The punching bag

plane leaving Montreal, I truly felt a sense of accomplishment. Something like I could stop holding the breath I had been holding for so long. More so, I was looking forward to the unexpected. Looking forward not to be on a fixed schedule and have your surrounding expect a lot from you. Somehow leave that performance bubble behind.

Life always has a lot of surprises for you if you are attentive and receptive to see them.

Away from my internship in Geneva for a weekend in Zurich, I was visiting Andrea, an old friend that I initially met in India who lived with me in Montreal last year for few weeks. Along with her boyfriend, Anthony, the three of us ordered our cappuccinos and were chatting as a friend of her boyfriend came in. As they greeted each other in Swiss-German, he looked at Andrea and me. I looked at him and somehow that face was familiar. I saw him getting closer to me with his eyes wide open also thinking I looked familiar. He said: « No way! ». We instantaneously gave each other a hug and started laughing. This was Massimo.

About two years ago, when I was living downtown Montreal, we had one of our roommates leave us at the end of the year and sublet his room to an exchange student who was from Zurich. In fact, Massimo and I had lived together, shared breakfast, talked about politics and speak Italian about the student strike.

Now, the two of us were standing in that bar downtown Zurich after more than two years not hearing from each other and having any clue of what each other had become. What were the chances of us meeting through two intermediaries. It took Andrea, Anthony and us two a little while to truly realize what had just happened. Massimo being an old friend of Anthony, we ended up inviting him over for dinner and had a pretty cool night.

The last time I was in Europe was before I started clerkship. Before my first rotation, my first assigned patients and back at the time I had vague ideas what I wanted to do for the rest of my life. Also, initially wanting to pursue a career in global health when entering medical school, I rediscovered in Geneva that spirit; those buried ambitions and demystified the institutions that used to represent so much of those dreams like the ICRC and the WHO.  I also had the chance to go back up on top of Montmartre in the early morning before the tourist flux and just feel the wind blowing my scarf away, looking in the distance. I had up there the exact same sight I had three years ago but my thoughts were different. I find it reassuring to be coming back to places you have been before, meet people you have not seen for a while and note the progress that was accomplished in the interim. Look back. Think. Reflect.

Travelling to see places can become futile at times and the sole motivation to tick places on a map, take photos or cross them off my bucket list does not suffice to keep me going. Meeting with people, sharing a conversation over lunch with strangers, carpooling between cities and making the most out of the cooking space are much more significant and rich. Away from my family, this year I had the chance to drink a beer with my neighbour and remote best friend, to celebrate Christmas in Berlin with Christian, an old friend that travelled with me and to spend a day with Marcin, a polish friend I lived with for one month in Sardinia. Throughout that journey, I had the chance to be accompanied by Catherine, a close friend from Montréal who's always been there to share thoughts and explore deep and somewhat existential questions. I think our friendship got stronger by spending close to two weeks together and simply since we've always been there for each other in times of hesitation and uncertainty.

When you compare the draft of the person you were aspiring to become many years ago and compare it to what you are now, it feels good to see that most things are on track and heading towards the good direction.

Often times, we don’t know what the future has for us and we don’t like to spend too much time thinking about the past. Actually, I have found peace during this journey thinking about the past to orient my future.

This morning, I said goodbye to Cath and wished her the best of luck in her upcoming adventures. Now in the car, I am completing the last leg of a loop on the old continent to meet up with my girlfriend tomorrow and go skiing for a week. 

Reviewing the itinerary and my stories, I can truly say: « Life goes full circle! »

Over the past three years, I have worked hard with many of my colleagues from medical school in the audience to build a stronger sense of community at the McGill level and particularly in global health. This article is an attempt to express why I failed to do so and why the same story happens to all of us every year. 

There are four reasons I can think of:

The high turnover of students

The preconception that motivates students to get involve

The incapacity for us to stay involved at 50% leading to frequent abandon

The modular and punctual funding available

-- 1 --

We all know that the window during which medical students can get involved is really short.  There tends to be more students with extracurricular involvement during the preclinical years mostly since the material presented is dry and is often used as a compensatory mechanism to have a contact with patients or more with the population served. That small window actually pressures us to have quick results and have everything done for tomorrow. Then add to this the fact that there is a high turnover of coordinator and often times an improper transition period, you end up with student projects who are changing vision year after year, hence losing all credibility and institutional memory. Every year we risk of repeating the same mistakes again and again.

-- 2 --

A second argument that could be brought to the table to explain our failure is the fact that students are getting involved at the beginning of their medical school, when they are still naive and optimistic about their impact in the community. Over the years, I have developed a theory that when someone participates to an activity with a preconception, they will carry on that preconception through their involvement regardless of the various factors that could make them change their mind. For example, someone goes to Tanzania thinking that the population there is really poor and sad and needs any help possible to fix the situation. Even though that tourist will be exposed to different social classes, different environment and perhaps a lot of locals who have accepted what life had to offer them, that person will still remember the one and only kid who came to her asking for chewing gums and crying for it. There is going to be subconsciously a skew or a bias of the real situation, almost discriminating the elements that would refute her opinion before leaving. I sometimes feel like this theory can be applied pretty much to a lot of student initiatives in the sense that a project will be focusing its work with a community trying to improve or provide education about a specific topic, regardless of the actual situation that is not as bad as described. We are seeking for a utopian society and are often OCD[1] in medical school. We will then focus on the injustice we find worth fighting for that the local population has accepted or learned to deal with long time ago.

It is perhaps due to the fact that most of the time, a medical student is not going to gain anything from the outcomes of a project as they will never be reached, so it will focus its attention on promoting the project and showing the world he doing something while it clearly is not helping out. Medical students will then carry the preconceptions that were present before getting involved with a vulnerable community and be happy to discuss the fact that this problematic is still present and he did something about it.

There is also a whole different class of “reasons why to get involved” and those are formal recognition and CV building. I will not spend more time talking about those, as they are unfortunately non-genuine and self-explanatory. These will again, most of time, not force the student to see on the long-term and do the extra work behind the scenes to bring a project to completion or elevate the project to a new level.

-- 3 --

Now knowing that the window is small and that it is hard to get people who want to get involve for genuine reasons, why don’t we keep our members longer just as advisors?

The truth is that if a Student A has started a project, put in a lot of effort to bring it to life and had a vision of what it could become in the future, it is going to be hard for A to let Student B take over the project and witness every actions he would have taken differently. At this point, the Student A will be demotivated about the project and will prefer to quit the implication to 0% instead of just being involved at 50% and feeling powerless about the loss of potential. In medical school, we also deal with strong leaders that want to take on full charge and have sometimes difficulties sharing the work and decisions. This is a gray zone that any project will face and where the new coordinator will impose his choice and where the previous coordinator will feel less and less stimulated to continue the leadership of the project.

The easy abandon of projects by simply fading away and the facility for new projects to be created often leave the stage for similar projects created over and over from scratch at every five-year interval.

-- 4 --

Lastly, most of the funding available to student organization is given following an application process that is relatively simple. Filling in couple of forms, stating a quick budget and the targeted population and voilà. Often times, it will be presented in a contest or competition framework where only the innovative, fresh and impressive idea will win. So the funding we receive from corporations and non-profit is not taking into consideration the long-term development of a project. Whichever funding body will favor a new unproven project over a recurrent sustainable one, since it is all about marketing and the image that are projected from this funding body to the general public. Strong applications often get selected because the end-goal is needed by society or is sensitive to current issues and not because they have started work and prove their project was working. However nobody has ever thought of the fact that because a project, who claims to do X, is given a 1000$ once, it does not mean that the project will reach its objective. It often takes years before seeing any impact in the community. In most cases, a project that has been running for 2-3 years will have a hard time getting funding, as it will look “recurrent”. I have seen ideas of a project getting funding over a recurrent successful event. That is a problem. 

One would be tempted to say that having corporations and non-profit supporting the students and getting some popularity on the other side is a win-win situation. I don’t think so. I think the donator for sure gets a lot of attention from the population when funding a social or community initiatives. As costumers, we feel like the company is “taking care of us”. In another perspective, funding organizations don’t even have to hire a comedian for their next advertisement. It is as effective to give your project 500$ and get you to be featured in the next TV add. In exchange, your project gets this sporadic, non-renewable funding and does not get you anywhere near the “said” mission featured in the TV ad.

There is a well-known event and award night in Québec that is called Forces Avenir. This event is held annually and is funded by some private companies and a lot of university funds for community involvement. Don’t get me wrong, the idea of having a platform for students’ projects to compete is great, however I sometimes feel like this is too much of a brainwash in wanting to promote new projects and new personalities, without reinforcing the projects that are up and running already and that are struggling. We want to look open and interested into innovation, but we are not even supporting projects enough to see them come to life.

This failure is not only affecting us, it is everywhere in all non-profit organizations and a lot of community groups. I am thinking of Engineers Without Border who published for the third time earlier this year their Failure Report[2], stating what has not worked and the improvements to be made.

Now how do we move forward and deal with those two problems. Since we cannot really lengthen medical school, we have to implement a change in our funding system.

For me, the perfect sponsorship package would be a guaranteed amount every trimester for a 5-year period during which the students would give continuous feedback and follow up report about how they are progressing on their 5-year vision development. Regulating income would make it more likely to retain students in the project. It would potentially also attract new students since the project would be stable, more focused on the future and consistent with its mission.

Universities have always been good at setting new trends and starting new movements. I believe this is the time for us to raise the bar and structure our funding so that it promotes the long-term perspective, taking into accounts the factors above. Eventually, corporations and foundations will copy those funding strategies since they will prove themselves to be effective with projects finally coming to maturity.

It took me three years to get at that point of criticism and I am already fading away from student politics. I hope that this was enough to get some students to think and reflect about how we want to structure ourselves for future generations to benefit from it.

OG

May 19, 2013

  [1] Obsessive-Compulsive Disorder

Dear twenty year old me, stay who you are.

Although you might have the impression that the goal is to become a doctor and give away bits of your personality, you should see this the other way around. Your origins will allow you to create a great therapeutic alliance to the 51 year-old male who did not want anybody else but you to touch his chest tube and eventually assure his return to his baseline function. You will feel, upon writing his discharge summary and handing over his exit prescriptions that you meant to him what he meant to you, a feeling of being home.

Dear twenty year old me, let them talk.

You might think this will never happen to you but it will. That urgency of interrupting a patient’s story to save some time just to squeeze in the questions that your residents will later ask you. It is not worth it. While a patient talks, smile and nod. Be present. This will allow you to get pieces of information nobody else might have gathered. Always remember that day a patient told you she was getting a “perfusion” once in a while when she was going to the hospital, which nobody knew about or assumed it to be homeopathy. Discovering that she was taking Remicade in another hospital for Crohn’s disease will flip your differential and will grant her an admission.

Dear twenty year old me, always ask yourself  “What else”

Even if there might not be 20 other things to do for a patient, or new blood test to order for them, repeating that sentence will make you forget less. You will always forget. There will always be too many things to know and to remember. Going late at the end of your shift to investigate how your 51 year old status asthmaticus lady is sleeping during the night will lead you to the Jackpot. You’ll find that her airway irritation, anxiety and persistent fatigue are not improving probably from the dry cough she has during the night and never told you. Nothing else but a Codein syrup PRN prescription will make her comfortable and back on her feet way faster than you thought.

Dear twenty year old me, be honest.

There will be many times in which you will not really know what to say. In some cases you will have to learn to express yourself with silence. Put simply, you need a silence that is more than the absence of words, a silence that allows everyone in the room to breath, to hold hands, to feel your hand through the bed sheets comforting their quadriceps as you sit at the foot of the bed. On December 23, you will find yourself telling a gentleman who presented to emergency with back pain that the origin of his pain are metastasis to many verterbrea of the lumbar spine seen on CT. You are allowed to tell him that it’s not fair. That this is horrible. Although we have to be optimistic and appropriate with our patients, being able to show your empathy and to be honest in a context of poor prognosis will put a band-aid on his compliance. It will be enough to have him come back to have a full metastatic work-up the next day, on Christmas Eve.

Dear twenty year old me, step out of your comfort zone

You will quickly realize your staffs are filtering the cases you can see. Their intention is to give you the straightforward and nice patients that are good learning cases. Even if you feel like this works well for you, there is a lot more out there. You will only learn by experiencing the “raw” unplanned interactions, the cases in which your presence is optional and where establishing a good communication channel is the priority. As you are coming to the end of your obstetrics rotation, ask if you can go see the Intra Uterine Fetal Death patient in the IUFD room, behind the double doors. While dealing with the happiness, the excitement and the actions of the vaginal deliveries, in that private room is a mother who gave birth to a child she loved and carried for many months. She will teach you that holding your child is one of the greatest gifts, even when they have not had the chance to see their parents. Upon discussing and passing around photos in that isolated room, you will find a sense of pride that is identical to the parents in postpartum down the hall. She will remind you not to give up on life.

Dear twenty year old me, follow your interest

Particularly in the pre-clinical years of M.D.,C.M. , take the time to do those extracurricular activities or attend talks in Thomson house or at the Annex. There is no need to know what you want to do in life just yet. You should aim to become a good MD before thinking of being a good R1 applicant in a given specialty. Those initiatives and student projects will lay the foundations of a lot of problem-solving skills and will allow you to come up with a better understanding of the big picture. Learning from experience always pays back.

Dear twenty year old me, enjoy the ride

You will have the tendency to look ahead. To criticize what you are doing now and envy the upper years. Don’t worry, it goes by fast. You will soon see your degree fly by and wished to still be at the stage you are at now. These should be some of the best years of your life. It is up to you to make it happen.

Although you might be tempted to focus on the end result and on the person you will be twenty years down the road, you should aim to make every day a pleasant day. Knowing how to enjoy the small things always go a long way.

Remember, life is a journey, not a destination.

  Olivier Gagné

M.D.,C.M. 2015

________________

Hoping to come back with more energy to confront them or refreshed enough to feel like they are new problems.

Hoping to see them from a different perspective and tackle them once and for all.

Leaving central station, I had this feeling of freshness just as the train started to move. I felt satisfied to be going somewhere. At that point it did not really matter where I was going or with who. As long as I was moving forward.

Leaving something behind.

Always at the look out for the next thing, wanting to enjoy the fresh air...

Got off the train and enjoyed a Peroni at the hostel where I got to know a group of friends from the UK. After many beers, we then went out to the restaurant and ended up going to a party in a friend of a friend’s loft downtown Melbourne. I thought we shared a lot on life and had similar ways of seeing things.

The party was pretty fun. It gave me a flavour of what life as a backpacker might look like. What my life could have been like had I taken a year off.

Staying in a hostel, an affordable accommodation known to be easy to book online, you thought you would eventually get to integrate yourself in a city, a group of friend, that time will make it work.

Instead, you develop a group of friends in the hostel... International friends who all came for the same reasons and meet here.

Then you meet someone from your country. You are both happy and surprised by the other’s presence, despite being secretly annoyed by him or her. You know you did not travel all this way to meet someone from your country. However you are so happy to have him on your side to discuss the things you miss about and your impression on things based on your shared cultural references. 

Things settle down, you get a job, you run out of money.

You smoke, you drink.

You work at a small café at minimum wage to try to pay it off or at least break even. You find work easily in the restaurants from your country. Italians in the Trattoria, Germans in the wanna-be-german-brewery.

Slowly you adopt a routine that you did not expect yourself to be in when you planned the trip. You end up partying with the international friends. Spending all your money on boose, working more. You don’t explore the country as much anymore.

The locals are not so interested into hearing your story. They have met other travellers from your country with the same goals and lifestyle. You are just another generation of travellers that feed a pattern to their eyes. You understand what they think of you because you though the same of some dude who crashed the home party you had for Halloween three years ago. Quickly, you realize that you could have had the same experience in any other country, same job, same friends while living in a hostel.

The irony is that you had spent proportionally a higher part of the planning of the trip about country specific characteristics that really convinced you to come. All the touristic attractions, the nice food in the restaurant, the attitude of the locals. None of this is part of your experience anymore.

You realize that you spend more time on public transit than on the beach. More time with friends from the hostel than friends from the city. More time earning money than spending it. You eventually know almost everyone at the hostel. You are not sure if you are making the most out of it after couple of months.

I used to want to take a gap year. However after having a very lengthy conversation with a friend of mine, it became clear that the means for backpackers to reach or achieve their gap-year goals is perhaps not the most appropriate one. 

I used to want to be everywhere and nowhere, jumping from planes to planes, having no limitations, no commitments, no expectations. The danger by having this kind of lifestyle is that you might end up escaping and always compensate by travelling more, giving you the impression that you are more alive than people who have families and friends. It is an easy fix to a deeper-rooted problems. The truth is that you may never end up building something stronger than a short-term relationship whose expiration date is your return flight ticket. 

The final quote from the 2009 movie Up In The Air illustrates well this dynamic:

When travelling has become a normal way of living, you feel home wherever you go. You make friends easily and you play the game very well, knowing that you will never settle anywhere. In other words, you are not required to like your daily routine as much since you know that it is only for a bit. Your excuse is that you travel too much or are simply too busy.

For a big portion of society, travelling a lot and to many places is outside of their comfort zone.  To the normal dude, the traveller might look like a superstar, like a billionaire or simply like a free man.

As medical students, feeling random is part of our everyday routine. It is often mixed with a feeling like we don’t belong or that we were just parachuted in the most random conversation. In those cases, it is easy to be a bit jaded and just loose the reason why you are there, because you will not be there tomorrow anyways and you don’t experience that long term patient satisfaction that drives the specialist you work with. Meanwhile, we act like little cameleons, there to copy and imitate our supervisors. We start to use the word « usually » after seeing three patient with a similar condition. We learn from our patients, everyday. 

The first patient presents with a constellations of symptoms that correspond to a viral upper respiratory tract infection. That’s when we start playing the cassette. Literally repeating the same information, answering the same questions than discussed with other patients. All of that is done using that calculated wording towards the patient to make him feel good, make him feel like he is well looked after and cover our asses legally at the same time.

Second patient wants to have a renewal of her birth control pill.

Here goes another cassette. 

Third patient is called in the room. The label of the consultation given by the front desk is “intoxication”. I start to plan in my head the content of the consultations, the alcohol/substance abuse questions. That’s when a 26 year-old male walks in the room. He is from China, in his second year of university in Australia. You would think he corresponds to the stereotype right,

but then the story took an unexpected turn.

He starts talking about how his sexual function has been affected for the past 6 years, how he is not able to maintain an erection and that he thinks it is all due to a poison he was given in China. At this point, I orient the interview towards a psychiatry / anxiety consultation. I listen to how he always knew he was gay and had trouble to express himself in China. How his parents put a lot of pressure on him to marry and have a kid. He tells me all about how one day in a class a teacher had put some drops of poison in his water bottle while he was gone to the bathroom. According to him, there might have been three to four instances where he was given that poison; an old Chinese tabou recipe that claimed to induce chemical castration.

Ever since he attended high school, he had been bullied by his "friends" and coming to Australia was one thing he had been looking forward to for a long time. Far from making the problem go away, the patient still experience erectile dysfunction with his parter which we investigated with some blood test to make sure. The hormonal levels showed that he had hypogonadism. Was it from the poison or was it intrinsic to his body, nobody knew.

What I learned from this patient is never to stick to your first impression, what makes the most sense or what is the most common condition. We have to overcome the pressure of absolutely getting a diagnosis right.

Over the day, it is easy to forget that patients are worried. That our bread and butter means a lot to them. That it is their health condition, their survival. That they have requested a sick day from work, took another bus and came all the way to our clinic and waited a long time to see us. What they get in return is hope, understanding and a little piece of paper.

The patient was referred to an andrologist who deals with infertility and ED.

At your age, I was the same. I was a very social individual with a very basic conception of what was socially acceptable when it comes to stranger. Just like you, I could stare at strangers as long as I wanted because I did not perceive the awkwardness. I was just curious. So are you.

In fact, I capture your interest by pulling out my GoPro, a very cool looking camera and film the outside scenery. At this point, you probably think I have a robot or what seems to be the most interesting toy you have seen in a while.

I know how you think because I remember.

I remember those years, when I started to realize that there was a transition between adults and kids, that all kids became adults one day and that all adults were once kids.

I remember looking at the older teenagers, jumping from the highest diving board at the pool, examining every single move they did, how they interacted with each other and what was a « cool » swimsuit to wear.

I remember one day receiving a presentation by a cool young adult who was a university student. At that point even the spelling of the word « university » was a challenge for us, so we thought whoever attended that school were geniuses.

I remember…

And you are still staring at me. As if you were there to remind me of something or just undergo the current introspection.

You make me realize that I am now on the other side, although I still feel like a 7 year old sometimes. I remember looking up to people at that age as role model and I wish I could do the same with you, if I actually knew you. Regardless, in this twenty-minute silent encounter, I might have an influence on you; just like many strangers had an influence on me in ways they could not imagine.

To your eyes, I probably look old. I am wearing a sports outfit, unshaved beard, sunglasses on, headphones with paused music to give myself the time and space to think.

Today, you allow me to live those moments of reflection back when I did not know what my future would be after grade 6. So this letter is intended to the 7 year-old me you allow me to remember.

Here are some advices I was able to come up with:

You will be great, no matter what choices you make later on. Keep supporting the people you love and they will support you back and give you the fuel you need.

Continue playing LEGO blocks and making sandcastles. Creativity and 3D perception will be your biggest strength when the time comes.

Spend a lot of time with your sisters. Although you think they are sometimes bothering you, those long car rides sleeping on each other’s shoulders will lay the foundation that will keep you close during the rest of your life.

Go fishing with your dad when you can, learn from him and his stories, tell him you love him; he might leave quickly and sooner than you think.

Put the Kleenex over the candle to try to make a hot air balloon. This will end up burning a patch of the green rug and that patch will serve as a daily reminder that certain mistakes can leave unforeseen permanent marks.

Play with the neighbours, stay naïve and continue running towards the base of the rainbow. Although you might never end up getting to the base according to fancy laws of physics and optics, you should always remember your goals and keep working for them even if they seem impossible.

Continue to believe in Santa Claus. Even if your older cousins tell you otherwise, celebrating Christmas with family and unwrapping gifts from him is a nicer experience overall than receiving a 50$ gift card from your mother.

I would like to call this paying it forward, but I doubt you will get to this blog in the due time.

Cheers,