Mykala’s getting her MA in Human Development and another MA in Counseling and Psychological Services, so she’s reached the point where she’ll do something called a practicum. It’s not unlike an internship, except you earn credits for doing the work and getting the experience. We’ve talked a lot, and Mykala is interested in, well, not pathologizing people. Clinical psychology, the DSM diagnoses, etc. have their place, but she wants to take a well-adjusted person and help them stretch to reach their potential. So, Mykala interviewed for her practicum at the St. Thomas Career Development on Friday. The interview went so well that they called back later that day to offer her the position!
I took a walk at St. Thomas while waiting for Mykala’s interview. In the five years since my last visit, they’ve had the biggest building boom in over two decades. There’s a beautiful new student center. There is also an athletic complex, about the size of a city block, whose luxury and scope are unparalleled by any college athletic center in the five-state area. The sandstone dressed walls, rising two stories straight up from the sidewalk, make the campus seem like a dream to me: worn, familiar spots juxtaposed with the completely unfamiliar.
I found a sunny spot on a bench outside the three-story glass curtain wall of the just-completed student center. I looked around at the college students. “They’ve no idea how nice this is… but, I guess I had no idea how nice it was when I was here.”
I sat at the site of the old O’Shaughnessy Athletic Building, built before World War II. It had a basketball court on the top floor, lit with natural light — it would get roasting in the summer. Ancient fixtures in the locker room were original to the building — the girls locker room was crammed in later, when St. Thomas became co-ed. I went to the weight room there every other day of college, and I got used to a few things about the building. First, when I started working out there, it was just this concrete floor and amazingly decrepit ceiling. The music was provided by an old boom box. Rusty weights, equipment from the 1970s. Sometime during my first year, some very generous donor contributed, and the weight room got a new floor, ceiling, mostly new equipment. Yet, any 60+ year old building has certain oddities: for example, there was radiator heat and no air conditioning. I remember the heat blasting so high in the winter that we’d have to open these old single-pane swing-out windows. I felt like I was in a castle: brick on my side, stone on the outside, unhinging this old iron latch and swinging the leaded glass out into the weather. You’d feel little bits of snow land on your face while you worked out. When the weather was transitioning from late winter to spring, the radiators never seemed to turn off — so, we’d have all the windows open on an 80° spring day, and the radiators would be cranking out heat. You’d just sweat and sweat and sweat. The hours of the building were not good at all — on the weekend, random doors would be locked, so you’d have to figure out how to get in there to work out.
Thing is: I liked it then. I really did! This may sound like an “uphill both ways” story — but that building had charm. And, remembering back — that sure was a fun experience. Except when random doors were locked. That was… not fun. So, any gym now seems luxurious by comparison. Plus, what history in that building! It had these ancient, heavy metal classroom doors, dusty wooden trophy cases overflowing with since-forgotten awards, dead-end hallways, disconnected clocks, weird closets, high-ceilinged lecture halls. To get to the upper level and use the leg machines, you’d climb this spiral staircase in a concrete turret, passing a mostly abandoned storage area on the way up. At the beginning of each semester, you’d occasionally run into someone saying, “I’ve never even been in this building… and I have a lecture in it? Where’s my classroom?”
Since then, of course, it’s all been razed and replaced by a sleek new building with the latest in everything. It’s all well-marked, well-lit; I’m sure nobody is ever lost. Flat panel televisions for signage! Those would’ve looked very wrong in the old building. Where there used to be a random student at a flimsy table sitting on a salvaged chair swiping cards if they didn’t simply recognize you, there’s now a fancy check-in desk with uniformed folks reminding you of membership dues and card requirements. Where there used to be a musty old locker room, there’s climate-controlled luxury. Individual showers. Carpeting. There’s no mystery, no sense of history in a brand-new building. In a tasteful nod to what went before it, the new athletic building has the two main doors from that old building I worked out in for four years. These are massive, oak doors, lacquered to a high shine, made up of carved panels. They have custom-wrought metalwork forming massive, over-engineered, almost medieval handles. Nobody, and I mean nobody makes doors like this anymore. They wouldn’t look out of place on a cathedral. It was a complete shock to see them mounted on a wall, no longer swinging or leading to anything. My fingertips graced the metal. “I… used these doors. And now, they’re just stuck to a wall.” Just stuck to a wall.
My mind returned to the place I was sitting. There used to be a four-story tree growing here. Freshman year, I was reeling during my first few months, adjusting to living in a dorm and having complete control of my own schedule. Freedom was hard! One Saturday, I laid down outside the old athletic building, under this tree, and took a nap in the late afternoon sun. All that’s gone now, except in my mind. I can’t go back in a building that isn’t there. You can’t nap under a tree that’s gone, either. All I have is the unreliability of the human memory… and some pictures I took of the outside of that building.
Despite my idea that I wasn’t going to write more about it, I might as well record this thing for posterity. I’d like to describe in detail, both for myself, for my wife, for my future children, what it was like to survive “the worst hazing in all of medicine.”
The first thing you must understand is the way that licensing works. Licenses are doled out by states, and certain fiefdoms have been established around the US where you have to take a certain test to practice dentistry there. So, you do not receive your license, that is, your legal permit to do the job of a dentist, from your dental school. You receive it from the state in which you plan to work. Thus, upon graduation, you receive your school’s diploma and then you submit materials to apply for a license. I think that all of us working in Minnesota will apply for “Licensure by Exam”. That requires the following:
Pass “Minnesota Jurisprudence Exam” (know the laws governing you as a dentist — this is very straightforward).
Pass written boards: “American National Dental Board Examination, parts I and II”. Three days of exams.
Pass clinical boards. For us students, this can be CRDTS or Canadian boards.
Canadian boards are the NDEB.
Advantage: you don’t need to find patients to take the exam.
Disadvantage: devilishly difficult multiple choice questions. You can only practice in Minnesota with this one.
CRDTS stands for Central Regional Dental Testing Service.
Advantage: you can practice in 17 states after passing these boards.
Disadvantages are covered in the remainder of this essay.
I, along with the majority of my class, opted to take the clinical exam through CRDTS. In order to even qualify for the privilege of taking this 9 hour exam, you must do the following:
Pay $1995 via cashier’s check. No credit cards. No simple checks.
Find a dental assistant to work with you throughout the day. Pay them $350.
Find a “perio” patient. This is someone who has periodontitis as a result of increasing pocket depth, calculus accumulation. I’ll give you an idea of the requirements for this patient: “The quadrant must have a permanent molar with a proximal contact (explorer does not pass freely between the contact) and a minimum of six natural teeth (any dental implants in the quadrant are not accepted). The 1-4 additional teeth, if needed, must be contained within one quadrant. At least 14 surfaces of qualifying subgingival calculus must be present in the Treatment Selection presented. At least 9 of the 14 qualifying surfaces must be on non-incisor teeth. At least 3 of the 9 posteiror qualifying surfaces must be interproximal on permanent molar(s).” Crowns on the teeth make the work hard, too. We mostly had folks in their 30s — they were old enough to have a lot of calculus, young enough not have a bunch of crowns.
Find a “Class III” patient. They have a cavity of a certain size, shape, and location between their front teeth. The smaller the cavity, the better.
Find a “Class II” patient. They have a cavity of a certain size, shape, and location between their back teeth. The smaller the cavity, the better.
Arrange to pay the patients for their time, in a sealed envelope, out of sight of CRDTS examiners. After all, CRDTS frowns on us reimbursing patients.
So, in January of this year, us D4s set up a weekend clinic and ended up screening almost 1500 people in order to get enough patients for boards. This evolved into the grueling process of “contributing to the general pool” and hoping you were assigned a good patient as a result of your hard work screening patients. Stressful, but manageable.
So, after the worst night of sleep ever, I began the 9 hour clinical exam on February 26, 2012. My first patient shows up (YES). If he hadn’t, I would have had to try to find a back-up patient, or risk failing. He’s the “perio” patient. Things go great. We clean the heck of out his teeth, perform the required exam, complete the required measurements.
My operative patient (from parts (4) & (5) above) is one guy, two lesions. That’s wonderful. He shows up. Yay again. Still on schedule, I begin to remove decay from his front tooth. I send in a few “modification requests” so I can remove all the decay. I remove more… and more… and more decay. Oh my God, we might hit the pulp of this tooth (you fail if you don’t notice this… happens every year to someone). I am sweating. I send in for another “modification request” — basically, this sheet saying “This is how I will be deviating from the ideal tooth-cutting that CRDTS requires. I’ve already shown you I can do the ideal, now I will tell you how I have to change that shape and depth so I can get all the caries (cavity) out.”
I’m behind schedule. I am almost, but not quite, panicking.
After an interesting discussion with a nice floor examiner (“you don’t really think you’ll need to place a cap on the pulp, do you?”), I regain my courage, and send this GIANT hole in the tooth over to be evaluated. It comes back fine! (If I had missed any decay, I would’ve failed.)
But. But but but. But I am frazzled and behind schedule.
The fill of this tooth is a STRUGGLE. I am just not working how I usually work. The materials don’t feel the same in my hands. I’ve got great isolation (not battling patient’s tongue or saliva), but I still can’t find a flow. Things take so long that I have to submit something that I KNOW doesn’t represent my work. I submit.
Keep in mind that after each submission (of the tooth hole, of the modification requests, of the final fill), you have to sit, alone, in your dental cubicle for 20-30 minutes while the patient is processed in an adjoining room. People have thrown up during this time. My entire body was frozen while I waited.
There is one thing that you don’t want to have happen and that’s this: the chief examiner (wearing a suit) visits you. They tell you, “you’ve done something outside the bounds of the test, and it’s time to stop the examination.” This happened to members of my class. So, I’m sitting there, desperately hoping someone in a suit doesn’t come by. They do not.
But, I receive an “instructions to candidate” form. The examiners have graded my fill, but they’d like me to change a few things before continuing. This is NOT, I repeat NOT good news. A very friendly floor examiner stops by, guides me through the changes, and I’m on my way.
But I am WAY behind schedule.
“Tell me when it’s 3:45,” I tell my assistant, as I blast into the next tooth. Cut, cut, refine, refine. Remove a little bit of decay (man this guy has deep decay), and I send it over for an evaluation. Time stops. I get ANOTHER “instructions to candidate” form. Holy shit. I’m in full-on panic mode. This nice floor examiner stops by, I make the recommended changes, I’m on my way.
I have NOIDEA how many points these “instructions to candidate” reduce my score by. All I can think is, I am no longer performing like a thinking, reasoning person. I am working like a caged animal trying to gnaw my leg off to escape. This is really really reallyreally bad.
Somehow, God knows how, I pull it together and place the v-ring system to establish proximal contact with the posterior composite restoration. I burnish. I remember this moment vividly, because I said it aloud: “I shouldn’t have burnished.” This, I really believe, is the moment I saved the exam: some sliver of my human brain came back online and said “replace that v-ring system, and you’ll have a good contact.” I took the extra time to replace the v-ring system.
“I do NOT see any flash. Honestly, that margin is good.” I vividly remember saying this, as much for my own benefit as to just put out that positive thought into the air. My assistant agreed. I sent my patient over for his last check.
I could see that fill in my head and I thought… it is right. We began cleaning up. My patient comes back at 4:56 (the exam ends at 5), and I hand him his envelope of money. Right in front of a floor examiner. A different one from the happy ones before. An unhappy floor examiner.
“Wait wait wait. You are not done.”
“What. The. I’m… what? I’m… oh my God. I’m. What?”
Those are, quite literally, the words in my head at this point. I’m 9 straight hours in, I’ve had a part of a sandwich and maybe a bathroom break (I honestly can’t remember). I sputter to my assistant: “We, uh, I mean, we have to set up. There’s ANOTHER instruction to candidate.” She stood there in shock for a moment before she started setting up the cubicle again. At 4:59pm. The exam is supposed to end at 5.
The floor examiner looks at my fill for quite some time. I can tell that whatever the issue is, is minor. That doesn’t make the situation better. “See, right there.” He points at the mesiocclusal cavosurface margin toward the lingual of the tooth. “The material is a little high there.” I’m not even kidding, my hands were SHAKING at this point. I polished.
“Sir,” I heard myself saying, “I’m ready to have you take a look.”
He looks, sees another spot (not mentioned on the “instructions to candidate” form) and has me change it. I yank my loupes off and tell my patient “I’m going to be a little close to your head for a minute” and make the change. The floor examiner comes back again. I’m, quite literally, praying behind him.
“Okay, I’m going to be kind of mean here, but there’s just one more spot to adjust.”
My blood pressure has NEVER been that high. In a haze, all I can remember was me polishing and muttering, in some sort of panicked whisper voice I’ve never heard come out of me before: “I just don’t see it. Where is the spot he’s talking about? I just don’t see it. Where is it?” My hands are SHAKING. Bad. Like, the polishing bur is banging against the tooth I’m shaking so badly. I polish and have him check. I’m finally dismissed.
Strangely, the fact that he said “I’m going to be kind of mean” made me feel better. I realized that, if this were actually a big deal, then he would not have been so casual. I come home. Melt. Down.
Sobs wracked my exhausted frame as Mykala held me. “I’m sorry, I’m so so sorry. We can’t afford this…” is all I could get out, repeatedly. Though that final “instruction to candidate” didn’t seem to be a big deal, the others seemed to spell doom. Over the living hell that was the days of waiting for results, I thought about each part of each procedure that day constantly, and while doing so oscillated between “maybe I passed” and “there is no way I passed.” I only ever said the second one aloud, to myself. Usually while biking to clinic.
In what I consider to be a miracle, I passed. It feels amazing, because I know I have the clinical experience necessary to pass these boards, and to do good dentistry. That’s the next step, thank God.
Once, back in 2008, when I was about to start school, I saw a guy at the gym and he said his wife was nearly done with school. When I asked him how it was for his wife, he said, “Pure hell.”
I actually started crying for joy last night, jumping up and down and hugging Mykala. I had my hand up in front of the screen for a few seconds after I’d logged in, hoping for the best and bracing for the worst. We took a closer look at the numbers… and then called to confirm them this morning, which is when I finally let the last adrenaline-fueled knot in my chest uncurl. I don’t know if I’ll write more about it because, frankly, I’m ready to be done tagging things “dental school”. But, the news: I passed my final FINAL final set of boards. Worrying, waiting, for four years… I finally got to say to Mykala and my parents today: “I’m out of the woods.”
“A patient of yours just checked in, has no appointment for today, and axiUm says the chart is checked out to you.”
This was not the voicemail I wanted to hear this morning during breakfast. I sighed, closed my laptop, and hurriedly biked down the hill to school to see the patient.
“I want you to know, I’m not mad at you, but the previous dean was not enough of a man to renew my contract. So, when I recently got a new contract to work here at the school, I explicitly put in the contract (it’s a numbered item!) that I would have a cube available. How did you end up in that cube?”
That was not the impression I wanted to give our very good oral path instructor. Luckily, my appointment went well, I cleaned up, and evacuated the professor’s cube as soon as possible.
“We would really really prefer you get the radiographs before the day of boards, but if you have to do it, you have to do it. We’ll have a spot on 8th floor open for you to take x-rays.”
I breathed a sigh of relief, knowing I could update the day-of. It was time to go home.
As a general rule, I get home mid-afternoon and Mykala gets home late in the evening (9, 10pm-ish). However, Mykala didn’t have her evening class, so we went to Chipotle and had a great conversation about her career. (Takeaway point: you can go in two different directions trying to “do what you love”. Direction 1: You seek to meet your own needs. Direction 2: You seek to meet a need out in the world. The trick is to balance the two.)
We came home, and Mykala made vegan hot chocolate with chocolate salt. A few grains of salt are plenty for me, I think. I’m still adjusting to the “sweet salty” thing — I’d still prefer “all sweet”. We went to church for Ash Wednesday. Lit candles for loved ones who’ve passed. Came home and watched television shows on the couch. Nothing can be that bad when I have my health and some time to spend with my wife when we’re home in the evening.
We are five days away from my final final final (final) board exam: “Central Regional Dental Testing Service, Part IV & V”. In this one, I spend 9 hours at the school working on patients, proving that I can do selected procedures at an acceptable clinical level. Doing the procedures isn’t hard, it’s the proving that you can do them that can be tricky. There’s a lot of paperwork, and a lot to coordinate.
If your patient fails to show up, you have two choices: get them on the phone and offer to send someone to pick them up and drive them to the school OR find a patient from a “backup pool” to work on. You really REALLY do not want either one of these things to happen to you.
So, right now we’re trying to figure out who will drive which patient where, if needed… and if we will put a patient up in a hotel for the night, due to the risk of snow.
I am worried and frustrated that all I do is write in platitudes, and that the quality of my prose has stagnated at “barely mediocre” for the past 5 years. When ideas are flowing from my brain to the keyboard most naturally, I still seem to lose their essence and elegance during editing. (Or, I lose them completely when the browser crashes. I’ve got to stop composing in the browser.) Although I have done nothing to fight against these concerns, I continue to write here, hoping that I can break through to the next level of writing quality. Focused practice seems to be the only way to advance, and the stagnation in my writing quality has correlated directly with what can only be described as years of literary dilettantism. I will keep practicing, starting here:
During the quiet moments of my day, when the mechanics of life have briefly faded, and I’m left with my thoughts, I’ve lately been returning to the preciousness, the fragility, of our health. Humans aren’t just vulnerable to cancers, diseases, infections, but also to falls, collisions, lacerations. And so, all of our future moments grow from each moment of now. The manifold ways we may go are unimaginably varied, some spectacular and some monstrous. I wouldn’t trade this free will for any assurance of future safety, but lately I find my self acutely aware that lives don’t simply sometimes hang by a thread, but they are woven from them, each one fragile and each one finite.
This should be a sad thing, right? That no future is certain, that no life is infinite, that no thing must follow from another? I haven’t seen it that way. Being human, I do not have the capability to live every moment in the awe that should accompany the amazing realities of life, or this place, but I am now reminded to feel and to try to understand the preciousness of each beat of my heart.
That somewhere there is a clock ticking shouldn’t cause us to lament time lost, but to redouble our efforts to draw everything we can from each hour.
Early in the evening yesterday, I was tired. I hadn’t really had a good weekend of sleeping in, my sleep deficit was high. So, a little before 5pm, I went upstairs and went to sleep. 4 hours later, I woke up. Mykala got home, we chatted and ate, and I went back to bed to sleep for 7 more hours. When I sleep that long, I end up with a lot of REM sleep in the morning. Conversely, when I was quite sleep deprived during my first few years of school, I recalled my dreams exceedingly rarely.
So, yeah, dreams. I’m nearing the end of Walter Isaacson’s Steve Jobs biography, and I finished another chapter of it before going to sleep. Unsurprisingly, it provided the raw material for my morning dreams. What was surprising, though, was the quality: I dreamt some of the most cinematic, beautiful, affecting dreams I ever have.
With soundtracks.
The picture comes into focus: late afternoon sunlight streams in across a garden by the sea, silhouetting the balding head of a titan, struck down by cancer, little time left. This klaxon warning of the approaching end has only recently pushed him to acknowledge his family, yet his limitless commitment to his career never flags.
Really, this is just a slightly romanticized version of facts from the book. But shortly after, my dream shook free the facts and vaulted into imagination. The camera sprang free from executing simply a dolly-bound tracking shot — first, it looked as though it was on a jib, then became almost a virtual camera. The shot vaulted over the man’s silhouette, using him as a three dimensional pivot. The destination for the camera movement was, at first, the garden. The construction, execution, condition of the entire garden was not almost perfect or evocative of perfection, no, it was perfect in the way that you can only see in dreams, imagine in your mind. Every petal laced with dew, lit by the sun, every leaf alive and positioned exactly where it should be.
Some kind of impossibly haunting, bittersweet melody only possible in dreams increased in volume, and I was made to understand that this man, though not dedicated to his family, threw his every waking moment into perfecting these things that I saw. That garden, that walkway, that home. Down the each and every tiniest detail. Platonic ideals, each one.
He may not have been able to, as the platitude goes “take it with him,” but these things would continue in his absence.
“That’s omotenashi,” Thompson explains, “a kind of
hospitality that involves anticipating what your guest
needs.”
It’s interesting that I’m doing my best dentistry when I can tell that the patient needs a break to take a swallow, or would like to get right to the next filling. Anticipating what the patient needs is hard, but worth attempting.
Finished another root canal today, which means I can stop worrying about that person’s tooth. Wrote up an extensive treatment plan. The school is generally horribly inefficient — though it can be a great place to learn if only you have the right instructors.
Now, I’m at home, waiting for Mykala to get here. She’s at work until 10pm. We don’t see one another nearly enough: maybe two hours on a good day. Last night, she fell asleep in my arms on the couch. That’s my absolute favorite.
I’m relaxing on said couch right now, writing some code and listening to the Berliner Messe by Arvo Pärt.
I do weird things now, things I never consciously realized would be a part of my life. I clean trash cans. Sort mail. Go to the store to purchase toilet paper. Clean out the fridge. It’s fascinating that, though you have relatively little freedom as a young person, you have a very unique freedom from these adult responsibilities.
Nobody ever asks a child “why didn’t you add ketchup to the grocery list?” or “I hope you paid your bike insurance, otherwise you won’t be able to drive.” That’s a pretty unique freedom only afforded to kids.
My parents shared a deep desire to preserve this preciousness of their children’s formative years: “Your job is school,” they’d say, “you can work at a job when you are older.” By no means did this allow an abdication of responsibilities — I was still instilled with a potent work ethic and expected to do my chores on time and with a pleasant demeanor (not to say I was a paragon of virtue: I frequently struggled with the “demeanor” requirement, grudgingly carrying out tasks with a dark cloud over my head). But the delay of joining the workforce looped back into what I learned from my parents about money: don’t chase it. Save it. They never said those words to me, but instead lead by example.
These attitudes painted a bright line in my mind — there were things I could have and things I couldn’t. At 15, many of my peers were chasing cars. They’d work their summers away at the local Target, then put it all toward a car they wanted. Guess what? I wanted to do that, too! I wanted a car of my very own. Partly because, and I vividly remember this conversation: “girls won’t want to date me if I pick them up in my parents’ minivan.” No, girls didn’t want to date me because I was socially awkward, poor at eye contact, and introverted. It had nothing to do with the car. But anyway, for me, my very own car was on the other side of that bright line — on the “not happening” side. This produced a change in me whose value I didn’t realize — denying the possibility helps extinguish the desire. I don’t say that it automatically eliminates desire, but it helps.
This bright line uncoupled me from the material world during a good chunk of my formative years. Sometimes, there was nothing I wanted more than to reach over that line and grab what I thought I needed, but in hindsight I understand what happened. Instead of mindlessly ringing up goods under fluorescent lights during those summers, I was outside, enjoying the invincible bodily machine we get exactly one chance at enjoying: during our youth. I was outside, swatting tennis balls and mosquitoes through the long, thick days of July and August. Running around. Playing pick-up basketball until I couldn’t see well enough to pass the ball, then playing kick the can. Soaking up every last bit of it, not even going inside for water, gulping it from the garden hose instead.
Sometimes I think I should put more stuff on the far side of that bright line. Deny my striving, reaching impulses so I can settle back and enjoy what I have. After all, the siren song of Stuff is potent only in the present, its song never sounds sweet upon remembrance. The thing that makes me most convinced of that is this: when I take a walk through those summers in my mind, all the sharp edges have worn off. No fluorescents or cash registers. It’s just bright light, heat, youth, sweat, all mixed together in a hopelessly lovely jumble of memories.