almost, or less far

Today was productive. Both my patients left the hospital in the morning, so my team let me go in the early afternoon. I went on a run, took the exam and completed my evaluations and portfolio for my medicine rotation, scrubbed the bathroom, cooked dinner, watched The Office with J, finished packing for our month off, and purchased two Christmas gifts. I think I was in a frenzy for control and completion today in part because yesterday I was helpless. It was the hardest day of medicine thus far. I crumbled for a moment smaller than I needed, then crumpled the sad and angry and pain in my hand, and it's stayed there since. It deserves much more time and care than I can give here. But it has given a needed push to what I feel I might devote my next year to, a year we call the fifth year because it's an extra year to the conventional four-year program, but happens in between our third and fourth years of school, and is there for us to pursue anything we feel would be useful. And it emphasizes how much has built up over these months, and how much I will need this next month of school-free to process, even as I know this will only be the beginnings. The pressure inside looks forward to a short expanse of warm faraway blues and the effortless welcome of home.

thanksgiving in the hospital

I finished working at the VA hospital a few weeks ago, and started at the Yale hospital for my second month of medicine. I told my 90 yo patient in the hospice unit at the VA that I'd come by and see him every so often after I left the VA. The last few weeks have been so incredibly busy that I kept saying, tomorrow will be a better time. I finally went back today. He'd passed away.

This possibility had crossed my mind since I last saw him, but wasn't palpable; he hadn't been actively sick when I last saw him and people in hospice at the VA can have up to a six month prognosis. I'd envisioned visiting him for months. When someone else was in his room, I walked further down the hallway; maybe I'd remembered incorrectly. I walked slowly back and slowly found my way to the board with patient names and rooms, and slowly scanned it up and down for his name. I wasn't frantic like I might imagine I would be. Everything sunk slowly but not steadily, like steps down a ladder where you don't feel the space in between until you feel the suddenness of the next piece of metal. I walked around more trying to decide what to do, as if there were any options. I thought about looking him up in the computer to know for sure, but I couldn't remember the zillion passwords. Finally I asked the front desk, and they said, yes he passed awhile ago.

I wonder how it was, and most of all I wonder if he was sad near the end, whether he'd ever come to accept leaving life, a reality he was still mourning when I saw him last. I remember so much of what he said, not just because sometimes it was funny or sweet or touching but because always it was true. One night when I was on call and saw him, he was so surprised to have a visitor in the evening. He told me that it was late, someone would snatch me, and to be safe. Lying frail in bed the way he cared about my vulnerability took me home safe. Watching Jeopardy on television, he'd say he knows all the answers but "sometimes the game isn't there." Held up his fingers like he was sifting sand that wasn't there, and looked at me: see, nothing.

Needless to say I feel awful for not being able to say goodbye, for failing my promise. As students the one thing we have more than others is the time and the awareness for good intentions, and the one thing I feel I can offer is the drive to follow through with the intention to care. Yesterday someone reminded me that we can always find time for what's most important; it really is a matter of will. I'm sorry that I didn't have it in me, that I disappointed once more. Even as all these things give more reason to try harder, I sense that circumstances and fallibility align such that I'll disappoint again. One, try harder not to; two, figure out how to proceed once I have.

*
I spent Thanksgiving in the hospital this year, and while I complained about it and missed my family all the while, it was ultimately a source of gratitude. I admitted a patient with lung cancer that's spread all over; when I asked how he was feeling he started sobbing. Upon questions, he said he was worried about his family. Upon more questions, he kept repeating that he just had so much love for them. So much love, it can be hard.

Across the room from him is a patient our head physician is taking care of, I've gotten to know him since he's been here for awhile, and my doctor allowed me to be part of an end-of-life discussion with him. She says he's sweet, you can tell that life's been unfair to him. It sounds strange to call that sweet, but I know how she felt; I think she meant the hardship people carry that endears you to them. He has no car so his wife can't come visit him, and few resources, so that they couldn't find other transport. But on Thanksgiving his grandkids visited and they had a car, so his entire family came to see him. That was nice to see. It was also difficult. As this was the only time his family came, the doctors took the opportunity to speak with them about the same end-of-life issues that they'd discussed with the patient the day before. Like my hospice patient, this one hasn't let go yet, isn't ready to accept that his lungs, heart, kidneys are failing, when his thoughts and feelings are so clear and functional.

The Friday after Thanksgiving, I was on my way out of the hospital and I told him I'd miss him over the weekend. He said well then you should work over the weekend. I said I'll come by to see you. He said that's very nice but you won't. I laughed and said I would. I did, after I drove back from the VA after finding out about the hospice patient; a schedule and route I'd planned in my head this morning before I knew anything, and after I knew, I fought hard against using my guilt and obligation as motivation. And when I saw this patient who is not so well but still alive, and he said, maybe I'll see you tomorrow? -- there's no need for any other reason.

meat

Realized that in my last two entries I used the phrase, the "meat" of something. On both these nights I'd eaten ground beef for dinner; in spaghetti for one and in ma po tofu for the other (http://ineluctable.org/ieatfood/ma_po_tofu/ma%20po%20tofu-9.jpg). I hope this means substance is brewing.

essays

In the hospital I become acutely aware of what I'm good at and not good at. The latter list is extensive: picking up things on physical exam (I'm tone deaf! I can't tell whether that's dull or resonant. And why can't I elicit reflexes, ever?), immediate differential diagnoses, remembering yesterday's lab values, the finer points of the plan for a patient, interpreting radiological studies. Sometimes in these moments of incompetence (and also through the first two years of med school when I realized I knew about 1% of the basic science my classmates knew and was also 1% as quick to learn new information, resulting in an exponential lag between me and them), I think back to when my primary occupation was one in which I was relatively competent. That is, being an English major and writing about stories other people had written. There are a lot of ways I'm a shoddy English major (probably most of the ways one typically thinks of). I can't remember a lot of what I read other than how I felt about it, I can't quote anything, and I even get my eras of literature mixed up because my wayward sense of direction also applies to chronology before my time.

But I did like writing essays and like others taught in the form of close reading, could write a decent one. It takes me a long, long time to write one. I remember my college roommate pulling all nighters to write amazing papers, but it would be literally impossible for me to complete a good essay like that. This roommate visited recently, and we talked about missing essay writing. But even before that, when I screw up the many forms to be learned in medicine, I drift back to those days in our cozy house library, to when I had a system. I'd go through the text first: picking out lines, turns of phrases, images, structure of chapters--pay attention to why this word was chosen, what it conjures, where it's placed in relation to another. I'd type out all the quotes in a document; I enjoyed the false productivity of filling my pages with someone else's words and it helped me immerse in the text. As I did this I'd stream-of-consciously type my commentary on the quotes, and let my ideas and thesis emerge organically from what I found and thought. There's a certain rush after you've been chugging along, either with a boring stream of nothing much or with spurts of disconnected epiphanies, and you suddenly string things together. This begins a flurry of grouping related thoughts and possibly in a general order. And then the introduction can be written. Some say to save this for the end, but for me it was always the most time consuming and important, to know what I wanted the essay as a whole to say, and that's what the introduction does. Even as it sets up the structure for the rest, it's the most free flowing part of the essay too, because it doesn't require immediate, constant concrete evidence. It's just a promise.

In the midst of the forest of scraggly trees that is becoming a good doctor, it is sometimes nice to remember what it's like to take a complexity and reform a small part of it into an essay. An order with enough loose strands to keep it interesting and realistic but overall compact and from the bareness of your hands.

Here is one introduction from my favorite English class in college, a seminar on criminals and misfits in literature.

*
The Real Prison of a False Identity

“He who is subjected to a field of visibility...inscribes in himself the power relation in which he simultaneously plays both roles; he becomes the principle of his own subjection.” -Michel Foucault, Discipline and Punish (323).

The cover of the 1995 Random House edition of Franz Kafka’s The Trial depicts a man’s face, colored in red, behind black bars. The image of a prison is evident, but whether it is the actual solid bars or the rectangular segments of the man’s face that comprise the prison is less clear. Initially, the black bars appear to restrict the man’s freedom, demonstrating a traditional view of imprisonment. However, the red face can also be perceived as the imposing force that breaks the unity of the black background. This dichotomy is similarly reflected in the portrayal of the “gaze.” In “Panopticism,” Michel Foucault asserts that power resides in a supervisor’s ability to view a prisoner while remaining hidden from him (321). Because his face is visible, the man on the cover seems to be the prisoner. Yet, closer examination reveals that he is likewise the supervisor: the prominent eye amidst a hazy face suggests that he sees more than is seen. Both the criminal in the Panopticon and Joseph K., the protagonist of The Trial, unknowingly exemplify this duality.

A man confined to a cell in the Panopticon is highly conscious of his lack of space and movement. K. resides figuratively in a similar prison but with one crucial difference: he does not see his boundaries. Whereas the prisoner in the Panopticon knows that he dwells in the periphery of the structure, K. envisions himself at the center. Neither person realizes that he also assumes the opposite role. Because individuality connotes one identity, these opposing forces negate the existence of a self. Unaware of this duality, however, the Panopticon prisoner and Joseph K. harbor illusions of self-identity which ultimately facilitate their self-destruction. The imprisoning structure maximizes its power by instilling in the criminal what is otherwise typically liberating--a sense of individuality.

*

Looking back, I enjoy it as I did then. I also think, in the end, it is as limited as medicine can often be. The senselessness of semantics and vocabulary, creating complications, wondering what the use is. But each form of practice and expression pushes us to work beyond its parameters. I find that the real meat in writing an essay about a piece of literature or a history & physical for a patient isn't so much to come to a conclusion (even though we sound like we do and this is the stated, accepted and expected reason for doing it), as it is to grapple and stumble. I like how literature and medicine as fields complement, parallel, and contrast one another at different points in my life, my day. They can play tug of war with me the knot in the middle, or gang up on one side with me on the other, or it can be we three against who-knows-what. I'm willing to stumble a lot for that range of visibility.

thirteen virtues

In high school English class, our teacher had us list Benjamin Franklin's 13 virtues in the order we personally found most important. We then split the room into 13 areas and as our teacher counted down 13 to 1, we walked to the virtues corresponding to that number on our list. I think Jen mentioned these on her blog awhile back, and for whatever reason I thought of them again today. I don't remember distinctly what my order was back in high school, but can't imagine it's much different.

1. Justice
wrong none by doing injuries, or omitting the benefits that are your duty.
2. Humility
imitate Jesus and Socrates.
3. Sincerity
use no hurtful deceit; think innocently and justly; if you speak, speak accordingly.
4. Resolution
resolve to perform what you ought; perform without fail what you resolve.
5. Frugality
make no expense but to do good to others or yourself; waste nothing.
6. Tranquility
be not disturbed at trifles, or at incidents common or unavoidable.
7. Order
let all your things have their places; let each part of your business have its time.
8. Moderation
avoid extremes; forbear resenting injuries so much as you think they deserve.
9. Industry
lose no time; be always employed in something useful; cut off all unnecessary actions.
10. Silence
speak not but what may benefit others or yourself; avoid trifling conversation.
11. Chastity
rarely use venery but for health or offspring, never to dullness, weakness, or the injury of your own or another's peace or reputation.
12. Temperance
eat not to dullness; drink not to elevation.
13. Cleanliness
tolerate no cleanliness in body, clothes, or habitation.

Groups of values are easier than the ones among them; I can easily choose the top five, the bottom few, all that should go in the middle but between those it's difficult to sort out, though the top two are clearly the top two for me. Number 3, 4 and 5 seem equally important to me and that order changes in my head from moment to moment such that it drove me crazy just to get that order and I give up. Those top five are hardest for me to accomplish, along with a couple of the mid-bottom, like silence. There are several qualifications of these values that caused shifts in their order ("cut off all unnecessary actions"--does the necessary unnecessary count? "trifling conversation"--does necessary trifling count?...these things are part of happiness, silliness, wholeness). Also, cleanliness as #13 doesn't mean I endorse mess, but rather than cleanliness I think "order" is more...necessary. I agree with the latter part of chastity (and personally or for modernity, could replace "health or offspring" with "love or connection") but the meat of it is about injury, and isn't that justice. Temperance seems to be solely related to food and drink, and moderation everything else, so that is low. If I had to make it up on my own, it'd be a little different. But these are important.

Come to think of it, not too good at most of these. Reminder.

delirium

I met a wonderful 90 year old who came to the hospital for a serious infection in his lungs and blood, who would go in and out of clarity. There were moments where we could converse happily and he'd tell sweet, funny jokes; other times he'd blink slowly and stare blankly, and throughout his stay pain management was an issue. His intermittent moans of pain, physical and inner, gave slight insight into his distress and distressed his neighbors so that he was moved to his own room. Sometimes there was a physical source; other times it seemed expression for something deeper. A gland in his mouth was infected, making it painful for him to eat, dehydrating him. A nurse described his tongue as lizard skin, crusted over with yellow and white; his teeth and the back of his throat covered in the same film. I watched swabs be used to clean him, and I'd never seen so much foreign come from a person's mouth. Each day we'd check, and it looked better after that but I found myself compulsively swabbing him anyway. Brought heat packs and massaged the area, as recommended by the ear nose throat doctors, needing to do something concrete even though quite unsure of the use. In the hospital he began having pain in his rectum. He had diarrhea so much that the nurses put a tube in him ("fecal management system"), and we tried our best--creams, morphine, opiates delivered directly to the source of pain. Sometimes he cried. Not out of pain; out of sadness. He recovered from his infection, but with his continued delirium and inability to do physical therapy, the decision was made to move him to the hospice unit.

When we came to see him at hospice, he was clean. Every day now he says he has no pain. He draws our attention to his smooth skin, freshly shaven. One day he was in the hallway, and said he was waiting for a hair cut (a trim of handsome white peach fuzz). There are still moments of sadness, of his forming phrases--I don't want to leave you, I know all the answers but the game isn't there, I want to live, yes I know but more. And sometimes there are still hallucinations. But he is clean and without pain, and while we try to not let that be everything, we're grateful for that something.

Later we had a class on delirium. After going through a long list of causes of delirium (infection, decreased oxygen, too little salt, too much salt, kidney failure, dehydration, so on and on), our professor asked us how to prevent delirium. Antibiotics for infection? No. We drew a blank on how to prevent all the other causes, and he told us to give up because that wasn't how to think about it. Instead, he told us that studies had been done to show that when people are confronted with these illnesses, six things were shown to reduce the incidence of delirum: sleep, hydration, cognition, vision, hearing, and mobility. Ensuring lights out and reduced noise during hours of sleep, keeping people hydrated, playing daily memory games to maintain cognition, supplying visual and hearing aids, and having some sort of physical therapy--these things kept patients' senses functioning as their bodies fought sickness. Except for hydration, these things didn't target the direct causes of delirium; the people were still sick, but among those who were sick, their alertness and awareness, and thereby communication, interaction and general comfort, were healthier. So it makes much sense that a place like hospice, a place focused on comfort, kept his delirium a bit more at bay, and the idea of holistic care carries hope.

I've been reminded to take care of myself during the intense medicine rotation, and I think I have. It is true that there is less time and energy to go around during this rotation, but aside from a handful of tiring nights it hasn't been overwhelming. The time to spare does have to be allocated and delegated carefully, and after taking care of myself there's not much left over, but this also means that I've paid good attention to the things that provide care, and subsequently relished them. Everyone has their own six things to keep them sane, with some basics and some variation, and third year had me finding them quickly: sleep, cooking, running, friends, dancing, and places. Sleep goes without saying. Cooking at least once or twice a week reminds me that the days don't have to be rushed or prepackaged. The other week I sat down and ate without doing anything else, for the first time in I don't know how long. No company, no phone conversation, no tv, no internet, no reading book or textbook. Eating, and eating alone, allows for rest and like with any other isolation, for heightened senses; in this case, taste. I also associate a certain strange satisfaction with finishing leftovers, so even those days held a certain sense of still functioning. Aside from a two week hiatus during the height of a cough I still have, I've been running a slow six miles at least twice a week. So far this pace and time is suiting my schedule better than faster or longer, and the thing I now remember with running is that what happens on one run doesn't predict the next. Some days you just feel better and faster, and other days you feel like crap, and I've learned to not feel bad about the crappy days. On those days I remember that it's good just to be moving, and that it's enough to do it, regardless of how, and that the highs and lows balance. And this makes me feel better about whatever else I might be doing not so well at the moment, or at other moments.

As for friends, I continue to be glad every day for the people in my life, here and around, presently and from my past, and find that every interaction affirms the gratitude. I feel lucky to be in an environment where I feel comfortable with a good number of people; namely, a small place, as I think the number of people had a lot to do with some of my isolation in college. I feel lucky to find time for snippets and sprawls of conversation, for the emails and gchats and calls and meals and outings, to know people I really love, and love knowing, and love knowing of their presence. These tend to be with people with whom I'm particularly close, while dancing can extend to my class as a whole. It makes me happy to be dancing with my college roommates on another Halloween, with whom I've danced so many good nights, remembering we don't need much else than ourselves to be crazy and escape-happy. It also makes me happy to be dancing with a crowd of classmates, many I haven't seen in months, in a flashback of our first year when we danced almost every week. Several have distinct styles that are equally awesome and smile-so-hard-it-hurts inducing. And there's just something inherently fun and wonderful about a group of people going crazy for no real reason other than that it's inherently fun and wonderful. This weekend we celebrated two class birthdays, both with a lot of dancing, one more club-style the other a la karaoke, and I wasn't anticipating such fun before either, so all the more reason to relish. It was nice and hilarious to see A., usually not so mobile, moving with such adrenaline; M. singing everything from Beyonce to Barbie Girl; and clusters of us interacting with each other through something simple and thoughtless.

Places may be the most vague, and maybe that's why I need it. The day when it was decided to move him to hospice, we happened upon an ethereal cemetery on the way home from the hospital, and we went. It was palpably cathartic, and beautiful. N. had never been to a cemetery before, and I'd never been to one in quite that way. The air was autumn crisp, with much sun, and we came back another day for pictures, lying on patches of leaves, and re-exploration of its huge open fields, the rows upon rows of stone, slopey hills, and wheat like weeds brushing the pond. We've driven hours north for fall leaves to come across shallow streams we don't dare drive across, and few miles away for a coffeeshop with rain stained glass where we hide until it comes down too hard to wait any longer. Each time I feel the distance from here, from knowing there is more and that though he will be in one room from now on the space is wide.

seven days at the VA

Much can happen in small spaces of days, rooms, a smattering of people and conversations, a flow of observations and semi-blurred details. I've loved my first week on my medicine rotation at the VA, where the patients are generally older males with one shared experience that's as widely varied as the fingerprints they made us give in order to work in a government hospital.

There's a lot about this place that suggests a bit more space in a profession that can often feel limiting, restrictive. My first patient from day one was still here at the end of my first week. An elderly man with blue eyes and the charm to match, he gives me recipes, flirts every other line, does a little dance when we walk him on unsteady feet, and worries about his wife while he's the one in the hospital. The pace of the VA makes it so I can talk to him several times everyday, and so I remember he likes 2% milk and hates his oxygen, and he begins to know me as the one with cold hands and notices before I do a new scratch on my face.

He's been worked up and treated for four separate problems, one of which brought him here and three that have arisen or noticed since, covering his lungs, his liver, and his joints. He let me learn about so many different things in one person, and reminded us that care is continuous and multifaceted. We treat the cough and sometimes its persistent presence smothers the pain of a swollen leg; his pleasantness we enjoy disguises the weakness of his muscles after illness. I'm amazed at how my medical team considers all of these, amazed that openness can require so much more learning on my part, amazed that this comes not as a disappointing realization but as a worthy goal.

It's been a hard argument to sell, but I generally counter worries about the negatives of medicine by pointing out the appeal of a challenge. A geriatrician made mention of things worthy of fight, during a conference about how to talk to patients about end-of-life care, noting that often patients don't see their difficult treatments as burdensome, but as a measure of how much they're willing to struggle for their lives. She made many, many good points during this talk, that will contribute to concrete changes to how I'll approach this in the future. Key terms include outcome, uncertainty, and decision. Patients make decisions based on outcome, not on treatment, but doctors often present their options in terms of treatment ("would you want to be intubated?"). It isn't whether they want to have their chest compressed, but whether they want to live afterwards with 10% of the quality of the life they had before, or 20, or 50, or 75, or 100.

But even as we offer possible outcomes of the different options, we have to relay the degree of uncertainty we have. Because we want to be and because we want to make it easier on everyone, we seem more sure of our words than we can be. And patients need both what we know and what we don't know, because as the speaker noted, decisions change as the possible outcomes become more or less nebulous, more or less likely, more or less intense. It's hard, because people do seek something definitive; we have to remember that no one wants to make these decisions; we get so caught up in asking for their preferences that we forget they need to figure it out too. This isn't too hard to appreciate for someone who finds it difficult to choose a flavor of steamed milk, but this brings up again the need for continuous care, to which I haven't given as much conscious thought. As things go one way or the other, degrees of certainty change and so do how people feel, so this is an ongoing, organic conversation. The speaker also gave objective advice: have families hear from the patients themselves what they want; studies have shown that patient and family preferences often diverge in significant ways, and it's hard for families, amidst so much emotion and uncertainty, to make distinctions between their wishes and those of their loved ones. Ask patients not how they want to be treated, but what outcome could they live with and then how much they would be willing to endure to get there. Begin with their subjective goals, and fill in the technical details for them about how they could get there objectively.

This goes back to the fact that patients don't want to make these decisions, and the speaker made an excellent point about how we can share the burden. This point is very hard to conceive in our minds, and then very hard to articulate, and I respected her very much for forming the thought and then conveying it. I won't be able to do it quite as well, but essentially--she told us that we don't have to make people feel as though they're deciding about every possible intervention or treatment. Instead, they can focus on the parameters for how they want to live. This is something people often feel rather than rationalize, and the hardest part can often be trying to rationalize how we feel. Our role is to implement the rational, while leaving them full control of the emotional, with our rationale only taking reign after being guided by their feelings. We let them know that we understand that end goals for quality and quantity of life are individual, but we can design our options and path to lead to their goals, and once we know how they feel we can steer them to those goals, allowing them to feel both empowered and taken care of.

I started this post and didn't have time to finish, and it's now the end of my second week. I can't quite remember what else I wanted to say, and since then much more has accumulated, so instead of trying to backtrack I'll let it be.

quality

A card from college friend--
On the front, a little one plucking shiny hearts from a nebulous flurry amidst a black sky. "She sows seeds of kindness." Inside: "I'm still drinking tea & honey, but I've moved to Mission Bay. Sometimes, I miss the East Coast and the autumn chill and New England foliage. The beaches in Norcal are frigid too! What are you going to be for Halloween this year? I made a costume last year, but didn't have time to wear it. You should come visit me. We can go wine tasting or eat raw oysters. Ah, medical school gets so hectic, but someday we should spend a nice summer in a cottage."

An email exchange with med school friend--
Me: I got another pair of boots.
Him: Might I recommend you make a facebook album profiling all your boots. Can we do a double makeover. I'll do one for you and you do one for me. We can have a set budget.
Me: Sure, but how am I going to make you any better?!
Him: Your flattery doesn't fool me! There are many things that could make me better.
Me: What's the budget... I'm curious as to what you'd make me over as.
Him: A stop light. Budget of $30. On the cheap.

A self-described long and complicated email from high school friend--
Thoughts on seeing self and what's around; this natural openness to seeing being the reason for and result of never settling for the sake of ease. It's a struggle we value, and reminds me to always feel with awareness.

A stamp-sized letter from elementary school friend--
It's a real letter with a tiny envelope and a tiny stamp and a tiny wax seal. So small that it comes with a little magnifying glass to read the letters, though I could do without if I read hard, and this is how it makes me feel it's just for me. "We've been friends for 14 years, can you believe it?"

Someone recently said that I'm too trusting of people, which I think was a slight misreading of openness to how far people go beyond our impressions of them. Openness is for everyone whereas trust is reserved for quality, and it's knowing such quality people over the years that makes openness worth the risk. I'm getting my best friend from high school and my med school wife to meet up in California, which makes me happy like e.e. cummings when he says "we're wonderful one times one."

adult primary care

A good friend/classmate of mine said to me recently that it's hard to help people. Now in medical school, we realize how elusive is the goal for getting here in the first place, that catch-all "I want to help." It's true, what they say: doctors can do more harm than good, in the flurry of work they can forget to be considerate, and there are indeed many other ways of helping people, so how can that be the sole reason to choose this profession?

Primary care, what I think I want to go into, answers some of this for me in a somewhat ironic way, in that it's proven to me just how hard it is to help. There are two parts to this: the purpose, and the methods. As seems logical, let's start with the purpose, and then the methods get all mixed up in there. If I want to get as simple as it gets, I think of medicine as taking care of a person. Specifically, what does this entail? Concretely, to prevent and treat illness to the best of our knowledge and range of resources. More abstractly, it means knowing a person, from conversation (how to ask questions, how to listen, how to explain and advise) to examination (how to look at their eyes and check their necks, how to situate them in a chair or table, how to maneuver their clothing to hear their hearts). It requires all sorts of memory: science, and personality. You have to know the medicine, but you also have to know who you're treating. Is she a person who likes feeling natural and keeps medications to a minimum? Does he have to construct garage doors for a living and finds muscle aches more problematic than his high cholesterol?

Taking care implies maintaining a certain level of quality of life. My friend brought up the question of whether we help at all, because we treat high blood pressure and high blood sugar, without necessarily healing the people with these problems, without helping them literally feel better, without adding the degree of happiness to their lives that would give them real quality, not just lab values that fall within normal. In primary care, the visits are too fast, the issues too many. It doesn't always seem possible to deal with all the health within the context of someone's life and feelings. So this happens frequently--tests and drugs are thrown at people without them having any sense of what and what for, mood is ignored and if seen, dealt with solely through meds, and privacy and tact has been lost in routine.

But awash in this background, the potential of what we can do is bright. The doctor I work with knows every one of her hundreds of patients by face and by name like the back of her hand, not only every illness they've ever had but everything about their personal lives that they've shared. Illness is vulnerable, and so is the personal, and I'm amazed every day at how much people bare, how much my doctor absorbs and holds. Primary care means that you take care of people through everything, not just when they get sick enough to be in the hospital, and you know about everything they have.

Intellectually, I find it more challenging than it's perceived and admittedly, more than I expected. A lot of "interesting" or serious diseases don't present with symptoms that land patients in the hospital; it's often progressive worsening of these diseases that put them in the hospital, under diagnoses made by the PCP. My doctor makes an extraordinary amount of first diagnoses for her patients, only sending them to specialists after high suspicion of what they have or for further treatment, and also always following up with each of the illnesses that they have, remembering what they go to the GI doctor for one week and why they see the cardiologist the next week. She is the one to screen and frequently finds cancer, and she is the one who already knows through and through, the person to whom she has to give that information.

I also love taking care of chronic problems, like diabetes and asthma. People find this boring after awhile, but in seeing people live with these problems day to day, you get such a better sense of how they live and what it means to have a disease, than when you treat them for an asthma exacerbation in the ER. Having people share, directly and indirectly, how they cope, what drives them and what makes them weak and strong, has the most sustaining power of all the things we experience. There's the pure pleasure of knowing people, not just the substantial stuff like their families and what they do, but are they organized? absent-minded? anxious? laid-back? funny? shy? tough? We naturally live in spaces occupied by people relatively similar to us (when you look at the entire scope of people in the world), and this gives us the chance to not just meet, but know, so much outside of ourselves.

Even with the best of purposes, it can be hard to get through and follow through. My friend compared the bleakness of what we do, alongside the happiness he was able to induce by making his roommate a delicious fruit shake. The sweet made his roommate happy, and that in turn made him happy. Because we're treating things that people sometimes can't feel, especially in primary care and preventative measures, and because we focus on long-term goals at the risk of not seeing people's immediate feelings, often we don't think we're helping or even that our profession is designed to help.

But I've learned from people I respect (both people personally in my life and the health staff in school) that everything is felt, such that small pushes soften thick walls. Connecting to people in any way gives a certain something that's vague and difficult to describe, and it can't be validated with science. I thought about this when realizing that one of my favorite parts of this rotation so far has been the Vietnamese patients. My doctor has a surprising number of Vietnamese patients, such that I see on average one a day. Even for the ones who can speak fairly good English, you can tell that speaking in their own language gives them that something. And with everyone, asking a person what it is that they want, how has it been with this-or-that, being gentle and mindful with the physical exam (and despite previous thoughts that these should be obvious, I'm grateful to Yale for reminding us of this so relentlessly)--I've seen it go noticed, seen it make a difference in one minute of the day. People who are at first a bit standoffish, or skeptical, or gruff, start to open and give way, in their own ways. People notice when they're listened to, when they're respected, when they're given a little extra consideration, and whether you're dealing with disabling pain or you're a healthy person with the standard stressful stressors, it can give that certain something. And what I really like about primary care is the potential to be a continuous source of this something, a place that people feel is always there.

This all sounds very ideal, but I'm not oblivious to the obstacles. I've been more tired on this rotation than any other, including the rotations with longer hours and weekend work. There's more paperwork, more thought to legal issues and insurance, and we're always an hour behind in appointments. Being responsible for routine health maintenance AND chronic diseases AND acute problems that arise is exhausting. And as we've been persistently reminded in this time of supposed reform, most of what I've described above as fulfilling and helpful isn't billable, and doctors have to cater some of their time to what will enable them to stay in business. There are also the patients who make it hard for you to give, those who need more than you can give, and you will fail even those you can help. I've found myself frustrated by language barriers, difficult personalities, the chaos of papers and phone calls, my patience wearing thin in minutes, the openness I claim to want closing in on me.

So to help is hard, and to help in the particular niche of medicine is hard. But having seen that this niche is in fact particular--that it's true that you can help in many ways, but this way is a unique one that I really, really want--makes me transition from deciding whether this is something we want to do to considering whether it's something we can do. I've talked to friends in different paths of helping, and it seems that a common theme is frustration with how difficult it is, amidst systemic and personal barriers, to help. On top of that, I think that a lot of people want to offer this help to those from whom it's been unjustly withheld, so battling deficiencies with a deficient system makes it all the more frustrating. But this has made me think--all the more reason to keep trying, because there is such a gap, such need. If it were easy to help, it would become a routine that forgets to remind us of the need for patience and openness, of how much frustration and fatigue that certain something is worth. And I think, I hope, these things deserve more than our hard work; they deserve us testing our commitment by not letting the illogical and unreasonable and unjust and ugly push us away. I'm not saying that it should be this way--our healthcare system should be a million times more just, and we as individuals can always be more fair; it shouldn't be so difficult to give people basic needs and that something more. But it being hard is not reason to leave but to stay, and makes me think of when Obama said during his inauguration, that "what began in the depths of winter must not end this autumn night." I'm going to try to keep this in mind, as it just became October and already freezing.

weekend

The posts of the past few months have largely been reflective of the intense weeks, neglecting a part of this summer I've appreciated just as much--the glorious weekends.

Started a little early on Thursday, when J. and I cooked dinner (J. made a new wintermelon dish) for a classmate. She's the kind who is nice to everyone, so I've been friendly with her throughout school and have exchanged a few emails, but we've never talked for more than a few minutes at a time. So this was the first time I spent substantial time with her. She started conversation about real things like how this year has been and how the past couple years of have been, without my having to ask, and I was grateful to know that time and routine doesn't have to wear away natural openness.

On Friday J. and I went dancing, by ourselves. We dressed up, black on top and jeans on bottom, and shared the bottle of sweet summer blush I bought when I went wine tasting with the college blockmates in Long Island, back in June. Being hermits, we considered staying in after that, but got ourselves out. Our first and longest stop was at Bar, where I haven't been since first year. The cover was $3 and the drinks cheaper, so we made the most of it and danced on elevated surfaces, causing some guy to ask us if we were "girlfriends." We hopped to Black Bear before realizing we were danced out, and wandered over to Hot T's and caught up with a friend I hadn't seen since before the summer. When the place closed we migrated home, where they finished the summer blush and I ate leftovers.

After my usual Saturday sleep in, we watched District 9, which was jarring and pretty fantastic. Though afterward it led me to be my annoyingly argumentative self, we declared peace over Jamaican food at a place I hadn't been before. Then it was off to see a play with a friend I've seen more substantially this year. We saw Henrik Ibsen's The Master Builder, at the Drama School (kitty corner from the Repertory Theater). I didn't know anything about it except that it's about an architect (he never uses that word to describe himself), and it was good. More abstract and conversation than I anticipated, which allowed ample opportunity to be immersed in the set, the best part of the play. The floor was constructed like the side of a house, with the windows flat on the floor and the shutters opening and jutting up into the air. The roof extended across the floor into the back of the stage, and looked like it extended into the backdrop, a gorgeous swirl of blue that dipped into deeper blues. From the ceiling, another roof hung and represented the outside of the house; at times a strip of orange red connected the two parts as people entered or left, at other times one simply remained there as the other entertained the characters. Such that you felt in and out at once.

On Sunday, was woken from an unpleasant dream by a phone call from A., with whom I was supposed to have breakfast. We'd planned on going to a place north of Cheshire, but the directions and locations and our motivation were vague, and after a bit of haphazard googling and yelping, he says, let's just drive. So we drive down Whalley, and at the intersection with West Rock Ave, find a farmer's market. He sniffs from apple to apple, amusing other browsers who comment that they should follow his sense of smell. "That's all I know to go on." He teaches the names of vegetables, and buys a watermelon and heirloom tomatoes, and we purchase the most delicious almond croissant from a bakery claimed by Martha Stewart to be the best in Connecticut. "Martha Stewart never lies."

Various turns later and arriving in a small town called Bethany, in beautiful late summer/early fall sun, we decide to stop at a small farm stand to ask where there might be a diner. They tell us that their town has one diner--Country Corner--which is next to their one ice cream parlor, near their one pizza place. They mention one bank but don't specify a location. He looks around, grabs cider, and at the counter finds some honey that my roommate had requested before we left ("only get it if it's from the side of the road"). There he asks the woman about her life: what are the hours like? is it hard work? is it satisfying? She tells us that she works seven days a week; animals always have to eat, and during harvest she'll go 44 days before a day off. Her husband works 15 hours a day, and she 12 but not including housework, and their kids helps out. It's a lifestyle. Not just a way of making a living but a way of living. The pay's not great, but the eats are good.

In the car leaving the place, he hands the bottle of cider for me to open as he backs up...I hear a big clank, and we've hit a pole.

He ties up his loose trunk with some netting, and we continue to the Country Corner Diner, which makes me happy because diners are all the same with their big menus and cheap fatty foods and cushioned booths and stools. On the side I finish the stray almonds at the bottom of the brown bag in which the croissant was packaged. Afterwards we go next door for ice cream, even though I'm stuffed, because it's ice cream.

On the way home he says he likes how pine trees are poofy, and we pass the waterfall he likes; he says he wants to go but doesn't want to walk to it. "You could rest first"--he turns around. The narrow path, lined with lots and lots of tall thin trees, feels open with the windows open, and the temperature is so perfect I'm amazed. We park and chat intermittently, and then nap, and never make it to the waterfall. Sun spilling on face and soft breeze from one window to another, and far enough to hear the steady hum of water flowing past, too far to hear the drops clash--I feel surprise at the ease of sleep right before I fall into it.

only oblivion, and then love.

"Emotions have their narrative; after the shock we move inevitably to the grief, and the sense that we are doing it more or less together is one tiny scrap of consolation."

http://www.guardian.co.uk/world/2001/sep/15/september11.politicsphilosophyandsociety2

Ian McEwan wrote that before the lives of 9/11 victims were unbelievably and unmistakeably taken by those empty of empathy, love was their weapon and their defiance. What did they say in their last moments? I love you. I love you. I love you. Individually, again and again, until the lines and waves were cut. Only love, and then oblivion.

Today and the following days, we work backwards. For days her presence was thrown unknown. They kept talking about how small she was. Every day the thoughts sank further and further. When she was found, in actuality so close--we are reminded that in the aftermath of nearly unfathomable injustice, we are to "recommit" to what this crime takes away from us--peace. Not in the sense of stillness, but of jostling to find the natural and unlikely fits between so many disparate pieces. When they've been flung with such malicious velocity, we're startled back into this original purpose of making connection. Holding candles, the wax's heat slides down against the creases of palms, and I think if I multiply this by a number higher than I can spend my lifetime counting to, I might barely understand the pain. A low hum of amazing grace, that strange melody suited for grief and joy alike, arises from this crumbly white staining our hands. Squeeze tight all that's in us, and spread this tragedy's opposite.

To A.L. and her family and friends and unknown passersby, and to our own and to each other's, we love you. Love. Love. Love.

angry

At the United States border, driving from Montreal Canada, a friendly man with a Southern drawl asks us where we lived, where we were coming from, what we did, and what we were doing. When I tell him we're students in Connecticut, he asks what we were studying. "Medicine." A slight grimace, and "...Why?" We break into real laughter, not of the oh-you're-funny sort, but of the oh-you're-right kind. "We've been wondering that the whole drive here."

I'm generally not that negative about the harder, less ideal aspects of medicine, mostly because 1) I keep hoping that we'll fight against them, and 2) even when that fails, I feel lucky to meet such variety of people, to witness and understand subtle individual qualities, to get strands of stories even as most are still wound tight. But this doesn't mean that I don't see the shortfalls of what we've seen of medicine, though I do worry that my modes of adapting to or coping with them will lead to passivity and unawareness.

Anyway, I get disconcerted and quietly mad throughout the days. Most days I see it and think about it and tuck it away, for storage and memory and recall and change. This keeps me sane, and optimistic even as I try to stay open to how that optimism may pan out (ie, it may not). Some days it's much harder; while the mad remains quiet, it's noticeably present to me and it gets to the point where hope gives way to worry and slight depression about why things are this way. A friend of mine who saw with me some of the saddest parts of medicine I've seen, asked me the other week to explain my distinction between sadness and depression. There's probably a lot to it that I feel and haven't yet expressed, but the best I could do at the time was that--I find sadness in loss that is natural, whereas unnatural loss brings depression. Disease and death is sad; injustice and undue unkindness or undue absence of kindness (more common than the former), depresses me. This hole amidst a profession of caretaking can really get to us sometimes.

At times like this I look around for the ground that we're supposed to stand in; at this point in our venture I don't mind if it's grass sunken from continuous downpour, if it's uneven pebbles that uncomfortably dig, even fresh tar that traps. But then there are those moments I look and there. is. nothing. We reach and reach, and we're left drifting in some two-dimensional space where the ground of taking care has been replaced with simple blank.

What to make of this, at the end of a day when I don't want to be helplessly angry? As with other modes of sustaining positivity, I'm not completely sure but hope that--in this fury we'll throw wide heavy blocks at this wall with no floor.

adjustment

It came to me recently, in a very obvious, always-known kind of way, that my life constantly requires adjustment--mostly in the most trivial corners--partly due to general circumstances and partly due to individual personality. My bedroom, which is meant to be part of our living room, doesn't have a closet. I perused Craigslist fervently for a week to find a closet, to no avail, until I found a suitable IKEA one in the lobby of our building, being thrown out and given to me for free. This is important because this revelation arrived as I was poking a hole in the side of said closet, so that I could attach a string from its metal rod inside to a hanging shoe rack outside (this rack wouldn't fit inside my closet). J. was impressed by this improvisation, much more so than by the sheet I haphazardly tied to my blinds as a pseudo-curtain, or my water-damaged phone that I often have to coax into working with a peculiar mix of turnings on and off. Granted, much of me requires adjustment because I'm clumsy and break things, because I don't throw things away when they're no longer working to maximum capacity. But a lot of things are out of my control. For example, because my body is non-ideal in several ways, a lot of my clothing requires adjustment to fit right. I've been only mildly successfully creative with tucking in, sewing up, fashioning makeshift straps, with hand-me-downs and my mom's clothes and my own since I was little. I think safety pins are as amazing as Scotch tape.

Adjustment is a blanket term. Some things just happen. For whatever reason my Polaroid takes pictures slightly off-center, so after I've framed something in the viewfinder as I want it, I have to shift it ever so slightly to the left, to have it turn out on film the way I see it (never exactly, of course). Then there's my surroundings. Growing up with siblings who had it ingrained in them to find all the roundabout ways to get the best deals, from loading a dozen people into one hotel room, buying CDs from BMG (12 for the price of 1; with shipping and handling, this comes to $5 a CD, a third of the average price), and watching four movies in one day (illicitly, for the price of one). Communication in my family is tricky as with anyone's, obstacles in the form of language, culture, age, gender. Known as the stubborn, fast tempered one in the family, I wouldn't say I've adjusted well to all those obstacles, but I think they've helped me adapt over the years, and at the very least, I'm used to things not being straightforward. It's true that logistics and emotions then get messy, but over the past couple years of struggling with how frustratingly mixed up I can be, I've grown to appreciate both the downsides and the pure value of requiring adjustment.

Ali wondered recently how people come to be well-adjusted. The above are the trivial; everyone has their smattering of more serious things to adjust to in their lives. I don't think I can say I've had much hard to adjust to, or at least, I don't see it as such because they were my adjustments, and I don't think people can always see their own very clearly. One of the best parts of seeing patients is being reminded anew every half hour, of how people adapt to the inconvenient, difficult, painful things that happen to them. It's true that some handle it with more grace than others, and that sometimes people are irreparably changed in a way that is less adjustment and more damage. In light of that, I welcome all chances to adjust, if only to feel how very very far fragility stretches before it becomes fragile.

"we're all scarred"

"There are studies that look at the factors determining prognosis after cardiac arrest. The most important thing is to determine whether his brainstem is working. There are some reflexes we test, and he had two of them. When we shine a light in his eyes, the pupils get smaller. When we put water in his eyes, he blinks. Two of the reflexes, he didn't have. When we moved his mouth tube, he didn't cough. When we put water in his ears, his eyes didn't move in the direction we would expect. Based on these, his chance of recovery is small. I know this is a really emotional time for you. But I want to be factual, and blunt, and I don't want to lie to you. I also don't want to take away hope. We will check him again when 72 hours have passed since he collapsed, and after all the effects of the sedative drugs we've given him have worn off."

One is thin and able to stiffen herself before hearing, such that her back is as straight as her lips except for at the corners, holding herself against the possibilities, and never releases. The other talks.

..."We've heard of people who have strokes, and their brain has been damaged, but afterwards they recover somehow and are still able to use their brain...?"

"The brain can't regenerate. When one part of the brain is damaged, the rest of the brain that is still working uses other pathways to recover. With a stroke it is usually one part of the brain that's affected. The difference with him is that his brain has been globally affected by the loss of oxygen. We will have to see how much of the brain was affected."

..."We'll test him again on day 3...?"

"Yes." Turning to walk away, he remembers: "And don't talk in front of him. We don't know how much he hears."

****

He's been on three Vietnam tours, and when he returned, he was knocked off a telephone pole by a haphazard car navigated by two underage drivers who too small to reach the pedals with feet used their hands instead, hit by said car, and dragged by said car. He broke too much for me to remember. Eighteen months in the hospital and forty years later, he speaks to all of us with salted candor and a sweetness more tactile than his bristly face.

****
Today someone mentions him, "...if he survives and makes it..."

When we first saw him in the morning, his daughter is sitting next to him reading Harry Potter. We subject him to all sorts of random maneuvers; he's not completely aware but he tries to oblige. He really, really tries. When we see him in the afternoon he's still intubated and can't speak, and his arms are tied to the bed. He intermittently nods in response. He tries to write, but in the end there's no communication. We ask him to do more sorts of things, the majority of which the confines of this place restrict him from doing. Open your mouth, say ahhh. Squeeze my fingers. He lends himself to us, for whatever it is that we're doing. When we applaud a task completed (he keeps his arms up against our pressure, he presses his feet down on our hands)--"Great!!"--and break out unconsciously in smile, he raises and shakes his fists in victory. Sometimes he rewards us with a thumbs up in both hands. When we shake his hand goodbye, he holds on tight. When we let go, he grabs again and squeezes long and tight, and the brave tenderness wraps around. When asked if he likes the classical music his family has left playing for him, he smiles around his tube, his teeth releasing the plastic and revealing the dark space of his mouth.

physicality

Hepatic sinusoidal obstruction. Encephalopathy. Hypoglycemia. Sepsis. Hypotension. Lactic acidosis. Intubation. Multiple organ failure.

Prepositions strung these words together, a litany of the goings-on in her body and what ultimately took her life. Having a slight sense of what these mean, the words were bullets. Instead of blood, they drew salted water. It can never be as visceral as it is for a person whose physical life is slipping, but it reminds us that it is visceral, and today I felt that maybe that's part of what they mean when they speak of all this as a gift. We tend to polarize, sometimes focusing on the science and other times emphasizing the emotions, with elbows nudging us to meld the two. In between lies something less lectured, less considered, equally present--physical sensations, from which so much flows.

I started my neurology rotation today, and we began by observing neurological exams on a couple of patients. Neurology more than other disciplines draws quite a bit from the physical exam; you can often localize what part of the brain has been damaged by what part and side of the body can't move, or what the person can't say. The brain is the center of complex feeling and thought; it's also the source of tactile sensation and bodily movement, and to me this can often be the most touching loss.

One test requires a person to close their eyes. Without visual balance, one should still be able to center themselves. When our patient closed his eyes, I heard a gasp slide from the classmate behind me. When our patient closed his eyes, he swayed to his right side, and had we not known this to be a possibility, he would have fallen. One way to treat his condition, which causes vertigo because deposits in the inner ear dislocate and end up in the wrong place, is to rotate your head and roll your body in various directions, to shift the deposits back into place. We marveled at this cure, so simple beside the antibiotics whose names I can rarely remember and the surgeries involving anatomy I often can't visualize.

A bit later we observed our first stroke code, meaning the standardized protocol when a person is suspected of suffering from stroke. Aside from the acute event, she had a past medical history of HIV, hepatitis C, breast cancer with metastases to the liver, COPD, and obesity. The four of us, students with nothing to do but watch, huddled in the corner but there was no way not to be in the way. Red stained needles and whatnots fell to the floor inches from us and we were benignly smacked as people went to and from a corner of the ED made flimsily separate with shoddy curtain. As all this went on, a doctor spoke loudly in the woman's ear: Close your eyes. Open your eyes. Stick out your tongue. Say your name. Lift your arm, and hold it there. There is a point system that adds up a person's ability to follow these commands and thereby determines how dire the state of a person's consciousness is. There's no modesty, much noise, and carved out among this are the listless failures of a body to move.

For fatal cancer, for benign vertigo, for someone in limbo--it can be these everyday sensations that are stolen, and sometimes never given back. A friend of Natasha told us in Natasha's words how she felt about her cancer, and she said this when she had relapsed: lucky, without regrets or a wish to turn back time and eradicate the experience. Because of it, she felt beyond what she called earthly, and I believe that must paradoxically be some kind of sensation too. We talk a lot about feeling happy, what seems a communal and obvious and ever elusive goal. It seems to me that between the innate and fragile capacity to feel the "earthly," and the "beyond" that we acquire and earn--there lies the most honest, coveted desire to merely feel.

gone

During an episode of Scrubs the other day in which the show quoted the statistic that 1 in 3 hospitalized patients die, J. asked me whether I identified more with the characters now that we were on the wards. I replied that I haven't had enough comparable experience to really empathize more than anyone else. We were talking about this again today, and J. mentioned how she's learned that one's person tragedy affects so many, often touching far beyond those who knew the person.

Two and a half hours after that conversation we received news that Natasha Collins, a student in the class below ours who has been battling an aggressive form of leukemia, has passed away.

Several months ago her class began a national bone marrow drive to find her a donor, and the registry was overwhelmed by the response and support. Friends to whom I've passed on the message did the same, and followed her story as one intimate to them. Because of the concerted effort of her loved ones, and the accumulated reaching out of strangers, she received a transplant last month. Earlier this month, she battled an infection with more perseverance than any of her doctors had anticipated, getting through in a few days what we'll spend the rest of our lives questioning, imagining, considering, without knowing. Today she passed away.

As with the passing of Mila, who I also didn't know, during our first year, I'm stunned by how deeply we're affected, how communal a community is, and how far commonality extends. Back then I was also surprised by how much was connected by this tragedy, these ever prevalent and recurring themes that seep into daily life, thrown into hard relief by the suddenness of something gone.

At the end of the show, the three main characters are each faced with a patient in danger of dying; three split screens fill the television, and for a split second we wonder who it will be: which 1 of the 3? In the end, all three pass. Because statistics are just numbers, and some days it will be more and some days it will be less. Each time, it will feel much bigger than 1 in 3; each time it will feel like there has just been one--correctly so--and now it is gone.

As with anything gone, we're left to remember and to continue better, for what they've given in passing. No one day, no one endeavor, carries the depth of strength that she showed, that having never touched her, we could feel carried from her air to ours. And so there is reason to continue.

failures

During the first two years of med school, we went to the hospital each week and interviewed a patient. I liked the conversation and experience, and disliked never seeing them again, especially since the interaction was purely for the purpose of teaching us; we weren't involved in their care in any way. So it always felt a bit one-sided, and I mentioned a few times to people that I disliked the drop-in feel to it. I interviewed one patient who asked me to come back and say hello; he came back to the hospital regularly for chemotherapy. Given this chance, I thought I'd actually have something to offer. So I had my first (and only, at least before the wards started) second visit with a patient; we talked for a bit and planned to talk again right before winter break. But when I came back with chocolates to share for the holidays, he wasn't there; the chemo must've been re-scheduled. I checked one more time the next morning, but wasn't there. That day I went home for a few weeks, immersed in chaotic family friends and studies, and came back to more chaos of second semester of second year. In the midst of it, I kept thinking I should go back and see how he was, knowing that he was supposed to undergo an operation right after break. But I was perpetually tired and busy, and in the moments in between that I was lazy. So I never did see him again, and since his cancer didn't have a great prognosis I'm left with mostly doubts. I still have the chocolates, keeping them as both a trivial means of assuaging my guilt and a reminder of my failure to actually take the opportunity to do what I say I'd like to.

I was reminded of this today, when I saw a teenager with strep. Despite my very recent post about how we should read patients' charts, especially in primary care which is ideally continuous care, and address chronic issues at each appointment--I've already fallen into the established routine, of reading the two-line chief complaint written in by the nurse upon the patient's arrival, and checking the chart and problem list only when seeking certain information. Despite my confusion about why we don't ask about a patient's depression each time they come in, for something like back pain, I don't think to consider that each new patient I see might have similar problems. Despite my discomfort with purely focused physical exams and our school's emphasis on observation, I get caught up in the problem at hand and today, the red throat caught my attention more than other concerning findings. It's not that I missed them; I saw them, and for whatever reason, made in a half-second the decision not to inquire further. After the patient had already left, I looked at her chart again and discovered that this was a recurrent, chronic problem. To be fair, it wasn't listed in her problem list, an issue I brought up before, so I had to write that in, but it was in several notes from her previous visits. This is the sort of thing I've so recently thought and wrote so much about, the need for follow-up and detailed, wholistic care. I neglected the opportunity to address it, and not because I didn't have time--as a student the only thing I have more of than doctors and nurses is time--but just because in three weeks of outpatient care I've fallen into a habit of sacrificing depth. It's not that there haven't been models of comprehensive care; I've found the PCPs to be incredibly caring and mindful. It's the pace of things, and the necessary narrowing of things, that pervades all of current healthcare that has become practice even despite my mental barrier to it.

I hope hard that these experiences remind me not to repeat the same mistakes, and push me to try harder, because I'm disheartened that they happened so early on when we're supposedly at the height of energy and time. And it's okay, don't comfort me! I know we're all hard on ourselves; this isn't so much for the present me as the future me.

In the end I wrote out my first prescription (penicillin), asked our social worker to give her a call and follow-up, and stared at her chart for half an hour. It felt about as empty as not eating the chocolate.

pediatric primary care

This summer has been full of full weekends, and I've really enjoyed having time to spend with friends here and elsewhere. This weekend, I decided to take some more time alone bumming around, because things have been flying. In that vein, I decided to do better with more frequent blogging about daily life. I'm not capable of cultivating the stories yet, so recording will have to do for now.

I'm finishing my pediatrics rotation with two weeks of primary care at St. Mary's Clinic, a nice 45 minute drive from here. Primary care is outpatient, like your family pediatrician, where you go for physicals, colds, and non-urgent symptoms. Ideally, it's continuous, meaning that the same doctor takes care of you from birth to adulthood. Overall it's perceived as less intense than inpatient medicine in the hospital. The illnesses are more common and considered less complex than those requiring hospital or specialist care, though I imagine that with comorbidities there is a lot to consider as well. A lot of primary care focuses on prevention, chronic illnesses, and counseling, all of which the current healthcare system does little to support.

Most (95%) of St. Mary's patients are Medicaid patients, and the psychosocial elements emphasized in school come up often. In front of each chart is a "chronic problem list," to remind healthcare providers of long-standing issues that should be kept in mind during each visit. Among those I've seen listed include asthma, ADHD, depression. One of the things about primary care that appeal to me is this wholistic approach. I do see also that we're very good with recognition, but not so much with management. A lot of the more behavioral and social issues are beyond the scope of a PCP (or PMD, for primary MD...perhaps because of PCP the drug and PCP the infection), and even though the doctors here spend a great deal of time with their patients, addressing these things at every visit isn't always possible or done.

On the purely clinical side, I've enjoyed clinic. I've had the opportunity to consider differentials for chief complaints--shoulder pain, fever, headache. A little more than with the inpatient rotation, where much of the differential has been covered in the ER, here I get to ask the first questions. Remembering septic arthritis from gonorrheal infection, I ask a young teenager with shoulder pain about her sexual history, and had my first affirmative and conversation about sex with an adolescent. Remembering papilledema (swelling of the optic disk in your eye) occurs with increased pressure in the brain, I used an opthalmoscope to examine the eyes of a kid with headache, but still have trouble locating the optic disk (especially the left eye; my left eye is so uncoordinated).

With respect to the patients, outpatient pediatrics is a happy group. I get to marvel at beautiful newborns and infants; despite the familiarity of the idea of babies to most of us, I haven't actually spent much time with them and their concrete selves are a mystery to me--their fast heartbeats, compressible bellies, and funny reflexes. I like seeing the younger ones, because I didn't see any younger than five on my inpatient rotation, and I like the range of ages up to 19. The babies are miraculous, the kids adorable, and the adolescents fun to talk to.

As for the dynamic, sometimes it's chaotic, with stressed parents, multiple kids in a room, and language barriers. There are many limitations in terms of time, resources, communication, and records. Things that have been documented aren't always re-read when patients return, especially things that aren't directly related to current symptoms, and many of the indirect things that comprise a person are lost in past. Three different health providers spent a total of an hour with the family of a wheezing boy with new-onset asthma, whose 15 year old brother took charge of the family's health problems while the mom, having dealt with traumatic stresses in the past few years, seemed unaware and unable to manage this chronic problem. We try to address the long-term with preventative care for the future, but the past is important too. As a silent observer I kept thinking of B's recent emphasis on mental health and PTSD on his psych rotation, and how after understanding what's important, how difficult it is to incorporate it all.

I'm still really interested in primary care. Also in talking to B, who asked me what I want to do, I felt slight inadequacy in not having more specific goals and ways of achieving my broader ideals. But I am surprised by how much sense of things we get from weeks of experience, and looking forward to more to come.

communication

In skimming a description of what babies look like if their moms have had alcohol during pregnancy, I came across the word "philtrum." Wikipedia tells me that the philtrum is the vertical groove between the lips and the nose. It "allows humans to express a much larger range of lip motions than would otherwise be possible, which enhances vocal and nonverbal communication." It's derived from a Greek word that means "to love, to kiss."

One thing I liked about anatomy was learning the words for things, even if it doesn't often enhance your understanding of it. It kind of made my day to learn what the philtrum is, partly for that reason and partly because I've been thinking a lot about communication lately, and had already planned to write about it today.

So much that's important to me comes down to communication. The things I've been in immersed in as of late have been crowding my mind, all for reasons relating to this. With patients, learning how to talk to people from different backgrounds and struggling to bring down to earth those loose commonalities of health, respect, empathy. With friends, feeling such love for the big and small offerings of ourselves that we swap. With myself, reminding every day to be honest. With the outside world, fighting against the perception of people as simple to know, the categories, the dismissal of depth.

There is amazing variety in the kind of interaction healthcare providers have with their patients, and from the small bite of exposure we've had thus far, I've been better able to formulate in words what makes for real communication between people. I've always been awful at verbal articulation, but it's even harder than I thought to carry on a conversation that conveys both information and feeling. This morning my preceptor spoke to a mother in Spanish, who responded to a PA in Portugese, who then translated in English. The woman's toddler howled in tears. As students we have the perspective of naive eyes, and with those I wanted to put down what not to forget when our eyes get tired--

*Really wait for the answers when asking questions. Then listen to the answers, and ask follow-up questions. We pay attention to the factual answers about symptoms, but we fill in a lot of the how-are-you's ourselves without waiting for the response. *Speak half as slowly as you think you should, and remember that even in English we need to translate. I have two years of medical education (maybe half a year if you consider how much I retained) over most patients, and I have so much trouble remembering what was said, what people really have and how they got it and how they'll get better. *Acknowledge everyone. I've been grateful for the kindness that comes with a glance my way, sincere greetings, the shifting of objects to accommodate another's path. I think feeling each other's weight makes us more aware of our own, in a way that lets my hermit self retain its shell but also keeps us grounded in something more expansive. *Write legibly. Seriously, what's the point of writing something no one can read? *Move deliberately, not hurriedly. There's some illusion of efficiency dangling before all of us time-crunched busybees, the one that whispers to us to flip pages loudly, plop folders on the counter, walk briskly out rooms without closing doors, to speed-talk, to write illegibly, because it saves seconds, precious seconds. It might, but I've seen the steady hand say more and last longer.

These things can take a lot of effort (at all stages of the game--initially, once you get going, when you near the end). It's nice to come home at the end of the day or escape to during the weekends, to something I'm used to.

I have an amazing wife (my roommate; I can't actually remember how and when we started calling each other wife). She once said if this is really what marriage is like, it might be nice, and I agree. I'm always happy to see her, even if after we retreat to our rooms like the lone ones we sometimes like to be. She makes comfort Chinese food, including the best hot pot I've ever had. She's never once been mean to me, even when I'm neurotic or annoying or irritable. The few times I've gotten upset, she's sensitive, not defensive. She always tells me I look nice, and after a year of living together she's still considerate about washing the dishes. She listens to me struggle through being complicated, and what I see in me as the best and worst, she values. When I break things (often), she fixes them. She glued together one of my tea cups that I shattered. When one of the drawers detached from my desk, leaving a gaping hole, and the center slowly sunk from the weight of my books, she brought home another desk that looked almost exactly the same. When I complained about morning light waking me up and I was too lazy to get a face mask, she got me one. When I tell her an embarrassing story, she tells me one back. I can't describe how it works with a list of what to do and what not to do, but I know that a whole lot flows in the space between us, and each day we're at home I'm thankful for that.

Last weekend my college friend with the same name as wife came to visit New Haven, then I visited her in Cambridge. We don't see or talk to each other very frequently, but we caught up quickly at first and then slowly. She showed me the new stores in Harvard Square that replaced those familiar to me, and I had that sensation of things stretching and rearranging my skin. It didn't hurt like I thought it might. Instead it felt the way it does to see old friends. There's new growth to recognize, and old to unearth. J. has been through a lot and through it, became and remains one of the kindest and most genuine people I know. In reacquainting ourselves with each other's presence, I so admired the capacity to see and emulate good after having experienced not so good, a value I've only been able to articulate over the past few years. She's mindful of what's been given to her; yet she gives not out of obligation to give back but out of her nature. This generosity makes it easy to share, and in traipsing around our respective corners, things were exchanged through the pores and cracks--the confusion of the sliding doors at the subways where there used to be turnstiles, the way sunlight infuses the solid marble of the windowless Beinecke rare books library, the fatigue after walks in summer heat, the browsing for cheap clothes and purchase of matching bright checkered patterns, the fear of dodgy characters in the South End, the drives.

I know these are rare and to be kept close, because every so often I get mad at the tendency of the masses to paint over the cracks, the way I cover the sunken middle of a cake with extra frosting. Of the things that really bother me, among the top is people boxing other people up. I think of character as the full range of what a person can and will do and feel, and I've found that for most, this stretches quite wide. On a bigger scale, I dislike speculation about people from afar, the way classmates and colleagues are branded as such and such, concrete images built from smoke. Brushing aside mass perception--frequently misperception--can be tough in practice; I hate being misunderstood, and I hate that people settle for lesser explanations because the true one is complicated. So it's part personal, and it's part indignation at the substitution of gray for black and white. So I'm still learning to ignore all this, and rely on what I know, and in the end I'm thankful to be pushed to self-reliance.

On a smaller scale, but often a more potentially harmful one, is the boxes we create from actually really knowing someone. I do it too. I appreciate the positive qualities people attribute to me, but those closest to me have learned that nothing is defining, or I still remind them because I know it's hard to let go of what we've built up. Some who saw me as rational and together recognized a bit late how emotional and lost I can get with relationships. I don't blame them; I was stunned by it too at first, but once you step beyond borders, you need to make room. I do fight and I am mean, quite possibly meaner in those arguments than people you naturally assume are confrontational. This applies to more trivial things too, that don't directly bother me but indirectly do by nature of pigeonholing people. I do like some rap music, I've kissed boys recently met (for relativity's sake--two), I've stolen, I'm even more neurotic than you already know, I'm envious of others' talents, I actually do like some sports but have gotten myself stuck long ago in a self-conscious image of conventional girl and never developed the skills to now get over it, yes I do like to keep things but I throw certain things away. I like knowing these for myself because they've helped me give other people leeway, to know them more deeply, or to at least be more open to whatever they offer. This isn't to say that our understandings of each other are flimsy; they're obviously shaped from real things. I'd hope that some baseline qualities remain underneath it all, and I'm guilty of expecting people to know me well enough to predict or assume my actions or feelings, which might seem to go against this idea of malleability. It's more that things can be rearranged, and sometimes they can be torn down; you don't need to assume that they have, but you shouldn't assume they haven't.

I mentioned this to a high school friend, someone I've mentioned in my blog before as the one person in my life who is completely open to who I am, who is never surprised by anything I say or do because to her I'm capable of being anything. She wrote back something that I imagine she typed freely: "i can't even begin to tell you how much i feel i've been pigeonholed about issues and situations, over and over again, like ppl can't accept contradictions and opposites, and such a simple thing as change. their limitations end up limiting me, and i start being convinced of their perceptions, but i'm learning to be strong.. i understand ppl can be jaded. but i'm jaded too. i still think everyone is a mystery. fun mysteries."

The past few years have me seeing those fine rifts between nose and lip, that are attractive in the manner of the hollow that ends the neck, the slight indent that lends delicacy and nuance. I think of those babies whose moms consumed alcohol, whose philtrums are flattened as a result. Knowing what it is to be dulled, I trace these lines again from time to time.

summer / travels

The days have followed a routine these past days, of early morning heat collecting more and more moisture that it returns at night with heavy rain, adding some noise and light in the mix. It's not just that this weather doesn't bother me. I love it, and I can guess how you'll respond--but it has nothing to do with a principle of appreciating imperfection. I tolerate the dry heat of California and dislike it when it hits the high 80s, but I love East Coast summers of the sort we've been having in July (not the steady cold gray rain of June), where the sun fries the days and we walk through dense air that cools with rain. Coming home to a stuffy non-air-conditioned house, I open all the windows and wait, and the water comes down so thick and loud that it's like being outside, hearing the slickness of the roads and the miscellaneous trees and railings interrupting the rain's course.

This is the first time I've been on the East Coast for summer since Cambridge in 2005. I have so, so many moments I hold so close from that summer, of being able to live through the night in summer clothing, of escaping to the river after the stillness of lying in front of the fan in my dorm room, of getting drenched in post-humidity rain. At the same time this summer takes me back to a places nearby, it reminds me of summers faraway. I've been so lucky to have been able to travel the last three summers, the past two in Asia where the humidity allowed me to slip into the foreign surroundings. I'll never forget the calm rain of Japan or those crazy amazing thunderstorms in Vietnam.

People say they love travel, and I would say that too except that I think it's more that I love places. I like transiting too, and the movement, and places may not quite be the same without all that, but mostly I think it's what place has meant to me, whether it's everyday corners or momentary visits. These summers have been Greece in love, Japan in transition, Southeast Asia in adventure, Vietnam in solitude and history, cross country in anticipation, Eastern Europe in relief. I never write cohesively as much as I'd like about these bulks of time, because as always I struggle between wanting to experience so that I may express and finding that experience takes from me the time that a slow one like me needs to write.

I did journal through a lot of it. In college, knowing that I wanted to go there one day, one of my roommates gave me a spiral journal clothed in a red Japanese print. When I went to Vietnam, my best friend from high school gave me a travel journal (it came with a protective plastic bag, perfect to shield from rain). It's funny how there are places you long for, that you still long for after you visit; then there are places you long for, that after you visit you don't imagine in the same way again. Japan preoccupied a part of me for some time, but is a place whose significance for me changed afterwards. My desire to go there developed from images, and now afterwards I can't conjure images the way I can for some places. But I do recall a lot of what I felt there--the struggles of that time period and that trip, understanding and learning (still) to value the tough nitty gritty of connections to my family and friends, the long train rides, how much I appreciated really living with myself.

From that journal more than two years ago, a day in Nara--

So many of the temples, statues and buildings here were destroyed in some way (burned, earthquake, conquered), and then rebuilt. On the train back to Kyoto--walked a great deal today, as the sights in Nara Park are very spread out. A deer bit my shorts and ate my map. The people here are very proud of this ancient capital--Japan's first permanent one, though it was only capital for 74 years, before it was moved to Kyoto for 1000. That endears me to this city, to which the Japanese are so connected to, despite its short life as capital. I like the idea that something like that persists in communal memory. The largest bronze Buddha is in Nara, and I liked the temple it was enclosed in very much--the largest wooden structure (and the original was even bigger). The building had been burnt twice and an earthquake knocked the head off the Buddha and melted it. Yet these were restored and the Japanese are all over the place as a tie to the past. I respect that kind of respect for history and conceptual entities.

It was fairly late after I left the temple and it was a far walk to the last sight I wanted to see, Kasuga Shrine. By the time I got there it was closed but I hadn't planned on seeing the inside anyway. It turned out to be the best part of Nara.

It's tucked away in the woods and contains 3000 stone and bronze lanterns. They went on forever. It was pretty empty since it was early evening/late afternoon but the few wanderers around asked me if I wanted a photograph of myself. Even when people offer it's hard to accept but I appreciate the sentiment. For most of this I was very much alone, and I liked taking my time to walk around. The lanterns were beautiful--I can only imagine how other-worldly they'd be when lit. I'm not sure why they appealed to me so much. Thinking of it now, the simple idea of sources of light is appealing, but also that there's something so heavy and sturdy built to contain a bit of warmth and light--something fragile, really. Also something with a lot of power. Mostly I like the idea of holding and containing and protecting light. The idea that it's a delicate thing which requires defense and protection with bronze and stone. And there were so many.

I like old Japan a lot, even contrasted against all the modernity. It's a refuge, and perhaps will never again feel like the original, not a part of daily culture, but it stands as a backdrop.

Apparently from 768 to 1863, the Kasuga Shrine was torn down and rebuilt every twenty years, based on Shinto beliefs of purity. How funny that rebuilding is both a philosophy, deliberate; and an unplanned necessity.

pineapple

I cut my first pineapple the other day, in preparation for one of my favorite mom foods. I used the huge wide knife J. brought back from China, which compensated for my lack of strength but not for my lack of precision. I watched a YouTube video on how to cut one (it also told you how to choose a good one, but I was about a week beyond that step, as noted by hovering fruit flies). You start by lying the pineapple horizontally and slicing the top and bottom, which is about a fifth of the fruit (more like a fourth in my case; will remember in the future that pineapples ripen quickly). Then you lie it upright and slice the sides, turning every so often to get missed curved edges, cutting into the fruit deeply to remove all the peel--and also the spikes embedded horizontally in the pineapple. This surprised me, because the spikes lie deeper than I expected, meaning that I sacrificed a lot of flesh to remove them (they are interspersed every few centimeters). You're then left with a hunk of flesh, which you cut in halves, then quarters. I was further surprised to find that in addition to the outer inedibles, the inner core consisted of a tough spine, a pale white that distinguishes it from the yellow edible. You form slices of pineapple around this, and add the spine to your pile of throw-away.

I think about the knowledge and experience I'm working to absorb, the frustrations in the midst of it, a depth that swallows and scares and humbles, a depth that is uncovered to me, a depth that is brushed aside, a fullness that's both suffocating and liberating, the bareness when I return home to myself after a day of people. I think of the brutality of this art and science, and what's left after we cut, cut, cut. Her red hair, the stud in his ten year old ear, his long eyelashes that are maybe an illusion of a small baby face.

The pineapple was sweet, its flavor fragrant and its skeleton awash in my hands.

in review

Pediatrics was my introduction to life in the hospital, and while it gave me time to cook and exercise and spend time with my friends over dinner and at the beach, finding balance still meant too tired at night to flesh out the day. So as inadequately as usual, some snippets of a wonderful four weeks working with school age children (spanning ages five to eighteen, though the highest I personally got was thirteen).

*Getting personal with swine flu: It was splashed anywhere our eyes and ears fell upon, and overexposure created distance. It's true that it's not much different from your annual winter flu, but it gave me a chance to see its effects during a summer rotation, out of its usual season. "Asthma exacerbation secondary to swine flu" sometimes made up a quarter of the hospital admissions while I was there, and it was my first patient. Heard real "crackles" in the lung for the first time (sounds like undoing velcro). Flu is inconvenience for most; for asthmatics it means being confined to a hospital room where people come in and out armed with a gown and gloves and strapped with a respirator mask, a mouth mask, and a face mask.

*Listening slowly: A patient with chronic pain, in the hospital for an acute episode, was my foray into this world of subjective disease and healing. I learned that one way to measure a pain is whether a person is "easily distractable," and learned that distraction is a two-way street. My sickle cell patient read aloud deliberately and slowly. So slowly that I lost track of sentences and just heard words. She decided she didn't like two books after a few pages; she did finally like Nancy Drew.

*Witnessing what's worthy: I never found a way to the feverish little one, who was seen by so many different doctors and nurses and random people like me. Politely answered my questions, politely refused offers of games, always said he was feeling good, in between and during fits of cough and sputum. But he lit up for his older sister, my age. His sister who stayed nights with him and left at six in the morning to commute to her job a couple hours away, after having left a detailed note about where she left his Taco Bell leftovers and full of thanks for taking care of him. Who was so happy to see him improve, happy maybe more ingenuously than anyone I've seen. When I told him he was lucky to have such a sister, he looked at her, smiled a slow crinkle of lips, and said I know. How many kids know, how many grown-ups really know.

*Finding the elusiveness of observation: So many of the kids we saw had been through so much, for so little body grown and so little time lived. Being impressed by their toughness became quickly ingrained, such that moments of outright vulnerability surprised me, and reminded me to let things show themselves and to consider them as they did. Hearing a little girl say she was scared, pulling her hand away from the IV, hearing her dad talk about not wanting to put her through another sedation, stood in my mind beside the images of her walking steady and holding her head firm, despite physical oppositions--I was pulled back to what was there, reminded to be open and not escape into all else that had formed.

*Gathering more and more respect: I admired one resident's natural cheerfulness through sleepless nights and ease of humor, another's tough efficiency and caring demeanor with the kids over whom he towered, and the attentiveness of everyone on our team to everyone else, past the patients to everyone in the hospital regardless of role or involvement. I was more than awed by the expertise of the nurses, their quickness and ease of movement. Sometimes I want to be them, with so much concrete need in their hands, more presence to their kids.

*Memorizing contours from senses: We've absorbed so much from sight and experience, almost without effort, that I wonder why I've tried so hard all my life to pound all that's outside inside. I think I felt this most with my last patient, who sometimes slept with his glasses on, and whose facial features would register at odd moments. Long after the day was over I found myself worrying about how he'd grow up and whether he'd gain the comfort of a secure home, the self-confidence of good health taken for granted, and the weight to develop into a person that could physically stand among others. He smiled inadvertently and in surprise when I beat him in Connect Four, with a diagonal line he hadn't noticed. When I remember that, I worry also that his teeth might always be in the wrong place.

*Seeing people return: I've seen more than a handful of patients return: with the same thing, with the same thing but worse, with a different thing, for nothing at all. It is strange to feel some sense of accomplishment with sending a patient home, then to feel a sort of regression when they return, because it's the same person. There's a disconnect between the linear or even cyclical image we have of a person's life, and thereby our relation to it, and the connect-the-dots relationship we actually have with them. I was disconcerted by some of the discontinuity, some of the chronic non-health problems.

*Seeing people disappear: We talked about how we thought she would still be there when we finished our month of inpatient pediatrics. Each day hearing of her tiny progress, only to find out the next that she'd deceived. She wasn't healed when she left. Watching her leave that one day, one day earlier than had been scheduled earlier that week, many days earlier than in my mind--face and nails made-up and leaving me a sense of glittery blue even as I'm unsure that's what she was really wearing--I felt I understood so little.



A., who likes to sit next to waterfalls, talks often of being humbled by feeling his smallness among big things and his incapacity to know anything in this vastness, and recently listed a slew of good places to perceive this: in the hospital, in a warzone, in love. I hope that the next time I forget, I'll try to think on how the immensity of small things and small people made me feel small too.