Three's a charm

In psychiatry, there's a set of three patterns of thought that are observed in depression known as the cognitive triad. The cognitive triad consists of the following:

• A negative view of oneself
• A negative interpretation of experience
• A negative view of the future

Outside of clinical depression syndromes, I feel it adequately describes the pattern of thinking in any episode of depressed mood. Having tried to think through my own periods of moodiness and depression, I've found that the mood often exists and persists only when all three patterns of thought are present. More on this later, but first a breakdown of how the triad has occured in my own thought process.

To start, I've had a decent amount of difficulty with self-esteem, and with large groups of people social anxiety as well. When I begin to start feeling depressed, it will often start with "a negative interpretation of experience". Usually with people this manifests as an anxiety that the person or people do not care for my company, or are bored of me, or less excited about spending time with me than were I to be someone else who's company they prefer more. In the past when I worked in Residential Life it manifest as "my residents don't seem to think I'm exciting to be around", or if I'm trying to plan a social event and people don't show up, I may become down on the event and blame myself for not being desired for company. These negative experiences often lead towards the "negative view of oneself" although not always a direct thought of "i'm a failure". Oftentimes I find an end-around to essentially reach the same conclusion, which is "these people/this person must think I'm a failure, or worthless". The only difference in stating this is I am accentuating the importance I hold in what others think of me, and that is a futile source of affirmation. The last thought pattern, "a negative view of the future," occurs when I believe that the previous two thought processes are true and unchangeable, and that the negative experience will ultimately continue or pervade other aspects of my life, or that I simply cannot be any more appealing to people than I am, and fail to feel validated.

I've thought through what might occur were one of the three thought patterns were to be removed. If I remove a negative view of the future, then the mood would never persist, and any negative thoughts about myself or an experience would ultimately be forgotten. If I remove negative thoughts about myself (and this would come only through affirming my worth through God, and disregarding any concern for peoples' opinions of me), I would never blame myself for something wrong that occurs, and likely be a lot more motivated to change things. If I were to cut away the negative view of an experience (which is often where I start in the first place) I likely would not fall into the other two thought patterns.

I had a conversation with a friend the other night about this kind of thinking during times of depression. It's no secret to many people that I've really struggled with depression the last two to three months, and a lot of it falls into the above triad; a few small things started the ball rolling, and eventually it was so big that what was left was a massive amount of hopelessness, despair, and unresolved anger. Some of that is resolved, but some of it I'm not sure. I know that I haven't completely resolved or done away with the triad thinking (and I'm not sure how to permanently remove it), but its something to work on. What it will ultimately boil down to, I assume, is a willingness to trust God's sovreignty on a good many things, and a faith that I am loved by God, something I think I have a difficulty with deep down. Lastly, a faith that I am loved by people and that my circle of friends is broader than three.

The Weight of the White Coat

Last week was the end of block test week, and at the very end of the week, on Friday, I left for Mexico, Missouri for my church's annual 22-hour retreat. For the last two years it has been perfectly scheduled to coincide with the very end of test week and the beginning of break week, and both times so far has been an incredibly refreshing way to escape the world of academic medicine and the bustle of the city. "Cell phones don't work out here," I mused on the drive out to the camp.

The camp where we hold our retreat is several small buildings owned by a Baptist church group out that way that allows us to use it each year. The property is the size of several football fields, with a creative array of fields, wooded hollows, remnants of a creek and some runoff lanes between rises in the ground. There's a lake with a dock that is the perennial wilderness baptismal. There's also a barn-like building that now serves as a chapel. A firepit next to an outdoor ampitheater, the fellowship hall, and a small group of three cabins rounds out the scenery.

After having the night's turkey feast, and the first sermon of the retreat, it was dark and a chill was finally developing. I headed to my friend Jesse's Jeep for my fleece to help fight off the night's cold. Walking back towards the fellowship hall, I started hearing my name, and approaching the light of the open door was spotted by my friend Ryan, who ran to greet me and alert me that I was needed. As I followed him into the hall, a young man was brought before me by my pastor John. With his left eye starting to swell, the white of his eye a uniform pink-red, and a trail of blood flowing from the outside corner down to his jawbone, I immediately knew why I was so urgently sought; the man needed medical care, and I was expected to provide it.

The young man had been hit by a hedge apple about the size of a softball in the dark (apparently, some people were throwing hedge apples around for fun). My stomach clenched a bit at the first sight of him. "What if I don't know what to do? What if I can't be of help?" I thought. I was afraid to let him and everyone expecting me to help down. Very quickly though, I put all that aside in favor of an air of authority and control as I asked for a flashlight. My pastor informed me that there was a better lit first aid room in the basement, stocked with medical supplies. He beckoned with his hand and led me and the young man down the stairs to the room. The room had a couple chairs, a cabinet with a stock of general first aid supplies, and a large examining lamp anchored to a desk corner. Soon Korrin and her husband Cannon (A nurse and a fireman with some EMT training, respectively) and my friend Ben (also with EMT training) arrived.

As we started to undertake cleaning the wound and examining the young man's eye, it became apparent how much respect was being deferred towards me and my decisions. I also became aware of my own initiative to direct the care of the young man. Thus it became evident the weight the white coat carries in a medical situation.

It is hard to find anyone who hasn't heard the proverbial question "Is there a doctor in the house?" in passing, but seldom ever do people hear it in honest inquiry. One time when I was in high school I saw it employed; at a chorale competition in the gymnasium in front of a crowd of families and friends from the competing schools, my assistant director rushed in from the hallways to announce that a lady had collapsed, and inquired if there were any doctors available. At least two, if not three if I remember rightly, quickly made their way from their seats to the scene. I can liken that scene now, roughly eight years ago, with what happened this past Friday night. The profession of physician extends beyond the realm of the office and the examining room, beyond the halls of the wards and the beds of the trauma unit. Once a physician it is an expectation that in the immediate presence of a medical emergency you appear like an expected hero, with the calm and the knowledge to handle the concern in an instant. Not even awarded the title of M.D. yet and I already feel this expectation.

Maybe this event seems different simply because of the blood. There's been numerous times stretching back to before even entering medical school that friends have approached me with a medically oriented question. Sometimes it's been because of an injury while out playing sports; a twisted or bruised limb is especially common. But the blood is different. People react. Some faint, some feel nausea, others panic. The doctor is expected to fulfill his role of hero and savior and not be bothered by the blood. The doctor is expected to be the leader as the first responder. His degree and his pay and his years of study preceed him in many people's minds to the point where it is a crime now to be considered fallible. Fallibility isn't a characteristic of a doctor, but negligence is.

Soon, patient encounters will occur on a routine basis within the hospital, but I will be the student in a world of professionals who know my fallibility. Slowly though, as the tails of my white coat grow (which is set to happen in May of 2009) and my presumed knowledge and authority increase (sometime after residency) there will be more people who will defer to my expertise, and I will have no choice but to shoulder the responsibility. Patient's and nurses and residents and medical students will all at some point lean to my authority. The implications of that are beginning to reach me, and I am deeply humbled.

Welcome to the Big Leagues

The summer research jump from last year to this year has been quite a step. I did a small research project, not too terribly important, last summer, that was published in a free online-only journal (in other words, not a real big deal, but worth being proud of).

This past summer, I worked on infectious disease research in the pediatric department at the University's Children's hospital. My mentor, Dr. Mato, gave me and my classmate Amanda assurance that we would most definately see our work published. Yesterday, when I dropped by Dr. Mato's office while up on the pediatrics floor, she spoke of submitting my research for the Pediatric Academic Societys' annual meeting in Toronto for presentation. If my work is accepted, it would mean the chance to present my poster and research in front of doctors and researchers from across the country.

Being only a medical student at best, I was humbled to find out she sees us presenting research amists other researchers who have done this their entire lives. Maybe I won't end up getting to go at all, but I'm excited and hoping that I'll get the chance (and hopefully my classmate Amanda will get the chance to go as well, and we can keep each other company having fun in Toronto).