"Perseverance, dear my Lord, keeps honor bright" - Act 3, Scene III, Troilus and Cressida

"Isn't it time to give up this game?"

"What are you thinking? You're almost 50 years old! Stop trying to do something you can't!"

"Why are you putting your family through this? You obviously cannot pass."

"You are a failure. You have always been a failure. You will always be a failure. Throw in the towel."

Like cold pebbles dropping into an empty jar, these thoughts ping around in my head, bouncing off of the hope that once filled me as I started medical school in 2014. Next year, my class will graduate and move onto residency - I will be in my fourth year of school, still hoping to pass.

This journey has been more difficult than I could have imagined. Yes, I knew the academics would be challenging. Never in my wildest dreams, however, could I imagine that I would be a two-time failure at my medical boards and slip between the cracks out of my class. I feel that I have become one of the vulgus rejecti, one of the rejected people in my school and my profession as I heap failures upon my head. It is at these times, when such feelings assail me, that the whispering of the thoughts elucidated above becomes a roar.

Please don't misunderstand me. My school has been very patient as they wait for me to pass. My family has been almost supernaturally kind and supportive and, most of all, God has not forsaken me: He has been there this entire time to gently remind me that He is present and powerful and loving. Despite all of this, feelings of inadequacy persist. Maybe, as I was advised by a dear friend years ago, I actually am crazy for trying this at my age. Maybe these failures are God's way of telling me to throw in the towel.

It is during times like this, when these feelings and thoughts bubble to the surface, that I purpose to remember why I started this journey. May I list these reasons for you?

1. God placed in me a desire for medicine from my youth. Despite my failures, this desire burns in me to this day.

2. Becoming a physician will help my family, providing for them a future that my own father could not provide me.

3. I love caring for people. I love dealing with their hurts, seeing them get better, consoling their bodies and souls. There is literally nothing else I want to do.

Dear reader, I'm not giving up and I refuse to give in to the doubts that impugn my conscious. I might go down, I might fail out of med school - with two board failures under my belt that is a possibility. But before God I promise you this: I will not go down without a fight. I will not let feelings of inadequacy and fear of failure rob my family or myself from this goal. I will, again, pick myself up from the ashes of my defeat and doggedly place one weary foot in front of the other until one of two things happens: I reach the summit of this great mountain or I die trying. 

I don't know what challenges you may be facing right now. Nor do I know with what failures you may be wrestling. I do know this, however: if your effort is for good you will meet with great resistance. Can I encourage you to never give up, never give in, never stop fighting to achieve what is right. Sometimes, life calls for just such an effort.

The Theatre of the Bizarre

As quickly as they come the months go, falling on each other like turning pages of an old book. Since learning of my second COMLEX failure at the end of October, I have completed a month-long medical boards prep course in sunny (and humid) Florida.

This course was very.......unusual, to say the least. One of the first things we were taught is that the medical boards exist less to "test knowledge" and more to "weed-out" medical students. The purpose behind this, we were told, was because of the profound disparity between the number of medical school graduates every year and the significantly lower number of available residency slots. It is for this reason that the boards are deliberately difficult and obscure - they are an effort to trip up the test-taker. Additionally, we were told that the boards are more challenging for those persons who have greater clinical experience. As someone who has 18 years of military medicine under his belt, I would agree with this latter statement!

All of this started me thinking: in what shape is medical education, and the industry of medicine itself, if we find ourselves having to stoop to such base measures simply to make doctors? Over and over I have heard that there is a drought of physicians. Yet, we create hurdles, a grinding gauntlet of the mind, making the education of new physicians unnecessarily difficult. This, in turn, leads to a sense of elitism and thus robs eager young students of any altruism they may have had when they began this journey.

Medical school should be difficult. The responsibilities a physician faces are great as daily life and death decisions are made. To my perception, though, as one already two years into this process, there are efforts both at the level of the schools and on a national level, to make this procedure more arduous than it need be. The modern medical boards reflect this.

Some may read this and say, "Yes, but most students pass their boards on their first attempt. You're just saying this because you're angry." God bless those who have so passed! I admit that the boards have been very rough for me - more so than I ever anticipated. It is because of this that I have had the opportunity, more so than most medical students perhaps, to focus not only on the boards but on the purpose of the boards. Testing is a necessary evil. But this "thinning of the herd" simply because our system is broken is a travesty that limits the number of available quality physicians. In the end, the ones who pay the price are the patients.

Regardless, the boards are here to stay - at least for now. I am going to give this third attempt my best effort. Perhaps, one day, there will be a better more patient-centric system in place. Until then, we try our best to work with what we have while trying to bring positive change.

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Genug with Sitting Shivah

There is a tradition among my people: when a loved one passes away we spend seven days in mourning. We call it Sitting Shivah. "Shivah" means seven in Hebrew. During this time we abstain from common daily luxuries, pleasurable activities, and even cover the mirrors so as to avoid vanity. This period is set aside  to focus not only on what we lost but to work through the pain and anger of that loss.

As of today, it's been a week since I learned that I failed my medical boards again. While it is true that this loss does not compare to the loss of a loved one, it is painful loss nonetheless. Today, it was made even more painful learning, because of the delay in passing my exam, that I will not be able to graduate with my class. So, instead of graduating in 2018 I will walk in 2019.

The pain of these compound losses strikes deep within me. The mantra "You're a failure." plays over and over in my mind. I see my family suffer financially because of my current inability to get over this hurdle.

But Shivah is over now. I can no longer afford the luxury of self-pity. The time for wallowing in depression has passed. Now is the time for action. After consulting with faculty at my medical school, as well as my advisors, my family and I have developed an aggressive plan, a new approach, so as to pass the board exam this next time, God willing. My school allows four attempts to pass before I am expelled. It is my sincere hope that I will not have to avail myself of every one of those attempts.

So, time to dry my eyes, time to let go of the self-anger, time to replace the destructive mantra of failure with a mantra of hope. If there was ever a time to "pull myself up by my bootstraps" it is now. I have wanted to be a doctor since I was six years old. I am sure not going to let one stupid test rip this away from me.

So help me God.

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Nuts!

On December 22nd, 1944, the US Army was in the Belgian city of Bastogne, surrounded by the German Army. World War II was winding down and the Germans expected an easy victory against the American F Company of the 327th Glider Infantry Regiment, 101st Airborne Division. So sure was the German Army of their pending success that they typed a formal letter to the Americans asking the Yanks to surrender. US General Anthony McAuliffe, after reading the letter, gave his now famous response to the request: "Nuts!" Indeed, the good general had his terse reply typed up in a formal memorandum and sent to the German Army. Initially they did not understand General McAuliffe's reply so the Americans spelled it out for them: they were decidedly not going to surrender. Remarkably, the US Army survived a scaled down German attack and the rest, as they say, is history.

Yesterday, I received the results of my second COMLEX step 1 medical boards exam. Incredibly, and against all odds, I failed yet again. This makes two consecutive failures of my medical boards - a profoundly negative turn of events. The discouragement and shock are intense, as you could imagine.

Now there are pressing questions: should I go on? Would I be a fool for continuing this marathon toward becoming a physician? Am I, at this point, simply putting off the inevitable reality that I simply cannot make it?

Someone once said that the true timbre of a man is determined by the manner in which he handles his failures as much as his successes and I believe this to be true. I am not under the illusion that I am not in a most difficult position. Two failures look very bad on my transcripts and are a definite big bump in the road when it comes to residency applications. On top of all of this, my family is suffering as finances become increasingly strained. Would it be fair to them for me to try yet again?

Needless to say my family and I have been in much prayer. I have consulted with one of the deans of my school and with multiple professors. My family, friends, and faculty all tell me the same thing: don't give up. Don't surrender.

I am surrounded. The enemy is pressing in on every side. I am assaulted by failure, fears, and financial strain. These formidable foes have told me to turn in my stethoscope, told me it's time to move on to something else...

Nuts!

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The Medieval Torture that is COMLEX

This post is going to be a little longer than normal.

On September 19th, I had the joy (*ahem*) of taking the Osteopathic Medicine Step 1 boards exam, the COMLEX, again. I wanted to share with you, Dear Reader, my experience that day.

I woke up early after attempting to get a full night's sleep. My family was with me as I had a high protein breakfast and they dropped me off at the Prometric Testing Center. I confess I was nervous, though not nearly as nervous as the first time. (For those who may not know, I failed my first Step 1 boards attempt). My wife prayed with me and, with that, I stepped through the glass front door of the Center.

I signed in and was assigned a small locker into which I stored my cell phone and keys. I was led into another room where a friendly if not slightly bored person asked me to turn my pants pockets inside-out, lift my pant legs to reveal my ankles, and turn about as she waved a magic wand up and down my body searching, no doubt, for some metallic tablet onto which I might have engraved two years worth of medical knowledge. After being satisfied that I wasn't a felon, I was asked to sit down next to another friendly person who scanned my fingerprints on both hands. He asked for a picture ID. I obliged. After several minutes of him scanning my ID and tapping vigorously into his computer, I was given the "go-ahead". I had cleared Security. I could take the test! Whoo-hoo!

I was given a couple of permanent markers and several plastic sheets of paper and led into a tomb-like, windowless room filled with several cubicles, each of which had an outdated computer and simple chair. I sat down, listened to some simple instructions from the friendly lady who would monitor this room for the next eight hours, and was shown a pair of earphones. After being assured that I had everything I needed, she left.

This was it. I stared at the monitor. It stared back. Months and months of study and preparation came down to this moment. I took a deep breath, said another quick prayer, and clicked on the "Start" button. The first question came up. I read it quickly, scanned the answer options and, to my delight, actually understood what was being asked of me! This was a good start.

Four hours later I had finished 200 questions and felt, honestly, pretty good. I was not anxious as I had been the first time, and I was ready for a quick lunch break. I stood, left the earphones and plastic sheets at my station, and walked out to the bored attendant. He scanned my fingerprints (just in case I had magically morphed into a different person while sitting in my cubicle. One can never be too careful), made sure I had my ID, and let me go to lunch.

In the parking lot, my wife and kids had returned and we sat in our beat-up minivan together while I quickly downed a protein bar and bottle of water. My wife wanted to know all about my experience thus far and I was happy to report that I felt pretty good. After 20 minutes and another prayer, I was back in the testing ante-room, getting scanned, fingerprinted, and ID'd. Soon I was sitting at the desk and ready to resume.

And then I hit the wall.

My shoulders started to tense, my neck started to ache and, after a couple of dozen questions, I found myself having to read each question twice to understand what was being asked. The clock seemed to supernaturally speed up as I struggled to finish on time. What was wrong? What had changed? I felt anxiety begin to gnaw at the edges of my mind. I fought it back, took a deep breath, said another prayer (I'm convinced in the therapeutic power of prayer) and pushed ahead. I read another question. What the heck was it asking? I had to look up several lab results. The clock seemed to run even faster. I finished another set of 50 questions, leaned over in my chair, stretched my back, did a quick OPP treatment on my neck, and looked back at the screen, challenging it. I would conquer this stupid thing, so help me God. I heard a truck pass by noisily outside. Behind me, another test-taker was tapping his desk nervously. Great...

An additional four hours passed and I came to the final question. By this time, I was exhausted and, honestly, I could barely force myself to care. I looked at the answer options, realized I had no clue, and quickly clicked what I thought might be the right answer. The clock told me I had a couple of minutes left. I closed the test.

I was done.

I stood. My legs and hips groaned in protest. What had begun eight hours ago with confidence and enthusiasm ended with a sense of completion and exhaustion. I stretched, waved at the poor attendant who watched me through the glass, and left the room. More fingerprints, more ID confirmation. I went to my locker, grabbed my phone, turned in my locker key, and walked out. In a few moments my family showed up, ushering me away to a celebratory dinner.

Regardless of the results, I know it is a great honor to be given the opportunity to sit for the medical boards. And I, ever the over-achiever, sat for them twice. Now my family and I wait a month for the folks at the NBOME to process and post the results. I feel hopeful (more so than the first time) that I passed and can move forward to third year rotations. There remains in me an anxiety that I may have failed a second time, an anxiety shared, I've learned, by most of my classmates who later learned they passed. I am using this interim waiting time to sleep in and spend time with my family.

Thank you, Dear Reader, for making it thus far in this, my longest blog entry ever.

I will keep you posted!

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The Evening Before Tomorrow.........Again........

This is going to be short.

Tonight is the evening before the COMLEX medical board exam - again. Tomorrow I will spend eight hours huddled in front of a computer answering long and poorly-worded questions, 400 questions to be precise, covering all that I have learned during the first two years of medical school. 

After all of the study, and the 20+ pounds I have gained since July doing nothing but eating and sitting at a desk, I am so ready to have this over. I pray that all of the time, expense, and effort will prove to be enough.

Thank you, dear reader, for your time. I will keep you posted.

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Kill it - Kill it Dead....

The beast stood there, lurking in the shadows just beyond my sight. I could hear its low growls, gutteral mutterings that communicated evil intent. My breath came in short bursts: palms sweaty, muscles tense. My mind screamed at me to run but my feet remained rooted to the earth. With a supernatural resolve I forced myself to stay. Slowly, the beast lumbered toward me, greasy sinews taunt with power, fierce jaws dazzled by a thousand teeth made silver in the shifting moonlight. I felt my hand on my sword, oddly strong and sure of itself despite the huge mass that trembled before me. In a single move I drew the blade from the scabbard and held it before me. The finely tempered steel glinted as the razor sharp tip was inches from my adversary. This was it: we were going to fight...

It's been a couple of months since I learned that I failed my medical boards exam - the COMLEX Step 1 - this failure essentially bringing my young medical career to a dramatic halt until I pass. In the ensuing weeks I have taken a boards exam prep course, spending anywhere from six to ten hours a day in intense study. I have also plowed through over 2,000 practice questions. It's been good: I have re-learned a lot and secured a better grasp on two years worth of material.

During this time, though, COMLEX has grown in my mind. Before, COMLEX was merely a test, a hurdle to be jumped over en-route to becoming a physician. Now, COMLEX is the beastly creature described above, a hulking, heaving mass of sinister and destructive intent that I must destroy. Forgive me if this sound dramatic, but I'm really starting to hate this test. It's not that I find it unnecessary, it's just that I realize that now it's "kill or be killed". I love medicine and I love people, thus I will do whatever is needed to slay this beast and move on to third year, even if it takes me longer than most.

There are 17 study days left until my exam: 17 days to re-review and sharpen my sword. With God's help, I will see this thing slain and stand triumphantly over its decaying carcass.

Thank you for your time, Dear Reader. I will keep you posted.

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