Apologies for the long delay in blogging. However, I hope that the title of this post says it all. I've been spending the last two months really trying to take advantage of all that Ann Arbor and Michigan has to offer before I head off to Dayton, Ohio for my psychiatry residency. Having a Hospice/Palliative Care elective last month really made me appreciate whatever amount of time I am given in life and at Michigan in particular. In fact, trolling Dayton craigslist and mapping out potential apartment locations on a custom Google Map has been a bittersweet reminder that I'll be moving soon. In the meantime, though, I'm really grateful for all the fun things that have happened since my last post:

1. Ann Arbor Restaurant Week: eating at the Melting Pot and Jolly Pumpkin for the first time
2. Detroit auto show with Phi Rho peeps
3. Skiing at Crystal Mountain with Steph, Eunice, Paul, and Joe
4. Performing with Auscultations at the Biorhythms Winter Show 2012
5. Having a lead role in the 94th Annual Galens Smoker: Thrombin Hood and His Merry Meds! (Corollary: performing in the objectively best Stud Dance of all time)
6. Galens Banquet
7. Taking part in the first annual M4 Matchelor Party (paintball followed by suits and dinner in Detroit)

[#4: Auscultations debuting two new songs, Mariah Carey's "You'll Always Be My Baby" and OneRepublic's "Secrets." Kudos to Jess Bloom and Peter Park for outstanding solos!]

[#5: the 2012 Galens Smoker! Photos and Stud Dance video by request only ;-)]

[#6: Wojcik, me, and Kimball at Galens Banquet]

[#7a: Matchelor Party 2012 - paintball...]

[#7b: ...followed by suits and dinner at Fishbone's at Greektown Casino in Detroit. Dang, we clean up well.]

So much time has gone by, and so much fun has been had, it's hard to believe that graduation is only two months away! There's still plenty to look forward to also:

• Match Day 2012 is coming this Friday! Although I already know where I will be going next year, it will still be exciting to share this day with my other med school friends. Plus, Match Day party that night!
• The first ever Auscultations concert this Sunday!
• The Michigan Pops Orchestra presents: Pops in Peril!
• Season 2 of Game of Thrones!
• My birthday!
• Annual Tulip Festival in Holland, Michigan! And a potential second tattoo idea taking shape!

Stay thirsty, my friends...

[Can I still say that?]

Winter Break has come and gone. Going back home was pretty standard fare. My family's Christmas Eve party featured relatives playing Maj, my cousins and me playing Words with Friends, and everybody enjoying traditional Chinese food. The highlight of Christmas Day was going to a performance by my mom's dance group at the Global Winter Wonderland in Santa Clara. After the festivities, my family and I went on our annual ski trip to Reno. In addition to skiing, we enjoyed a performance of ZzyZyx (no, that's not a typo), bowling, and a screening of the movie Moneyball. Plus, I won $50 at poker! The other exciting venture during break was going to the Fiesta Bowl with the Stanford Marching Band. Although it was a heartbreaking 38-41 OT loss to Oklahoma State, the trip was a great time reconnecting with old friends and reliving the days of Rocking the F*** Out™.

[Hitting the slopes in Reno!]

The most exciting piece of news, though, happened before Winter Break even started: I matched into the Air Force psychiatry residency program in Dayton, Ohio! I'm very excited to be staying within driving distance of many close friends in Ann Arbor, and the program itself offered a good balance of psychotherapy and psychopharmacology training. Once the snow clears up in the spring, I'll have to start looking for housing. In terms of the rest of the year, I'm looking forward to my fourth month of vacation as well as my remaining rotations (Hospice/Palliative Care, ID Consults, Clinical Anesthesiology), with graduation in May! Time passes by much too quickly.

Hooray, a new blog post less than three weeks after the last one! Guess I'm slowly making progress. My days have been filled with lots of holiday cheer lately. I went home for Thanksgiving and joined the Stanford Band as an Old Fart for the Notre Dame game that weekend. This past weekend was also the 85th annual Galens Tag Days, where medical students stand out in the Michigan cold with red ponchos and buckets to collect money for Mott Children's Hospital and other organizations benefiting the children of Washtenaw County. This year Auscultations tagged as a group during Friday's Midnight Madness event on Main Street, singing Christmas carols and selections from our repertoire. It's not too late to help, so please visit the Galens website to make a donation: http://www.umich.edu/~galens/tagdays.shtml

[Singing John Mayer's "Heartbreak Warfare"]

Wow, time really flies when you finish all your M4 requirements. Since my last post, I completed my Medicine Sub-I and my Neurosurgery ICU rotation. Just yesterday, I completed the last set of quiz questions for Advanced Medical Therapeutics (AMT), the required M4 online course, and since my AMT project requirements are done, I am essentially done for the year (minus three electives in February, March, and April). I don't even need to go on any interviews for the time being; since the Air Force match results are released on December 14 and since I would have to withdraw from the civilian match anyways if I got into an Air Force program, all of my civilian interviews are scheduled for January. Bottom line: I'm living the good life, working out regularly, keeping up with my TV shows. Heck, I might even start blogging on a more regular basis.

[Part of the good life: fried frog legs at the Dexter Pub. Nomnomnomnomnom.]

As the end of medical school approaches, enjoyment of M4 year is also coupled with the realization that I'll be starting residency soon. This is both exciting and daunting. Exciting because my Sub-I rotation gave me a taste of the satisfaction that comes with being a (relatively) independent doctor with (nearly) full patient responsibilities. Daunting because I know my current level of knowledge isn't going to cut it for much longer. Right now, I bask in the admiration of underclassmen who marvel at my understanding of psychiatry (admittedly a bit narcissistic), but having the time to attend various psychiatry talks and to watch various online psychiatry lectures also helps keep me grounded by showing me just how much more there is to learn.

I'm not even talking about the prospect of essentially memorizing the DSM (I imagine that will naturally come about with more clinical exposure and more clinical practice); I'm talking about the need to add depth to my knowledge. The stereotype of psychiatry is that it's a field of hand-waving medicine ("we give you this pill and you magically stop hearing voices"). What is becoming more apparent, though, are the advances that are beginning to shed a light on the pathophysiology of psychiatric disease. All throughout med school, we had a cursory introduction to the receptors, neurotransmitters, etc. that are involved in mental illness, but I have to admit that those topics took a backseat to learning the patterns of symptoms that make up a diagnosis or the broad categories of medications used (SSRIs, TCAs, typical antipsychotics, atypical antipsychotics).

No more. To quote Dean Wooliscroft in this year's State of the School address: "The status quo will not continue." As a resident, and even more so as an attending, I will have to have a better understanding of neuroanatomy, various brain circuits, and how psychiatric medications exert their therapeutic effects. It will no longer be good enough to simply recognize a particular class of medications; I will need to start differentiating between members of the same class, to distinguish their particular properties, in order to be able to justify prescribing one over the other.

With these thoughts in mind, I particularly appreciated a recent post from "Insights on Residency Training," the JournalWatch blog run by chief residents in family and internal medicine. The author was reflecting on how the nature of learning changes, from pre-med to med school to residency. I was a bit relieved to see some of my current habits already matching with some of her suggestions ("Look up answers to your questions, not just subjects you are instructed to read about." "Start some sort of filing system for helpful articles or handouts." "Register for free e-mail alerts from Journal Watch."). What really stuck out, though, was this piece of advice: "We are all naturally curious people who want to be the best doctors we can be. We cannot help but learn. We should have a bit more faith in the process and trust that when we’re spit out the other end of residency, we will have acquired enough knowledge to be good doctors."

Ho geez, wow, I guess it's time to blog again. Yikes. In my defense, I have been on an Internal Medicine Sub-internship (i.e. Sub-I) for the past month. That's a rotation where an M4 student acts like an independent intern, a sort of practice run before actual internship begins. Part of being a Sub-I is also having the schedule and workload of an intern, hence my absence. But enough excuses. How have I been? Thanks for asking.

The Air Force psychiatry rotation at San Antonio went well. I finally met other M4s on the HPSP scholarship who were applying to psych. It was exciting to meet future colleagues of mine. Even if we don't match in the same program, it's a small Air Force, so we'll probably bump into each other and work together eventually. Some highlights from Texas:

• Visiting the San Antonio Riverwalk. Pretty touristy, but it was still fun to listen to an acoustic soloist rendition of "Drunken Lullabies" and "Come Together" at Waxy O'Conner's. (I wonder if there's any relation to Ann Arbor's Conner O'Neill's...)
• Traveling to Houston for a weekend, visiting Martin Duncan and Sandy Williams.
• Making the 560-mile total round trip to an In-N-Out Burger in Fort Worth, Texas. I discovered this on a whim, messing around with my In-N-Out iPhone app while in Texas. Turns out there's actually quite a few branches in the Dallas area.
• Returning to Michigan in uniform and avoiding annoying baggage fees at the airport.

And of course, as mentioned above, I came back to my Medicine Sub-I at the VA. There was a poetic sense of homecoming, particularly because my very first clinical rotation of M3 year was Medicine at the VA. Not only that, but for this Sub-I I was assigned to the same team I was on during M3 year (Gold Team), and my senior resident for the first few days of the Sub-I was the intern I worked with during M3 year. Talk about taking a 360. At the same time, I was really amazed by how far I had come in a year. Although I am nowhere near senior resident level in terms of my knowledge base, it turns out that over the course of M3 year I had learned enough to be fairly independent in my work. Sure, I still needed to have my orders co-signed, but in the simplest terms, I felt "I knew what I was doing." Maybe not 100%, maybe for example there were diagnoses on a patient's differential that I wouldn't have considered unless my senior offered the possibilities, but for the most part I loved the feeling of getting into a groove. Having full control of my patients and running the show without working through an intern actually helped me remember daily plans and helped me keep track of orders better.

What's more, these past two rotations gave me the opportunity to teach and mentor M3s. In San Antonio I gave a teaching session on the differential diagnosis for psychosis, and at the VA I gave a similar but more medically-oriented presentation to the M3s on the work-up and management of altered mental status. I had alluded to these opportunities in my last blog post, and it was exciting to actually get to pass on pearls of knowledge. Although I may have come full circle during this last month, it's pretty obvious that my circle of experience has expanded considerably. What an awesome feeling.

[The components of a psychiatric history & physical. Whoops, just realized I forgot to include the Biopsychosocial formulation during this talk. Luke's teaching career, still a work in progress.]

Hi folks, I guess it's been a while since my last post. My rotation at Wright-Patterson AFB in Ohio went really well. Some highlights:

[Taking the first step to my psych residency!]

Now I'm at Lackland AFB in Texas for my second Air Force psychiatry away rotation. There was a recent didactic session for the interns on how to be good teachers and role models for med students, which reminded me of an article that my friend Gordon Chien forwarded to me a while ago about burnout in medical school: http://abnormalfacies.wordpress.com/2011/06/22/problems-with-clinical-mentorship/

Being at the bottom of the med school totem pole can definitely wear out lots of people. While we can't change the immense amount of material to learn, the seemingly endless studying for seemingly endless tests, and the unforgiving work hours, what we can change is how members of the medical team interact with each other. After reading that article, I began thinking of ways I plan to (hope to?) prevent burnout, not only for myself, but also for future med students.

[Traits of Effective Clinical Teachers]

[What's Expected of Residents]

[Create a Supportive Learning Environment]

[Create a Positive and Supportive Learning Environment]

[Supervise/Mentor Effectively]

[Teach Dynamically]

Hi folks! After two weeks of studying, I took my USMLE Step 2 CK (carpooling with Brandon, Zoe, Steph to the test site), and then drove off on a roadtrip from Michigan to visit friends on the east coast. Highlights from the roadtrip:

• Meeting up with my old college roommate and fraternity brother, Sunny, in Maryland.
• Driving with Sunny to meet up with Jill, Matt Spitz, and Lori (friends from the LSJUMB) in New York City.
• Driving with Sunny from NYC to Washington D.C. and eating at Comet Ping Pong pizzeria.

[Harold and Kumar hit up New York City]

After returning to Ann Arbor for an evening, I promptly started driving to Wright-Patterson AFB in Dayton, Ohio on July 4 (God Bless America) for my first Air Force away rotation in psychiatry. This would be the first of my two Air Force psychiatry rotations, the next one being at Lackland AFB in San Antonio, Texas.

[My room for four weeks at the Air Force Inn at Wright-Patterson AFB]

[The Wright-Patterson Medical Center, literally right across the street from the Air Force Inn. Very convenient.]

[July 4 fireworks in Ohio]

[Surprise! A Bar Louie in Beavercreek, Ohio.]

But enough of pictures. I want to talk about a feeling. That feeling you get when you know something clicks or is right for you. You could compare it to falling in love with "the one," but I want to extend it beyond romance or relationships. My first few days here observing the Wright-Patterson psychiatry program have cemented my love for psychiatry.

On my first day, for example, I heard a resident recount a story of a patient who claimed to communicate with fairies, but also practiced Wicca (a nature-based religion), which raised the issue of whether she was being schizophrenic, delusional, or simply practicing her religion; I knew I would love psychiatry when I found myself wishing I could have been at that case presentation in person and learned how she was eventually managed. I took it as a good sign that I got fired up answering practice questions in my head during a lunch review session for the PRITE exam (the annual national test for psychiatry residents). I was also fascinated to see a patient demonstrate CBT techniques during a follow-up visit and was happy to see a psychiatrist convince a patient with refractory depression to seriously consider ECT. An introduction to psychodynamic counseling left me wanting to hear how residents negotiate a patient's Id, Ego, and Superego.

What's more, all of these experiences have happened during a hectic week when residents are in transition (new interns arriving and old residents moving up one year). As a result, I haven't had much direct patient contact yet unfortunately (mostly shadowing attendings so far), but if I'm getting this excited at this point in the game, I can only imagine what I have to look forward to next week when I hope to have patients of my own, and next month when I get to compare Lackland AFB to Wright-Patterson. It's gonna be great!

Finally, some time to catch my breath.

I was originally hoping to blog about my trip to Chicago for Step 2 CS right after I came back. Obviously that didn't happen. However, I can list some highlights:

• Driving through clouds of white cottonwood fluff on the highway with green trees on either side of the road was surprisingly serene.
• Arrived in Chicago on Sunday night, 6/5, and had dinner at Giordano's with Ari (fraternity brother from Stanford) and Dave (my cousin). Chicago stuffed pizza with ground beef and mushroom paired well with frosted mugs of Stella.
• Later that same night, Ari and I went out to sing Live Band Karaoke with some of his friends.
• Breakfast of yogurt/fruit parfait and coffee at Starbucks with a last minute review. Lunch from Chipotle.
• Eight-hour long test. Had to remember the following keys to passing the test:
  1. Speak English. 
  2. Wear professional clothes. 
  3. Wash your hands before the physical exam. 
  4. Drape the patient. 
  5. Don't punch the patient in the face.
• Breakfast at Orange Restaurant with Ari, Claudia, and Tina (more friends from Stanford), had a nice driving tour of the Chicago neighborhoods with Ari, lunch with Dave at Lao Sze Chuan in Chicago's Chinatown (pork kidney, Mongolian lamb, garlic spinach, minced beef = yum!)
• Driving back through clouds of cottonwood again.

Between taking Step 2 CS and starting to study for Step 2 CK, I had a weekend when I flew back to California for the wedding of Kalena Masching and Sam Howles-Banerji. I had known Sam for four years at Stanford through the Stanford Band (he was the Tööbz sexion leader when I was the Bonz sexion leader; and no, those aren't typos, that's how we spell in the Stanford Band). I had known Kalena even longer, since middle school in fact, where we both played trombone. They are both very good friends, but the reason the wedding was especially meaningful for me was this story: although Kalena didn't go to Stanford, she stayed in Palo Alto after high school, and since I knew she played trombone I invited her to join the Stanford Band my freshman year, which was where she eventually met her now-husband. That unremarkable, casual invitation was an act of friendship that had incredibly life-changing implications (something that Kalena's parents very explicitly reminded me and thanked me for while I was at the wedding).

Going back to all the med school hoops, my point is this: oftentimes, despite our best efforts to extrapolate meaning, the most meaningful points seem to be the ones we never anticipated, stemming from actions to which we would never have given a second thought. If something as simple as asking a friend to join the Stanford Band could affect both her and her husband's lives so deeply, imagine how much we can help future patients if we put our minds to it. Yes, it can be difficult at times to see purpose in what we do, but we all have a part to play in this life, even if we don't know what it is. And those preciously rare moments when we are blessed with the opportunity to see what part we did play...though they be few and far between, those can be the moments that help push us onward in times of doubt, in times of struggle, in times of seemingly useless endeavor. Keep those moments close and use them to carry on.

[Congratulations, Sam and Kalena!]

First month of M4 year: done.

Emergency Medicine was a wild rotation. It was a great way for me to hone my H&P skills to under 15 minutes (which will come in handy for my upcoming USMLE Step 2 CS exam), and it gave me the chance to see all sorts of medical conditions, from the acutely psychotic to the acutely traumatic (flexing both my mind and my suturing skills). For the most part, the rotation was a microcosm of my entire clinical education with one large exception: it was the first time I had seen a patient die.

Less than a week into the rotation, within the first ten minutes of my shift, our team was notified of an incoming patient: 21-year-old female with a history of heroin abuse presenting in cardiac arrest. She had been found down and unresponsive for an unknown period of time. The doctors, nurses, and techs were ready to receive the patient in the resuscitation bay when EMS came in, performing chest compressions and bag ventilating. It was not looking good. After the team quickly moved her from the stretcher to the bed I started continuing chest compressions, the only thing a med student is usually qualified to do in that situation. I remember thinking how terribly young this person was. She had an eyebrow and lip piercing, and a tattoo of a bird on her arm. Completely unresponsive. As is standard protocol in the ED, we used trauma scissors in order to cut off all clothing when she arrived to give us IV access. About halfway into the resuscitation attempt, the team laid a sheet over her lower body as the patient's mother came into the room to be at her daughter's side while chest compressions were still going on. Twenty minutes after the patient's arrival, with her heart only twitching on ultrasound despite medications and CPR, we informed the mother that we had to call it. She couldn't bear to look up from her daughter's hand. All we could do (all I could do) was move on for the rest of the shift.

In some ways, medical students are trained to handle emotionally-charged situations like this through simulated patients. Part of the Emergency Medicine rotation, for example, is completing a Standardized Patient Interaction on Breaking Bad News. I certainly appreciated the feedback I received from the volunteer who played the role of a wife whose husband had just passed away in the ER (make sure all relevant persons are present and accounted for, use the deceased patient's full name and address the relatives by name, offer family members the chance to see their loved one). I also was relieved that I could keep my emotions under control during that exercise, and was happy to hear that I apparently have a soothing voice and demeanor. However, I feel like these lessons are designed more for a physician-in-training's future patients than for the physician-in-training. The communication techniques and tips help doctors console patients, but how can doctors frame these experiences for themselves?

For me, taking part in my first code revealed the brokenness of the world in a way I had not known before. I will never know when, how, or why that 21-year-old woman became addicted to heroin. I will never know if our resuscitation efforts were futile from the beginning. What I am thankful for, though, is the chance to contrast the brokenness I experienced that day with a vision of what the world could be. Just a couple of days after that ER shift, Phi Rho friends and I took a trip to the movie theater, a rare treat for busy med students. We not only bonded as a group, but also bonded with a subletter from the UK, Mandeep.

At first glance, this simple display of friendship might seem insufficient to balance out the tragedy of a needless death. I guess my point is that we (med students, physicians, humans) shouldn't discount these happy moments as any less real or meaningful. Why do I have this conviction? Well, going to the movies that day, Laurel mentioned how she participated in an autopsy of a 20-something woman from St. Joe's who had died a couple of days ago. Sure enough, upon further questioning, I found out it was my patient. Taking that story full circle, the juxtaposition of brokenness and renewal, helped me realize that happy moments like the one I was experiencing at that time were still worthy goals to aim for, goals for us and for our patients. No matter what specialty my classmates and I choose, we can do our part to help renew others, even if the renewal is as simple as enjoying a trip to the movies with friends.

In other news, residency applications are starting to loom over the M4 class. I have my Dean's Letter appointment this coming Wednesday, which basically consists of going over comments from my clinical evaluations and reviewing a draft personal statement/CV. In writing my personal statement rough draft, all I could say was thank goodness for this blog. Turns out my online ruminations were helpful reminders of why I want to go into Psychiatry, and my path to committing to that specialty. This weekend I drive to Chicago for my USMLE Step 2 CS exam, then comes 3-4 weeks of vacation...to study for the Step 2 CK portion of the test.

Med school life, fo' sho'.

Now that I've dipped my feet into the cool waters of M4 year, there has been enough time for me to reflect on the medical mission to Honduras.

One of the pleasant surprises of the trip was being able to utilize the Spanish that I had learned during high school. It was awesome to still be able to converse (albeit rather brokenly at times) after more than 7 years out of the classroom. The experience has reassured me that I might be able to (barely) get by in a Spanish-speaking country for an extended period of time, if the opportunity ever arose.

I was also amazed at the resourcefulness of Hospital Suizo. By necessity, team members were limited to one surgical mask, one hairnet, and one pair of shoe covers each day. The surgeons had to be extremely mindful of what instruments were needed in any given procedure; if possible, they would try to use equipment that was already on the field rather than open up new packages. And in clinic, we had to sterilize and reuse otoscope funnels instead of throwing them away after a single use. Outside of the OR, the people of La Ceiba have to get by with less as well. The church we visited on the Sunday before clinic started had to use a pay-as-you-go system in order to expand the building. Instead of paying everything up front and constructing the building straight through, the church pays to build one floor, raises more money, then builds the next floor, etc.

Finally, I treasured the relationships I developed on the trip. I met new friends and reconnected with old friends who had grown distant during M3 year. Most importantly, the trip has made me more comfortable about my relationship with God and about associating myself with Christianity. This isn't to say that there were thunderbolt revelations or anything on the trip. However, over the course of the past 6 months or so when I started exploring Christianity, there have been times when I've felt God's presence, and I have no doubt He steered me toward this mission trip to do good work. Since returning, I've also become more open to talking with others about my beliefs. Just the other day I had a genuinely civil discussion with a housemate about my journey to Christianity and why I believe what I believe. Recounting this entire spiritual journey would probably require an entirely new blog, not just a separate blog post. Needless to say though, I hope to continue the conversation with others and welcome dialogue.

It's now almost a week into M4 year and Emergency Medicine. During orientation and in the ER, I was definitely thankful that I had the chance to practice IVs while in Honduras.

[The true test of friendship: starting IVs on each other (left: me; right: Brandon Smith)]

[The aftermath of the IV workshop during Emergency Medicine orientation.]

[I offered to be a human pincushion for the day.]

My rotation at St. Joe's has been pretty good so far. Reasonable hours, enough time to enjoy pleasures outside of school (e.g. 2011 commencement, Biorhythms). Lots of things to look forward to in future blog posts!