Chapter 42: Focus On Learning

August 25, 1989, McKinley, Ohio

"Good afternoon," I said to the assembled incoming class of medical students. "Every morning, when you get up and look in the mirror, you see the person primarily responsible for your medical education. It's not the deans, it's not the professors, it's not the doctors on your clinical rotations. It's you. Period. No exceptions and no excuses.

"You have one simple task for the next four years — learn. And that is on you, not on anyone in a long white coat. Yes, of course, we are tasked with teaching you, but, in the end, you have to learn. And that means taking responsibility for learning, even from poor teachers and even in adverse circumstances.

"You cannot succeed by being passive, though you need to temper your aggression based on your skills and knowledge. There will come a time when you have to demand to be taught, and that demand might well be rejected. Don't take a 'no' as a 'no', but as a 'not now'. Ask. Ask again. Ask why. Will some doctors and professors find you annoying? Damn straight!

"Just before I left the hospital so I could attend this ceremony, I was told, and not for the first time, that I'm a pain in the ass. I don't take that as an insult; rather, I wear that as a badge of honor. I ask questions, I challenge answers, and I make observations. That's all part of learning. And learning continues even more intensely when you change from a short white coat to a long one.

"Even when you attain the coveted role of Attending Physician, you will still learn. And you're responsible for that continuing education, be it from journals, seminars, conferences, or one-on-one instruction. If you don't learn, you fall behind. If you fall behind in the next four years, you won't Match. If you fall behind after the Match, you won't become an Attending. And at any stage, you might wash out.

"You'll face many challenges, both in learning to be a physician and in your personal life. You'll encounter many things which can trip you up over the next decade — academics, lab work, clinical rotations, stress, lack of sleep, and poor physical health. You can earn academic honors and fail clinical rotations. I've seen that happen. You can be a top-ten student and lose your life to stress. I've seen that happen, too.

"Right here, right now, resolve to take control of your medical education. Right here, right now, resolve to challenge us to teach you. Right here, right now, resolve to learn. Right here, right now, resolve to be the best physician you can be, and put together a personal plan to achieve that. Nobody is going to do it for you; only you can do it.

"Finally, never forget that you're asking for admission to a very selective, exclusive guild. To gain admission, you have to satisfy every person involved in your training. Failing to do that means you won't be a physician, no matter how badly you want it. Succeed, and you'll have the most rewarding, fulfilling career in the universe."

I left the podium and rejoined the other doctors at the back of the room.

"A Loucksian address if there ever was one!" Doctor Strong said quietly. "A reaction to Krista Sandberg?"

"Yes," I replied, my voice just above a whisper. "I felt they needed fair warning."

"It's an important message," Doctor Lindsay observed.

When the ceremony ended, the medical school deans walked over to where I was standing with the doctors from the hospital.

"That wasn't what I expected," Doctor Mertens said with a smile. "We were sure you'd give your usual service speech."

"I felt it was warranted," I replied. "My second option was to focus on Doctor Osler's prescription for medical training."

"He was addressing Residency," Doctor Warren observed.

"And yet," I replied, "it applies just as much to medical students as it does to Residents. You know I'd like to see medical schools be six years and take High School graduates rather than those with undergraduate degrees. Two years of classroom work rather than six and four years of clinical rotations would serve the profession better."

"That would require wholesale revision of the system," Doctor Worth observed.

"And your point is?" I asked with a grin.

"We can't just do that," Doctor Worth countered. "Our accreditation depends on following the pattern. Being first risks our students not being selected for the Match due to licensing regulations in fifty different states."

"So, confer a Bachelor's degree," I said.

"Which requires basically four years of coursework," Doctor Worth replied.

"It's done similar to how I proposed in Europe," I said.

"Good luck convincing the 'Europe is socialist' crowd to copy anything Europe does," Doctor Strong interjected.

"Europe is not socialist, the perverse fantasies of some Americans to the contrary notwithstanding. And I should know because I'm married to an actual socialist!"

"I bet that leads to interesting pillow talk," Doctor Lindsay teased.

"Interns do not have time to talk in bed," I chuckled. "We sleep!"

"Uh-huh."

All the assembled doctors laughed. Given my schedule, I bade them 'goodbye', then left to head home so I could spend a few minutes with Rachel before Kris and I headed to the banquet.

August 26, 1989, McKinley, Ohio

Saturday morning was typical, with band practice, grocery shopping, a trip to the bakery, and a stop at the record store. At lunch, we celebrated Rachel's second birthday, though her big party would be on Sunday afternoon after church. Instead of cake, we had cupcakes, which Serafima had baked, and Rachel managed to eat more than she wore, unlike her first birthday.

I gave Rachel her bath, then left for my shift at the hospital. As I wouldn't be able to attend the service Viktor had scheduled for that evening, I allowed a bit of extra time so I could stop at Saint Michael the Archangel. I visited with Elizaveta, said abbreviated prayers for the dead, and placed flowers on her grave before heading to the hospital.

At Moore Memorial, I went to the surgical locker room to change, then headed to the ED, where I received the handover from Kylie. There was only one patient waiting on admission to Medicine, and once Kylie had filled me in, I went to find Jake and Heather, my Saturday medical students. I found them in the lounge, but before I could even greet them, nurse Terry let me know Doctor Mastriano needed my help with a central line in Trauma 2.

"I've seen a few but haven't done one," I said. "I'll need to call for another surgeon to come down to supervise. Let me make the call, then I'll go see her."

I called upstairs, explained what I needed, and the charge nurse said that Doctor Blake would be right down. I thanked her, then went to Trauma 2.

"What do we have?" I asked.

"Jenny Smith, twenty-two; IV drug user, probable heroin OD; no veins for an IV."

"I've only observed central lines. Doctor Blake is on his way down to supervise me. He should be here in a moment. Did you try an ankle?"

"We couldn't get a good vein."

"Status?" I asked as I washed my hands and put on gloves.

"Naloxone IM in the field; intubated; Foley with decreased urine output; pulse 58; BP 100/60; PO₂ 92%; CBC, Chem-20, tox screen, pregnancy test, full-spectrum STD test."

"There's an MI risk," I said. "Let's get her on a five-lead."

"Kurt," Doctor Mastriano said to her Fourth Year, "Five-lead, please. Terry, set up the ultrasound, then central line kit to Mike, but we'll wait for Doctor Blake."

At the mention of his name, he walked in.

"I hear you need supervision for a central line," he said.

"I've seen three but never done one."

"What are your risks?"

"Hemothorax, pneumothorax, hematoma, and inadvertent arterial puncture."

"What do you do?"

"Trendelenburg; sonogram to define anatomy if there's time; lidocaine cutaneously and subcutaneously and around internal jugular. Then, using the Seldinger wire technique, insert the guidewire. Next, make a 3mm incision in the skin, cutting away from the wire so as not to damage it. Pass the dilator over the wire and gently but firmly dilate a track through to the internal jugular. Sponge as necessary to clear the field, then grasp the Seldinger wire and remove the dilator. Pass the central line over the Seldinger wire. Once the line is in place, remove the wire. Suture, dress, and connect to the IV."

"Proceed," Doctor Blake directed.

I nodded and, with help from Terry, I followed the steps carefully and methodically, knowing I had a bit of time. I completed the procedure, and Doctor Blake checked my work and pronounced the central line was properly inserted.

"Let me have your procedure book, and I'll sign off for you to do this solo."

"Thanks," I replied.

I stripped off my gloves and I took my procedure book from my back pocket and handed it to him. He wrote the procedure, wrote his approval, then signed the book. He handed it back and left the room.

"Anything more, Doctor Mastriano?" I asked.

"Call me Isabella, please. And that's all for now. Thank you."

"You're welcome."

I left and went to find my students, who were just coming out of the exam room with the patient being admitted to Medicine. They walked over to me, allowing the orderly and the Third Year from Medicine to escort the patient.

"What schedule do you two have for next month?" I asked.

"We're both on 0600 to 1800 Monday through Saturday," Heather replied. "Basically, we'll be with you on every shift except the one where you're at the clinic."

I hadn't checked on any of the medical student schedules except Krista's and hadn't been surprised that she was on shifts that mostly didn't overlap with mine. I didn't like that because I felt nobody would give her the shot she deserved, even if she was ultimately unqualified.

Unfortunately, I wasn't likely to be able to do anything about similar situations in the future, as I wasn't an ED Resident, despite working in the ED. That meant I would never be Chief Resident on either service, as I'd serve my third year of Residency as a Surgeon, and the ED Chief Resident was always a third year. Because I wasn't a dedicated surgeon and would spend most of my time in the ED when I wasn't in the OR, I wouldn't be the Surgical Chief Resident, either.

That didn't particularly bother me, as it would mean administrative work, which I didn't particularly enjoy, and I didn't feel not being a chief would interfere with my career progress. I most likely wouldn't be Chief Attending either, though I could, ultimately, be Chief of Emergency Medicine, but that was more than ten years away, and I wasn't sure I wanted it.

We had a busy afternoon, with nothing remarkable, and I had no trouble meeting Clarissa for dinner at 6:00pm. After dinner was equally busy, but also unremarkable, and I left the hospital just after midnight.

August 27, 1989, McKinley, Ohio

Sunday morning was typical, with Kris, Rachel, and me attending Matins and Liturgy at the Cathedral. We didn't stay for the meal after liturgy, as we had to be home to set up for Rachel's party. We had help from Elias and Serafima, as well as Lyudmila, and everything was ready at 2:00pm when the first of Rachel's dozen toddler guests began arriving along with their parents.

Rachel's most important guests were Abi Green, Larisa Antipov, Viktoria Kozlov, April Webber, and three girls from daycare — Melanie, Kathy, and Jennifer. She was far less happy to see Viktor Gennadyevich, my brother Pete, my nephew Michael, and my godson Michael.

Rachel was also happy to see Clarissa and Tessa, though she was happiest about her Aunt Lyudmila, as they seemed to be forming a strong bond. That was a good thing, though I could do without Lyudmila teaching Rachel to speak French, which she was doing simply to annoy me. Of course, being able to speak a foreign language was an advantage, and French was far more useful than Russian, so it wasn't really a bad thing.

The kids all had a wonderful time, and I spent most of my time with Joel, Elias, and Subdeacon Mark, as all the other kids had been brought by their moms, with the exception of April and Peter, who had come with my sister. The other invitees — Viktor and Yulia, my mom and Stefan, and Kris' parents, all arrived for dinner at 5:30pm. My dad and Holly had been invited but had declined.

After dinner, cake, and presents, we said evening prayers with everyone, including those who weren't Orthodox, and then all of Rachel's guests left. She had her bath, we read The Bears' Picnic, and then we put her to bed.

"Care to come to bed to see if we can arrange for a sibling for our daughter?" I asked Kris.

"Three times to make sure?" she asked invitingly.

I happily took her hand and led her to the bedroom.

August 30, 1989, Southern Ohio Correctional Facility, Lucasville, Ohio

My Monday to Tuesday shift had been relatively calm, and I'd managed to get some sleep on Monday night. Now, on Wednesday, after spending the morning at home with Rachel, we left to have lunch with Clarissa and then drove to Southern Ohio Correctional Facility so I could see Frank Bush. I endured the usual security checks and questions and was eventually ushered into the visitor's room. Two minutes later, Frank Bush was escorted in and sat down across from me.

"Thanks for the book," he said. "I'm enjoying it."

"You're welcome. How have you been?"

"I have a completely regimented day with no freedom. How do you think I've been?"

"I was more concerned about your physical and mental health," I replied.

I was concerned about his spiritual health as well, but I didn't feel he was ready to hear anything like that just yet.

"Physically, no complaints, but prison is mind-numbing. I have an advanced degree, so Ohio won't allow me to take correspondence courses on their dime, and I have no personal resources beyond my commissary. Pretty much the only intellectual stimulation is books, and as much as I like to read, there comes a point when it no longer helps."

"I thought you played chess," I countered.

"I'm not particularly popular with the small group of dedicated players."

"Would you like to play while we talk?"

"Sure."

I got up and asked the guard for a chess set, which he provided, and Frank and I began playing while we talked.

"What book can I get you next?" I asked.

"A Time to Kill by John Grisham or The Russia House by John le Carré."

"I'll get both of them for you," I said. "If you wanted to take a correspondence course, what would you study?"

"History has always been a hobby of mine."

"Let me speak with someone at Taft and see what I can arrange. I can't promise, but I will try."

"The cynic in me wants to know what you get out of this?"

"It's not about what's in it for me; it's about fulfilling Jesus' instructions in the parable of the sheep and the goats —

"You don't think I knew that and had to quote it?" Frank asked.

"I think you know the words, but you don't know the spiritual truth. As Keith Green reminds us, the only difference between the sheep and the goats is what they did and didn't do."

"Works righteousness," Frank replied disdainfully.

I shook my head, "Not according to James. We can discuss it if you wish, but I only cited the verses because you questioned my motivation."

"How are your friends?"

"If you mean Robby and Sophia, they're married and likely moving to California so she can serve her Residency at a hospital specializing in pre-natal surgery."

"He walked away from the lifestyle? Commendable."

I wasn't about to take that bait, as that conversation could have no positive outcome.

"Saturday was my daughter's second birthday," I said, changing the subject.

"They grow up so fast. One day, Melissa was in a crib, and, seemingly, the next, she was in medical school. It was the same for James."

I won the first chess game as white, then Frank won the second as white, and I won the rubber match as black after we drew for pieces. While we played, we had discussed my Residency, and he reminisced about his as well. By the time we finished the third game, our time was almost up.

"I'll let you know what Taft has to say," I said. "I'll also get those books ordered for you. My next visit will be on a Sunday afternoon in September. I suspect three weeks, but it could be the last Sunday of the month. Is there anything you need?"

"Not that I can think of," he replied.

"If you're interested in understanding me, there are some other books I could send you."

"Trying to convert me?"

"No, just trying to answer your question of 'why?' and give you some insights you might not otherwise have. I'll send them, and you can decide if you want to read them or not, and if you want to share them with others or not. I think you'll gain a very different view of what I believe than the one you, Tim Saddler, and others have in mind."