescription? My mom was saying that sometimes if you've had a problem before like this one -- especially a sensitive thing -- that I should ask."

I held my hand on the doorknob and paused. Good ol' Mama.

"She was saying, like, that her doctor if she has a yeast something she called it. . . . the doctor just calls it in or even takes her word for it. So she won't have to do that whole other part and get checked out all over again when they know what it is."

Damn. This was tempting.

Dat'll do. Dat'll do. Poopdeck wouldn't get out of my ear.

"This will be super quick. It's way easier than doing a pelvic exam. It'll take two seconds, okay? I'm only looking just to be thorough. I'll be right back."

I stepped out of the room before he (or me) could try to convince me otherwise. A few moments later I was back with Charlotte, one of our nurses. She offered a quiet introduction with only a smile and head nod.  Her job was just to be there and nothing else.

I instructed Quinten to put one foot on the step and to lean his body forward on the exam table. I kept reassuring him that this would be "super-quick" so that I could "quickly confirm that his hemorrhoid didn't need to be drained." He wasn't miserable enough to need emergent incision and drainage, but I felt the need to justify this mortifying position I had him in.

I rolled over on my stool to grab the neck of the positionable light and then flicked it on. "These are just my hands looking," I announced. Quentin's voice was quiet and far away as he mumble back an obligatory "Yes ma'am." I gently applied pressure outward to open the cleft and better visualize what was certainly going to be the tell-tale garden variety external hemorrhoid.  Just as I did, the bright light gave me clear view of the source of his complaint.

Or rather sources.

I'd been talking the whole time but now I was quiet. I looked carefully to make certain I was seeing correctly. And I was. Shit.

"Quentin? You said this was a little different than your hemorrhoids before?"

"Uhhh, sort of. I mean just. . .they didn't hurt as much."

"Um, okay." I inspected some more. "So, okay. How long has this been bothering you again?"

"On and off for like some months."

"Did the doctor who gave you the foam and numbing medicine last time do this kind of examination?"

"Like what you're doing?"

"Yes. Like what I'm doing right now."  This was awkward. Talking to someone who had their back--and their backside--to you. But this wasn't what I was expecting. I needed more history.

"No. It was my pediatrician while I was home for the summer. When he heard about me being constipated and the weight lifting he gave me the medicines and they kind of helped."

"Okay. Thanks for clarifying that, Quentin."  I went ahead and examined the rest of his genital region and then stepped on the other side of the curtain that Charlotte had pulled. "Go ahead and get dressed and we can talk about the plan."

"Yes ma'am." Of course. Yes, ma'am.

Charlotte was so busy that she was down the hall and into another task before I could even get out of the room. Moments later I stepped back inside to talk to Quentin about what I'd seen.

So what did I see? Well. It certainly wasn't a hemorrhoid. Instead, found a large collection of perirectal warts coalescing right at the entry. Some were pedunculated and red--I could see how this could be irritating to him.

I was mad at myself. First, I'd strongly considered not examining his rectum. Second, I didn't take a full sexual history. I"d gotten so caught up in making him a bread and butter case that I'd sized him up and forced him into my own story line. I was too experienced for this. To me, this was more the move of an overtired trainee. Not a full fledged attending physician.

Dat'll do. Dat'll do. 

"Quentin," I started carefully, "I didn't see hemorrhoids on your examination. I saw some pretty large genital warts at the opening of your rectum."

His eyes widened and his mouth fell open. "What?"

"It makes sense why you've felt this way. I think the medicines you took before quieted down the irritation but it probably wasn't ever a hemorrhoid."

"How did I. . . I mean, what does this mean?"

"I probably need to have a specialist see you. I can make a referral to help with that. I think since they're kind of big, they may want to remove them, like, surgically."

"Will that mean they're gone for good?"

I sighed because that was a damn good question. "Honestly? These often come back."

"Really?"  Now his eyes were glistening with tears.

"Quentin?" I softened my voice. "I should have asked you this earlier. You told me that you are sexually active. . . but are your partners female, male . . . or both?"

"Female," he promptly responded.

"Condoms? Do you use them?"

"Mostly. I mean, I've slipped a few times but mostly yes."

"Have you. . . .like. . . ever maybe tried sex with someone who wasn't a female?" It felt so lame to ask again but this diagnosis suggested unprotected anal receptive intercourse. We needed to get this out on the table before I could get to any problem-specific patient education.

"I tried it, yeah. Like only a few times, though."

"Okay. There really isn't an issue with whether or not your partners are only girls or only guys or girls and guys. The issue is mostly whether you use condoms. I think maybe one of the times that your partner didn't use a condom. . . .you might have gotten these warts around your bottom."

"Damn it! Really?" Now tears were falling down his cheeks. "So anybody who sees this on me will know, right? Like know that I've done that before?"

"Quentin, look. I know this is a lot and those kinds of questions are really complicated, you know? But to be honest, this can be as private as you keep it. There's probably more to all of this, I'm sure. Like, how you feel about all of  this and even how you feel about who you are."

"Yes, ma'am."

"My impression of you when I first met you is that you seem like a really respectful young man who obviously has been hitting the gym and the books." He offered me a tiny smile. "This is kind of crappy news to get on a weekend, but you're here, you know, and now you'll get the care you need."

"Yes, ma'am." He sighed hard and pressed the heels of his palms into his eyes.

"It's going to be okay, Quentin. Okay?"

He nodded and tried to believe me.

I wanted to say dat'll do and end it there but I knew I had to consent him for an HIV test, further screen him for other sexually transmitted infections, talk about safer sexual practices and arrange some referrals. He was gracious with all of it, and mostly he looked kind of relieved. Almost like I'd rubbed a genie out of it's bottle whose contents had been under pressure.

After all of this was said and done, the encounter was still pretty fast. I was out of the hospital by five thirty and yukking it up with a girlfriend over frosty margaritas on a patio overlooking Piedmont Park by five forty-five.

Yep.

I never saw Quentin again. I did see that his HIV antibody was negative and there were indications from his chart that surgical follow up was obtained. Otherwise, I'm not sure what ever became of him.

My guess is that he's somewhere working in finance and doing great things. I hope that he's being true to himself and not just saying "yes, ma'am" and "no, sir" because he thinks that's what everyone wants to hear.

But mostly I hope he's happy.

I never, ever forgot the lesson he taught me in not sizing people up with sweeping generalizations and also about fighting the temptation to cut corners. It's all so easy to fall prey to, you know? He also reminded me of how hard it is to be your authentic self in this world. Sometimes life nudges us to walk the seemingly easiest path when doing that really makes things less so.

Dat'll do. Dat'll do. 

No ma'am, no sir, it will not.

***

Can't get this out of my head.

Did you see this last night?

This has been playing on my mental iPod (and my real iPod) ever since I woke up on the couch in the middle of this artist Frank Ocean's riveting SNL debut. Something about the whole thing. . .the falsetto, the lyrics, the  emotion in his voice just grabbed me. It shook me awake and made me pay attention. (Especially once I realized that it wasn't Billy Ocean on an old school throwback.)

Yes, I realize that the song is kind of popular. But I guess I didn't realize it was SNL popular. And  hearing him sing it live without too much going on in the background made me hear it differently. Or better yet, actually hear it.

It won't ever get old, not in my soul

Not in my spirit, keep it alive

We'll go down this road

'Til it turns from color to black and white

Or do you not think so far ahead?

'Cause I been thinkin' 'bout forever 

Or do you not think so far ahead? 

'Cause I been thinkin' 'bout forever 

When I first met Harry, after our first date I called my father and told him flat out:

"Daddy? I think I've met my husband." 

And I was right.

Man. Those words resonate with me. Harry and I sat in the sunroom talking about this song this morning over coffee. Sure, I had to endure at least thirty two counts of him squenching his eyes and singing the falsetto parts but I also got to hold his hand and tell him how much I love thinking far ahead with him.

And he said he feels the same way.

From that first date, I thought far, far ahead. Man. I still do. I see us as empty nesters and then grandparents. I see us as crotchety and cantankerous old liberals who type crazy comments on message boards. I see our lights off at 9pm and us dressing up to go to doctors' appointments. . . then coming home at three PM and telling the middle-schoolers who just got off of their buses to get off of our lawn. I see all of that. And I see all of the extraordinary and ordinary things in between.

That song is kind of haunting because that's a scary thing to do to yourself. Thinking far ahead, you know? Like what if something happens, right? That's what the little voice warns you in your ear. I've heard the Grady elders say a million times: "Man plans and God laughs" but I just want to ask them . . . how can you not help but think so far ahead when real, true love presents itself to you? 

You can't.

So me? I'll sign up for the vulnerability that comes with those daydreams. Because it also means you get the delight of waking up and realizing that the thing you crossed your fingers behind your back and hoped for came true. You didn't jinx it. It's real.

Does that make sense to you? Please say it does and please tell me someone else does this in their head.

Or do you not think so far ahead?

Okay. I'm going to bed before I make someone barf all over their computer. Ha ha ha . . . 

Yawn. Nighty night, y'all.

***

Runners and gunners.

*Names and deets changed. You know the deal.

gun·ner (n.):

A person who is competitive,overly-ambitious and substantially exceeds minimum requirements. A gunner will compromise his/her peer relationships and/or reputation among peers in order to obtain recognition and praise from his/her superiors. (courtesy of urbandictionary.com)


_____________________________________________________

She was standing there with a stack of photocopied medical records shuffling them in front of me. Her glasses kept slipping down on her nose, partly because of their size but mostly because of the thin film of perspiration covering her face. The tremor in her hands seemed more pronounced because she was holding those rattling papers. I put on my most reassuring expression to help her relax but it wasn't working.

I suppose the whole thing was a bit nerve-racking. I mean, here she was a medical student presenting a patient to the attending on her first week of the Internal Medicine hospital service. At Grady Hospital, no less. For whatever reason, this rotation along with Surgery, are the ones that bring out the most nerves and insecurity in the students. I think it's because they are considered by many to be the "bread and butter" of everything else in medicine.

It was also a pretty big team that month. A senior resident and two interns, of course, but also three additional students not counting her. One was a fourth year who was nearing the end of residency interviews. He'd already decided on a career in Radiation Oncology and that fact, coupled with his experience, made him the most at ease of the medical students. Another student had been off cycle after earning a PhD. This was one of her final rotations so she, too, was mostly confident on rounds.

Then there were the other two. Seth and Parul. Both had just started the clerkship and were clearly neophytes when it came to the hospital service, but that was where their similarities ended. Seth, the one who wasn't presenting at the time, had enough swag for every member on the team. He was smart--and he knew it. All others in his presence had one choice and one choice only--step your game up or get your game stepped on. I liked how bright and enthusiastic he was but there were times that it seemed like he broke the code of "what's cool" when it came to his fellow learners. I didn't know how to feel about that.

Parul was pound-for-pound just as smart as Seth. I'd had a few brief encounters with her during the pre-clinical period and knew from those interactions that she was wicked smart. Somehow I'd gotten wind of the fact that she'd come to medical school on an academic scholarship and that she'd stealthily knocked nearly every test--including the boards--clear out of the park. Interestingly, she kept all that mum. No one would know how well she was doing from casual interactions because her confidence had it's "near empty" light on just about every time you'd see her.

So on our morning rounds, Parul walked bumpily through her patient presentation and it was mostly bumpy because she inserted an "um" between very other word. Otherwise, her information was well organized and quite fluid.

I make a point of treating the students as real, true clinicians and members of the team. I ask them the same management questions as I'd ask the interns--particularly when it comes to their opinion of what to do next. Parul's plan--though um-filled--was wrapped pretty tight so I didn't have too many questions at the moment.

"What do you make of the acute kidney injury?" I asked.

Her face quickly flushed and she swallowed hard. The pregnant pause was awkward, so again, I did my best to allay her nervousness. Finally, she parted her mouth to speak, but just as she did Seth spoke.

"Didn't you mention that she takes a diuretic? The hydrochlorthiazide could explain the AKI."

Parul cleared her throat and offered Seth an anemic smile. Instead of looking at her, he smugly looked at me to see what I'd say next. The resident started to say something about the diuretic but I put my hand up to stop him. With my attention on Parul, I nodded in her direction.

"Well," she started, "I did, um, consider the thiazide as a possibility. She was prescribed this three months ago, so that is a consideration."

"She's also hypercalcemic." We all looked at Seth who added this little pearl of information while holding not even a single sheet of paper. "The HCTZ could cause her some decreased calcium excretion, too."

I tried not to look annoyed with Seth but I was. I turned back to Parul and made myself more clear. "I want to know what you think, Parul. What are your thoughts?"

Again that lumpy silence as she carefully sifted through her words. And then, she put her own pieces together.

"I am not so sure about the thiazide, Dr. Manning. She wasn't taking them because they made her have to urinate too often and she catches two buses. I counted out her pills and the bottle was just a bout full. And it was dated from two months ago." She looked around with trepidation and then continued. "She is hypercalcemic--as high as 10.6--but I saw in her records that this preceded the hydrochlorthiazide."

"Okay," I said. "So what else did you find out?"

"That she's anemic," Parul quietly reported. "Her colonoscopy was negative and she was borderline iron deficient. She also had proteinuria on her urine dipstick in the ER and an unusually high protein against that albumin level."

"So you're thinking multiple myeloma? Makes sense." Seth had jumped in again. I sucked in a deep breath in the most subtle way I could. What I really wanted to do was grab him by the collar and tell him how uncool it was to steal her punchline like that.

"Well, duh!" I chided him. "Obviously that's what she's getting at. What's up with you jumping in on the punchline, dude?" I couldn't resist saying something. He laughed but still looked uber-confident.

"So, if it's okay with you, I think a serum protein electrophoresis might be indicated," Parul went on.

"Makes perfect sense." I smiled at her and put my hand up for a high five. She timidly met my open palm with hers. "Anything else?" This time I was glancing toward my resident and the rest of the team.

"Well, we could also check for HIV or hepatitis C," Seth mentioned. "That could also explain the gap between he total protein and albumin."

"Good thinking," Parul responded quietly.

"Has that been checked at all?" I had to know.  I knew that Parul knew this patient well and was willing to bet that she'd already thought of this. She was such a good citizen that instead of neck rolling and fingersnapping in Seth's face like Honey Boo Boo, she simply smoothed it over by letting him look  good -- even though he'd repeatedly been doing so at her expense.

"They were checked, Dr. Manning. Both were negative."

"Got it. Thanks, Parul."

So we finished up our rounds and that same kind of thing played out two or three more times with Seth one-upping his comrades with these medical booms he repeatedly lowered on them. Every point he made was a good one. But the issue was how he did it.

Not cool.

I pulled Seth aside later that afternoon. I told him that I could tell that he was bright and that he enjoyed learning. But I also told him that he needed to be more savvy about how he interjected his medical knowledge while another had the floor.

"There's a way to do it," I told him. "You want to be collegial, you know?" So I gave him examples like the whole deflating interruption about multiple myeloma and his insistence on getting the last word on other discussions. "Be careful," I said. "Medicine is a team sport."

"So am I just supposed to stand by passively? Not speak up unless it's my turn?"

"No. That's not what I'm saying. Not at all."

He furrowed his brow and looked annoyed. Annoyed in that "you're really just insecure so this is why you're saying this and not because I was treating my classmate like an asshole" kind of way.

He let out and exaggerated sigh and countered my statement. "Soooo. . . .if I hadn't mentioned the diuretic, I'm not sure it would have come up."

"Of course it would have. Seth she was still in the middle of her assessment and plan. You never gave her a chance."

"I mean. . . .she was just standing there hemming and hawing. I'm here to learn. This is frustrating to hear because speaking up on rounds helps me to learn. I can't help it if no one else wants to speak up."

I paused and tapped my fingers on my lips before speaking. "It wasn't that you spoke up. It was how you did, Seth. It was how."

What happened next was something I had never done. I commenced to give him a series of suggestions -- specific suggestions -- for other things he could have done and said that didn't undermine his colleague. Such as looking in her direction when speaking. Or letting her finish her thought before jumping in. Maybe even asking her, in a collaborative way, instead of a way that trumped her thoughts.

But especially not sucker punching her with extraneous information on her own patients in front of the attending. Not. Even. Cool.

"She hadn't mentioned the calcium level. How did you know the patient was hypercalcemic?" I asked him. This was probably the thing that was making me the hardest on him. I had the distinct impression that he'd looked up the labs and prepared to share facts that Parul hadn't mentioned. All in an effort to look good.

"I look up all of the labs for all of the patients every day," he said. "I'd seen it the evening before so thought I'd mention it on rounds."

"Did you think of mentioning it to Parul that morning? Like in case she didn't know?"

He was quiet.

"That wasn't really cool."

"I guess I was trying to put the patient first."

"Were you?"

"I . . .I mean, I just wanted to make sure we thought of everything. I thought me looking up labs and thinking about people other than just my patients would be helpful. Some call it being a gunner. I just call it trying hard and holding myself to a high standard."

I pressed my lips together and raised my eyebrows. I gave myself a five second countdown before speaking to make sure my words were chosen carefully.

"Look, Seth. I'm actually okay with 'gunner' medical students. I don't mind it when you're reading and going hard in the hospital--in fact I welcome it. But be a gunner for the patients. Knock down doors to advocate for them and to get to the right diagnosis. You can do that and be collaborative with the people on your same team, you know? Gun all you want on my team. Just gun for patients. If you're gunning for the patients, you don't have to step on toes to look good. It's just a by-product of your efforts."

"I wasn't trying to step on toes." For the first time his voice was small.

"Whether you were or you weren't, you kind of did today. You could have shared your thoughts with Parul before she presented her patient. Or you could have waited until she finished the entire presentation. I always open it up for others to share their ideas at the end."

"That's fair."

"Good." I reached out and shook his hand. "Medicine is a team sport. You got that?"

He nodded like he got it. Something tells me he did.

Later that week, I spoke to Parul and coached her on ways to be more confident in her knowledge. I commended her for counting those pills and reading the bottle dates. I also gave her props for data mining in the chart and thinking carefully about that patient. Then I told her about the night that my fellow in the NICU encouraged me to be a lion and also the night that Ida, the MICU nurse, saved my life (and a patient's) by nudging me to take the lead on a code way back when.

"We're going to work on your confidence," I told Parul in closing. Because in medicine, that's important.

I guess I've been thinking a lot about coaching and encouraging these days. It makes such a big difference. Don't you think so? I do.

So the rest of that month went really well. Parul and Seth worked well together and grew in their mutual respect for each other. They worked in concert and pushed each other to step their respective games up without tearing the other down. And that was a really, really good thing to witness.


It's funny. Confidence and competence are almost always mismatched in medical training and sometimes beyond that, too.

On second thought, that's not really very funny at all, is it?

Hmmmmm.

***
Happy Sunday.