autumn

I haven't kept up my monthly post for several months, and haven't kept up with my monthly goals, but it's been worth it to have a real summer. When I came back from vacation and started my new job on September first, I couldn't remember the last time I had been happier. I am so happy to be living in San Francisco, where I have my family and close friends from every phase of my life, seeing the city and bay every day as I commute to Berkeley, doing something I love that is the culmination of so much training but where I am still learning every day, in a clinic that feels just right for me. And hugely, at the same time, see M start med school and dive into his dream and experience the beginnings of this process. It's a crazy circle of remembering the beginnings and seeing the results, and I feel such extreme gratitude for every single thing in life right now. In the midst of it I've been thinking how to weave writing back into this texture and am working on new things. For now, just so much immense feeling for my first real autumn, post a real summer, into real back-to-school into-a-new-life feelings.

breaking habits

So I was going to title this "breaking bad habits," but I thought about it more and felt that context plays a big role in whether a habit is bad or not. Sometimes in certain environments you develop techniques to adapt, and it's not necessarily selling out or giving in, but finding ways to keep other parts of yourself in tact. That said, during residency I developed a lot of habits that I feel are now unhealthy for me and that I'd like to spend conscious time reshaping.

1. Making use of every minute.

In residency there was never down time. I always felt like I should be doing something, so that I could get home earlier, get more sleep, build up minutes to go do something. This was useful to me in residency because when there's so little free time, being productive while at work means you have more time for yourself later. Now, though, I have a lot time to myself and I find that I always want to be finishing a task or making a list of tasks. And it might be efficient, but efficiency isn't so much my priority anymore, at least not right now. I want fullness and surprise, life less edited and manufactured by me or by the system in which I function. I want not to cater constantly to "the system in which I function."

2. Not returning phone calls

In med school I talked on the phone all the time, despite seeing my friends all the time. In residency I was terrible at answering and returning calls from people. I've always been very good at keeping in touch, but when you spend so much of your time with people, and when you've been born a pure introvert and your environment has accepted and encouraged introverted qualities, it is hard to continue conversation after coming home. Especially because as an introvert your role in most conversations is to listen, and even when you love to do this, after you have spent 16 hours listening to patients, nurses, attendings, interns, fellow residents, you kind of just want to quiet down. By you I mean me. So in some ways not communicating with the outside world helped me maintain some reserve so that I could take care of my patients. But I am sorry not to have taken better care of the rest of my personal community, and am looking forward to reconnecting with the important people in my life.

3. Online shopping

I became a little addicted to online shopping during residency, because who has time to go to the mall? But I spent a ton of time repackaging and returning packages, and also way more hours mindlessly shopping to the point of headache, much more so than if I just went to the store. So often I bought a ton online only to keep one of the items. Of course, I said, I can just return them for free, always choosing places I could ship back for free (but often giving into Ann Taylor, feeling that I could return in store, which was always a hassle). But so it ended up that it took hours to buy really just one item. Despite loving clothes I kind of hate both means of shopping, but I do think that the intellectual feeling that online shopping is time-saving is (personally) not borne out by the practical ability to try on something and decide right then and there if you want it. Not going to lie, I'm still going to shop online but I do want to do it less and venture out more. Also, while I kind of hate the mall, several people have pointed out to me that it is a very different environment than my usual places of work, study, and recreation. And it is probably the most valuable thing to me to continually expose myself to life in all forms. That might sound like a stupid way to talk about a mall. But when you spend 90% of your life in a county hospital where, when you're talking in a narrow sense of function, half the people are the highest functioning individuals in society and the other half are the least, it is opening to immerse yourself somewhere in the middle.

4. Sacrificing sleep

M always told me that I should go to sleep. I'd want to climb, or read, or answer emails. He always said that sleep was most important and as much as I tried to listen, I always wanted to be doing things because so much of my day was spent NOT doing things, at least things related to my own life. Or, I'd want to be doing work-things because there was never enough time in the day to finish them and I wanted to be a good doctor. But I just slowly became more and more tired, and I don't think I can accomplish any of the above tired.

To that end, I'm going to bed at 10 PM on Friday night and am really happy about it.

the end of residency

I have a lot to say about completing my residency, but am feeling a little too under the weather to get into much. But wanted to put down some initial thoughts.

Residency was very hard for me, and I think there were a lot of things I feel I could have handled and balanced better. At the same time, as I am enjoying my time off in which I indulge in everything-for-me, I find myself increasingly grateful for three years dedicated to things outside of myself. Throughout it I felt that it was inhuman to force us to be so inattentive to ourselves. I still think this is true, but perhaps to a lesser degree as I think about how amazing it was to be so attentive to others.

During my time off since residency, I have been doing everything that I love and that had shaped my sense of self before residency. I've been active, going to yoga and climbing almost every day, running and swimming outside. I've indulged in the art of creativity of others, listening to hours and hours of music and audiobooks on end. I've been healthy, cooking meals and hydrating myself. I've gotten back into the flexible mindset of being able to travel, which I did in residency but always felt too narrow slipped between weeks of exhaustion. I'm looking forward to all the outdoors and travel I get to do this summer: lush Vermont and New York with M, Denver with my family, and a hiking/camping trip to Iceland with my brother.

I know too that as I throw myself into this, I'll wind down and find a place between these two extremes. This feels like a necessary time after a lot of sacrifice. And the sacrifice wasn't just of stuff-for-me; I was disappointed in how it also felt that I sacrificed some of my interests in medicine in order to do it. In medical school I was interested in geriatrics, palliative care, research and policy. In residency, I sought out very little outside of what I needed to do on a daily basis, and when I did have more time I spent it, reasonably and unregrettably, on the personal aspects of my life. So I hope that after some recovery I will be able to not only re-incorporate aspects of my outside-of-medicine life back into my identity but also revive the inside-of-medicine elements that drew me to it in the first place.

Throughout residency I felt moments of excitement about my growth as a physician, and moments of sadness over sometimes losing my sense of self. Looking back, this was most definitely a singular experience in which I lived what it was like to really put others first. I don't think it should be at the cost of one's own well-being, but it is true that you can go farther for others than you think and I feel incredibly full that I was pushed and was surrounded by others committed to the same. I'm glad that it's over, and I'm glad that it happened.

july 4th recipes

One of my top ten favorite things in the world: going to the farmer's market on Saturday morning and making food for the day with freshly bought foods.

Today for our July 4th meal I made:

1) Thai quinoa salad, recipe below. Such a pretty mix of colors, and I cooked the quinoa in a mix of vegetable broth and light coconut milk and the coconut really complemented the fish sauce and lime. M absolutely loved it, fish sauce and all. http://www.onceuponachef.com/2013/05/thai-quinoa-salad.html

2) This delicious marinade for chicken and tofu skewers; the spices were amazing: http://www.feastingathome.com/grilled-jerk-chicken-and-peach-skewers/

3)And veggie sliders made from chickpeas, from a friend's facebook recipe, which I've just prepared but haven't eaten yet so unclear how my execution of the recipe will be, but looking forward to it.

I love cheap farmer's markets on crisp weekend mornings, especially REAL weekend mornings where I'm not working, just SUMMERING. Happy fourth of July!

surprise / touch / inspire

In the last couple of days of my last couple of weeks of medicine wards at SFGH. I've been fortunate to have an amazing attending, an exceptional fourth year med student, great end of the year interns and then brand new interns enthusiastic to learn and dive in. I always forget how exhausting this work is, which I remember at the end of the day. I often forget how rewarding it is, which I remember at the beginning of the day. We've learned a ton of medicine, gotten to know great patients, and have had a lot of fun. But it is tiring and draining and I haven't had any chance to write. When I come home, I usually eat, shower, and sleep and because often there's half an hour between getting home and sleep, my sleep is fitful and more like an extension of day than a transition into night.

Needless to say there hasn't been much space for processing. I made time today to catch part of a lecture on finding meaning in medicine. She focused on trusting that the things we do matter, and make differences in ways we can't imagine or know. She also talked about reflecting each day on something that surprised you, something that touched you,and something that inspired you.

So for today:

Surprise: When we were called by a nurse saying that a patient had left his room and we went to his room thinking he'd abandoned the hospital. And instead found him covered in a sheet in another hospital bed in the hallway, stating that he was looking for peace and quiet, and promising that he wouldn't leave the hospital.

Touch: When an intern I had worked with a year ago and haven't talked to since, recognized my voice over the phone, and he later told my intern that he trusted my decisions.

Inspire: Supreme Court legalization of gay marriage, and the celebratory response. And also that we have convinced the proud and happy, but seriously ill, patient from the "surprise" anecdote to stay in the hospital despite his desire to leave and join PRIDE on Sunday, which he states will be "the biggest f---ing gay day in history."

last week of clinic

Last week was my last week at my clinic at SFGH, our county hospital, and while I feel ready to finish residency, I would stay in clinic here forever if I could. It can be frustrating, and can feel futile, and much less concrete than other parts of medicine. But saying goodbye to my patients and to the flow of clinic, despite there never really being a true flow to the hectic lumps and bumps of SFGH clinic, was and is hard. We often don't feel the role we can have over the course of intermittent 15-minute visits with people, but bonds form in all sorts of odd ways. And in particular for the patients who have few other support systems in place, I feel lucky to have been able to offer a base, as flimsy as it often was.

I feel so lucky to have borne witness to the paths of my patients. Over three years I've gained about a hundred primary care patients, maybe half of whom who come regularly enough for me to say that I know them; the other half I know of and for that I also feel lucky. I've seen a woman through the diagnosis and treatment of gastric cancer, and seen the strengths and vulnerabilities of her family through it, and seen the anxiety and worry that lingers afterwards. I've seen a man with physically debilitating inflammation of his skin and heart become emotionally debilitated by living with his illness, and see him slowly recover inside and out as he received treatment. I've seen young people my age whose characters have been shaped by a lifetime of battles fought by their bodies struggling through illness and bad environments. I've seen people with about a dozen life-threatening issues to their name continue to plug along, giving hope that we have time and space to tackle each in turn. I've felt so lucky to accept the stuffed animal, orchid, half dollar, scarf, and tears that patients give so, so generously in their farewell visits. Feeling that it is misguided to dismiss these physical gifts as material, because I know how it feels to want to be able to encase so much in something you can hold.

It's true that coming into residency you have little sense of what it is that you're actually going to do, and it's true that a lot of your visions are refuted by reality. But coming into primary care feeling that this is what I want to do because it's the most holistic perspective has proved itself right many times over. This doesn't mean that it always possesses the most holistic solutions, or even individual solutions to all of a person's needs, but it does mean that you see a whole lot of people. I will really miss the people who let me see them.

may

It's interesting that after several years away from the East Coast, my memories of May are what it's like over there--the beginnings of warmth returning. I was a little shocked by our cold San Francisco May, but it was a good month nonetheless.

1. Blogging: I had a lot to record with regular updates on weekly visits to the San Quentin prison. After those very full days that left us sapped of energy, emotional and physical, I was glad that I had a pre-formed space to dump some thoughts. This is something I'd like to return to with more nuance and filling later, so I'm very grateful to be able to put down a few of the details.

2. Recipes: My favorite recipe of May was an Indian fish dish that I was introduced to while I was in Uganda, and remains one of my top ten all time favorite dishes/meals. I tried at various times to replicate it, but there aren't many recipes for it and it calls for mint which I rarely have on hand and is a little pricey at stores to purchase for experimentation. But now that I go to the farmer's market most weeks, there is plenty of fresh, cheap mint, and cilantro, and I was inspired to try it again after finding this recipe: http://www.chillimix.com/indian-recipe/fish-and-sea-food/baked-fish-with-fresh-mint-and-coriander.html. It was very good, though I still haven't attained the divineness of what I tried in Uganda. It's hard to tell whether it's actual taste, or novelty, that I'm missing. Either way, I still loved the fresh mint and cilantro in this. I'm sure I tried other actual recipes to make my two new recipes a month resolution, but am forgetting at the moment, so will note that we also added the mint to our smoothies, making them newly refreshed (redundant? but seems appropriate).

3. Albums: In the vein of getting back into what used to be a major passion for me, I got recommendations from a music-trusthworthy friend and remembered why music is so awesome after listening to Future Islands (Singles) and fka twigs (lp 1), which had entirely different feels and equally unique. Also listened to Sufjan Steven's latest, Carie & Lowell, which felt like the return of an old friend.

4. News: I made significant headway on this, and then halfway through the month I discovered audiobooks, and I became really obsessed (they deserve a separate post). I think I will always prioritize fiction, and I think I will always feel a little guilty about that, and so will continue to incorporate real life into my knowledge base, but also with the acceptance that this is how I'm built.

5. Exercise: After incorporating swimming into my birthday party, I managed to swim twice and remembered how good it feels. Biking is something I still haven't incorporated back into my routine yet, but have decided that instead of making biking and running (which has been hard on my knees lately) long ventures, that I'll make my initial resolution (of biking, swimming, running, climbing and yoga each once a week) possible by biking or running very briefly before climbing. I'm hoping to make strides with this as summer approaches and work recedes...

insights

One of the things I love most about medicine is how much you learn from others, both patients and fellow providers. In these ways they remind me of what I love about books and writers--the ability to express something you've felt but have never quite expressed in the way that most embodies the feeling.

From a patient, on adapting to life in prison: "It's like when your body doesn't get what it needs for so long, it forgets how to ask for it."

From a physician, on advice to our graduating residency class: "Remember that you are not there to save them, but to witness them."

april

May flew by and forgot to post about April update on resolutions--

1. Blogging: This has been my favorite resolution because while I haven't written anything substantial, getting back into the mode of recording and reflecting has been good for me, and renewed the desire suppressed in residency to use words.

2. Recipes: The first week of April was blissful cooking, because I'd been working crazy hours for two months. I got buttermilk for some reason and made three new recipes with it: coconut buttermilk pancakes, buttermilk syrup, and homemade ranch dressing. We loved all of them, and I was impressed by how versatile cheap buttermilk is. M said it was the best syrup he'd ever had, and the pancakes were up there with our usual favorite lemon ricotta pancakes. These were a little more simple and less immediately out-of-this-world, but I loved the subtle coconut and the slightly tangy buttermilk that gave the pancakes a ton of depth.

3. Albums: On the flights to and from Amsterdam, I listened to albums that I'd listened to only passingly that I thought I would like with more time, and found that I did: City and Colour's Bring Me Your Love, St Vincent's Strange Mercy, and Cut Copy's Zonoscope. Favorite songs from each include The Girl, Cruel, and Blink and You'll Miss a Revolution. Outside of this category, I loved Passion Pit's new album. I remember first finding Passion Pit and that feeling of deep wonder that comes from unique beauty, and this album is more and more of it.

4. News: I had made a conscious resolution to get up to speed in April. Then my mom in the hospital, traveling, and recovering happened, and I got lazy. May's update will sound the same, but now I just purchased a diverse selection of subscriptions to feel like I'll actually be getting different perspectives and motivate me to be more well-informed.

5. Exercise: This resolution keeps fluctuating in terms of what I feel like doing. I don't think it's so much a resolution to keep me active since I'm pretty active, but to structure it in a way that benefits me most, because I've found that when I've had structure in the past I've been more fit with the same amount of time I spend on exercise now. But, I might've had less fun, so it's a give and take. Currently I've been focused on climbing the most, and getting better at lead climbing, so I'm happy with this goal of taking any opportunity to climb. At the same time I'd like to remember to diversify and keep myself limber.

And just like that, onto another...

therapeutic modules

One of the most powerful days at San Quentin yet. I spent the morning with a psychiatrist who provides care to the inmates in East Block. East Block houses Death Row inmates, otherwise known as the condemned. These patients live in small single cells, and are handcuffed at all times when they are not otherwise locked up. During a visit with a psychiatrist, they are placed in a clear cage so that the security guard can leave and offer a semblance of confidentiality. These cages are called "therapeutic modules" by the department of corrections, and are called cages by everyone else who actually uses them. These limitations made East Block distinct for me. I also had my own limitations--this is the only place in San Quentin others felt compelled to have me wear a security vest, which I have never worn before. In the same way that I feel lighter after leaving the prison and turning in my alarm system, I felt relieved to take off this weight after leaving East Block, despite its design for protection.

Many of these inmates have been here for twenty, thirty years. California hasn't executed an inmate in years, and is unlikely to ever do so. So these people are serving life sentences on what is called Death Row, and they have learned to adjust to a unique kind of life that I honestly never gave any thought to until I saw it in front of me.

There doesn't seem to be a set time for each appointment, and the loose wandering time that is locked up in our tiny interview room made me feel, in a small remote way, parallel to the inmate. He spoke incredibly insightfully and thoughtfully about his experience. "There are so many parts of yourself that aren't fulfilled while you're here, and you sit with your thoughts all day long trying to fill yourself." He spoke about experiencing by imagining experiences. "I thought, if I had money I'd go out and buy an expensive kite--the kind that costs a hundred dollars. I'd go out to the park and roll out the string until it flew high, so high you could barely see it...and then I'd pass it off to a kid. See the magical look in his face. Knowing that when I was seven or eight, that would just be magic." And for two minutes, he could feel the joy of this experience. Instead of being angry about not being able to experience it, he could really feel it. Then let it pass.

We talked about mindfulness, stories, and relapses. It's not always so easy to fulfill yourself without light to define shapes and senses. I thought about how I've never a thought quite like that one about the kite, an urge that captured quite that sentiment. I know it is too obvious, but it is too true that imprisonment opens parts of people that maybe everyone has but no one else truly experiences.

Unlike other times I've shadowed providers, these patients spoke to me directly. Asked me questions, explained things to me, looked at me instead of their actual doctor. They seemed to appreciate having another person to share with, to drink in the fact their words were being heard by a new person, newness being a rarity in this environment. One man sat quietly in the cage, and another pressed himself against the glass and stood on tiptoe, getting as close as possible to the small opening of air at the top. I've never spoken to a patient through a glass cage before, and never thought I'd feel such weight and closeness in that environment.

I spent some time in interdisciplinary team treatment meetings, where an inmate in the EOP (enhanced outpatient program for mental health) would sit at the head of the table and discuss his care with a team of psychiatrists, psych techs, and counselors. One felt he no longer needed these services. One wanted more services. Each meeting felt a little tense to me, partly because we were crowded in a room designed to house half the amount of people in it, and partly because each person in the room seemed to be either holding back or removed from the space. It reminded me of working at the Connecticut Mental Health Center in New Haven, where morning rounds which consisted of these strange meetings that I knew were meant to be patient centered but felt kind of like a court trial.

It's hard to write truly about these experiences, partly because I just want to record them before I forget more so than write about them well. But mostly because I don't really understand them enough to write about them, and I don't write well enough to write about things I don't understand. But it's this distance that compels me to stay, move closer, try.

ban the box

Another super interesting day at San Quentin Prison. When we arrived at the gate, the security guard took one look at my co-resident and said, "No blue." He was wearing blue pants, and since the inmates wear blue, this is a no-no color for any visitors into the facilities, the idea being that if we were being monitored from above we may be mistaken for an inmate and this could put us in danger. There was no leeway in this. We looked at each other and saw the other person rack the possibilities: gift shop? an employee with extra pants? sweet talk the guard? pull out the guidelines given to us that read "no blue jeans" and "no blue" but did not explicitly say "no blue pants"? Then someone suggested going to a nearby Target, which we did, where we acquired a new pair of pants, that we later returned after the day was over. Entering the prison that day I paid attention to their clothes, and found that their blue pants really did resemble what my co-resident was wearing, and it was interesting to consider how much that mattered, to distinguish ourselves.

We saw patients in the morning, which I generally enjoy for the exposure to the characteristics of this patient population (a lot of hepatitis C and liver disease, chronic pain, mental health in addition to the bread and butter diabetes and asthma) and for getting to know the individuals better. But the most interesting part was the afternoon.

We were able to attend a session in a class called Community Justice, that was started by a nonprofit called Alliance for Change. It is a 16-week curriculum where a group of inmates attend class four days a week to learn about civic engagement. It is organized by previous members of the course, and run and taught by the inmates to other inmates. Today's course was a debate regarding a real bill hoping to become a law, commonly known as Ban the Box. Simply, it bans employers from making an applicant check a box on their application regarding whether they had been convicted of a felony, until the applicant's full qualifications had been reviewed. If the applicant was then offered an interview, this information could then be attained, but not prior.

There were 22 inmates, and they were split into four groups representing 1) special interest groups against the ban; 2) special interest groups for the ban; 3) citizens against the ban; and 4) citizens for the ban. Each inmate had to go up in front of the large group and speak for two minutes about their position. It's amazing how much personality you can ascertain from two minutes, and I found it endearing when some of them were clearly very nervous about speaking in front of such a big group. Afterwards, the leader asked the group how many had never spoken in front of a group, and half a dozen raised their hands, which blew me away. I wasn't surprised rationally, but it was a concrete reminder of how different our environments have been, and it made me very proud of them for continuing this group and giving each other this opportunity. And some who had been very quiet during the small group discussions became clear and adamant during their moment, which was also touching.

I was also very impressed by how well the inmates argued against the ban. It was clear that the group was strongly for the ban, given their situations and experiences. But they carefully considered others' thoughts into this, and raised many strong points about economics, safety, and rights. They were also funny. One memorable speaker charged with speaking against the ban ended his argument with: "I ask those of you supporting this ban to ask yourself, would you want to work next to a creepy convict?"

Of course the obvious juxtaposition was that the group felt the very opposite of this stereotype. They were warm, engaged, very supportive and respectful of each other. And it seems that this is in large part due to programs and classes like these. I think the issues of what should happen in prisons and how and why are still very complicated, but there doesn't seem to be any question to this being good.

prisons

It took me forever to write this because this topic has become so extremely interesting to me, and there is so much to say about it.

In college I took two classes where I ended up writing an essay about prisons and/or prisoners--one in a moral reasoning (because they have to call everything by a different name; this is basically philosophy) and another in a literature class on misfits where I wrote about Kafka's The Trial. These were some of my favorite things I wrote about, mainly because I was pushed to think more deeply and in more nuanced ways about things I hadn't considered much, or had only considered in concrete ways. In the philosophy class, I wrote an essay about whether risoners had the moral right to revolt violently when certain rights were being withheld from them. This seems like it could be a straightforward argument, but being forced to use definitions and structured logic makes things both more complex and more streamlined. It made me think of a number of things more carefully. How is the prisoner different than the average citizen? How are civil rights different from human rights? The prisoner retains some baseline rights, but by definition is deprived of others, and also has more obligations to the state than the average citizen. But likewise, the state acquires different obligations to people when they become prisoners.

In literature, which in some ways is on the other end of the spectrum from philosophy, we also thought about prisoners, some more literal than others but the obvious one being in Kafka's The Trial, where a man is arrested for a crime that is never shared to the reader or known to the man himself. I didn't see it then but looking back, clearly there is a connection between the two disciplines in this topic--I opened my essay about the book with a line from the quintessential philosopher, Foucault: “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.” This was written about the Panopticon, which is a building designed to allow prisoners to be observed without them knowing when they are being observed. A guard can stand in the center and have view of all the prisoners around them, but they can't see him. So even if the guard isn't looking at you, you feel like it is and it's your own sense of this that limits you. I became really interested in how this sense of individuality--that things are centered on you, that you have this singular relationship with the guard, that you forget about the many other prisoners around you (because you also can't see them)--is a source of imprisonment. In our society, individuality is the means of establishing identity, but in this case it can be detrimental to your sense of self. It also poses an interesting contrast to the other essay, where prisoners are asserting their individual rights.

Anyway, that's all to say that I thought a lot about these theoretical and written arguments when I started my rotation at San Quentin prison a few weeks ago and then a few days after that when we visited DeLancey Street which is a residential program for ex-convicts and would-be prisoners. Obviously these are two very different structures for a similar population of people, so it made think again of the nuances and complexity of this slice of life (which is the totality of life for some).

Our day at San Quentin started with a brief tour and an orientation on the language, rules, and etiquette of the place. But before that, the day really started with getting into the prison, which wasn't the easiest thing to do as a "regular" person. You aren't allowed to wear a million different things (blue jeans, green in any form, yellow raincoats...), and I wasn't allowed to bring in my gray hoodie which I had only meant to help me ward off rain until inside. So I had to walk around in the rain and it was freezing. Then we needed to attain what looked like something I'd call tokens but they called chits, which are round gold coins that look like they were used from the time of Game of Thrones. There are various definitions and uses of the word chit, but I think the one that might apply here is "a signed voucher of a small debt (as for food)." We turn in our chits for our key cards, which let us into the bathroom and not much else. Then we needed our alarm systems--a device we were to clip somewhere on us and strictly instructed to keep it vertical at all times--because if it leaned at all from 180 degrees it would set off a prison-wide alarm that wouldn't go off until a guard found you and was sure it was a false alarm. This is meant to alert the system if you were to fall down as the result of an attack. This seemed a little scary, but then another new medical provider set it off three times that day, twice while leaning over and once while going to the bathroom, so it became a bit less intimidating and more annoying in how self-aware it made us. At another point during the tour, a guard yelled at my co-resident for not having his driver's license on him at all times and proceeded to remind him about a half dozen times that he needed to have his ID at all times. These sorts of things gave a small, strange sense of what it might be like to live there.

Then we sat down for an orientation to the prison. I'm not sure what I expected to be oriented to, but what happened was that we were oriented to a microcosm. We learned about the different units, who was housed there and why, and the lingo for what they were called. We learned about the leader inmates of the prison, called "shot callers" who will direct the behaviors of their fellow inmates, from what type of exercises they will do in the yard to organizing hunger strikes to drug dealing. We learned about which medications aren't prescribed in prison that we routinely use in the community because they have black market value in prison.

And we learned about the bane of the primary care doctor in prison: chronos. A chrono is a request from an inmate for some type of accommodation: a cane, a back pillow, and the most common and most coveted: the lower bunk bed. At first, doctors felt happy about their ability to give, and gave anyone who asked whatever reasonable equipment they wanted--and the lower bunk. So much so that they ran out of lower bunks, since everyone wanted one and the prison is already housing 400% more than its intended capacity. And so this has become a political issue in the prison, with people vying in any way they can to attain a chrono for a lower bed, and the majority of the visit between a doctor and patient can become about attaining this form. They liken this to pain medications in the community (which are very much limited in prison), where the relationship can become very strained over different agendas. So much so that they have devised a "Chrono Clinic," which sounds a lot like "Chronic Pain Clinic." No matter how we try to structure and shape an environment, common inherent tendencies arise from anyone and everyone.

When I left for the day, I found myself relieved to turn in my alarm system. I'd felt consciously limited by it all day, trying to make sure I didn't move in ways that would set it off and have an army of guards running to me. I actually ended up loving my experience much more than I'd anticipated, but I also felt more "other" than I anticipated and it was also nice to shed that when leaving. I had that freedom.

books on airplane

On the long flights to and from the Netherlands, I read two pretty good books. They both read quickly, and had some very good moments. They didn't blow me away but I enjoyed them, and wanted to record them briefly. I've found that even though I can recall the impression a book gave me long after I read it, I often forget what actually happens.

The Storied Life of AJ Fikry by Gabrielle Zevin This book is very popular, and was written to be a crowd pleaser. It's about a grumpy man who owns a bookstore, whose life changes when a baby girl is left in his shop. Everything is neatly tied together like a puzzle; there's a love story and each character is shown to be part of a bigger plot; but it's not meant to be realistic. It's meant to be a story, and I liked how much of the book was about the power of stories. Each chapter began with a reference to a story, book, or poem and the book was sprinkled with literary references. As common a gimmick as that is, I like it when it works well (love Gilmore Girls!) and I thought it was done well here. The book was also very funny, which I always appreciate because I can't write anything funny.

All the Light That We Cannot See by Anthony Doerr This is also very popular and is also a National Book Award finalist--and now that I'm looking it up, see that it just won the Pulitzer Prize. It alternates chapters between a blind girl growing up in Paris who flees after its occupation by Nazi Germany and a an orphan boy who grows up in Germany and ends up working for the Nazis by finding and hunting down radio signals of Resistance movements. I liked it, but I didn't love it and thought that another Holocaust novel it reminded me of was much better (Julie Orringer's Invisible Bridge). My brother recommended it as beautifully written but the writing didn't strike me as such. I did like how it explored a number of different characters during this time period and their nuances and circumstances. It made World War II and the Holocaust about very personal, individual stories, and I was invested in each of them, finishing the book in mostly one go on the flight back home. But I found myself thinking too often how the writer was going to develop the characters and connect them; it didn't feel organic to me.

I don't regularly read anymore, another habit that residency has changed, but am always reminded of how much I love it when I get back to it.

march

March was a blurry month that I am happy to say I will never repeat. Night shifts are fun in terms of work and horrible in terms of everything else.

1. Blogging: I did manage to sneak in four entries so roughly once a week, and am really happy about this resolution since it's kept me writing more and I just want to get back in the habit of it.

2. Recipes: Somehow I was able to try several new recipes in March. The theme was sauces, and I tried scallops with a white wine sauce and then to use up the wine, a salmon with white wine butter sauce. Loved both and made the scallops a few times since then. Also tried Emeril's creamy lime avocado vinaigrette, which we used on grilled shrimp. I love grilling and would like to learn more tips for this such as more vegetarian recipes and also figuring out exactly how long to cook things...

3. Albums: March was a month of re-exploring old favorites; sometimes I get caught up in exploring new music that I fall behind on artists I love. The inspiration was finally seeing Stars in concert, and hearing their most recent album, No One is Lost. Then also listened to Death Cab's most recent, Kintsugi. I've enjoyed watching their evolution over the years and I don't think that becoming more mainstream has hurt them; they have new sounds and I try not to mind when lesser known artists become mainstream, because after all when I love some form of art I want to share it. Also listened to Thao Nguyen's We The Common which came out a couple years ago; I heard parts of it at last year's Strictly Bluegrass and was reminded of how much I loved her.

4. News: I did better than in February, but if I had any free time on nights I was usually sleeping, not reading...

5. Exercise: I'm starting to think it's too ambitious to try to do all these different exercises in a week. I can usually easily run, climb and yoga in a week but the biking and swimming are a lot harder to fit in. I'm thinking about starting daily workouts from blogalites, continuing to climb and yoga when I want to since I do those frequently out of pure desire to do it, and running a quick mile most days.

Almost already time for the April update! Life really flies fast in these segments.

amsterdam

It’s amazing how many places there are in the world that I had never given thought to and then fell in love with. The first time I experienced this was Utah; it’s a special memory for me in how new and strong the feeling was. I was absolutely amazed by the beauty, and in particular that I had never even known that Utah had anything in it to see. Then we drove through open roads with red rock flanking us, and my love for desert began and since then moments in the Southwest feel like a gift. Nowadays I talk to people about Utah and everyone nods in agreement, but I had no idea. Even though I played no part in making Utah, I thought this must be what discovery feels like.

Now Amsterdam is another place like this for me. I’ve never thought about visiting the Netherlands, but I’ll pretty much travel anywhere new when the opportunity arises so when my brother suggested it , I got excited about the exploration. But I had no expectations; I had no image at all of what Amsterdam looked like. In fact, my image might have been a little dreary because my only encounters with it were 1) when I passed through it on our way to Prague and I was sad that I got an Amsterdam stamp in my passport instead of a Prague one, and 2) when I read Ian McEwan’s Amsterdam and found it to be too dark and boring.

But, I loved it. Of all the major European cities I’ve visited (London, Paris, Rome, Florence, Venice, Athens, Prague, Brussels, Vienna), it is my favorite. Of course there are lots of countries I haven’t been to that may have competing cities—Ireland, Spain, Portugal, Germany. But as of now it’s Amsterdam. For my brother it’s become second to Paris. While Paris has the unparalleled appeal of mind-blowing big-city glamour and culture, I’d argue for Amsterdam for the following:

1) The water: Water is everywhere, and even though I’d read about canal cruises, I didn’t quite picture how the city is built atop water. People live in houseboats, and on cobblestoned streets lining canals, and there are hundreds of small and large canals and bridges. It’s just really cool to see water everywhere, how the reflections change through the day and night, and see visually how the city has been built around this natural force.

2) Bikes: People bike everywhere, more than any other city I’ve visited, and everything in the city is catered to bikes first. It gives the city a very quaint, freeing feeling, and it also creates a different kind of city community feel when you can see everyone and everyone is outside while commuting.

3) Language: I haven’t heard much Dutch, and thought it was very pretty. It’s less harsh than German, less self-aware than French. Also, everyone speaks English with a pretty accent. I love that the people are open to using English and the idea of being bilingual in general. There’s something about language—that I’m sure linguists have described much more eloquently—that opens up more avenues of thought and experience. I took more French in college not so much to communicate (my accent is pretty horrible and I’d be afraid to talk to anyone French), more to learn about structuring sentences and learning words, exploring nuances that are beyond direct translation. I think it’s nice that people in the Netherlands are so open to this, where I’ve found other countries in Europe can sometimes distinguish one language as superior to another.

4) Low-key openness: I guess this comes from being a less popularized European city, but overall the city is much more relaxed and less touristy than others I’ve been to. Besides that there is a general openness that feels akin to the Bay Area (the first country to have legalized gay marriage; prostitution is a fairly respectable occupation with health benefits and regulation; etc) without some of the judgment against those less liberal that can sometimes be seen in the Bay Area.

Some downsides include that it's a little expensive like other places in Europe, and the food isn't as memorable as other European cities. But overall, it’s just a beautiful, beautiful city with gorgeous architecture (old and modern), and narrow streets tucked full of images that remind me of how much exists that I haven’t yet discovered.

vincent van gogh / anne frank

I've always liked museums dedicated to one person. My favorite museum in Boston, and one of my favorites overall, is the JFK Library. I liked how going through the building mirrored going through his life. I like the idea that one person's life can fill so much--not just because he or she represents a country, a movement, or values that we value, but also because that one person's individual thoughts, feelings, and experiences are valuable.

We spent our first day in Amsterdam in two such places, first the Van Gogh Museum and then the Anne Frank House. Both are pieces of culture that I was first exposed to and loved in high school. They (Van Gogh especially) were the type of things that you first love because it's the first time you discover the ideas they represent, then distance yourself from as you find that everyone loves them too and it seems too cliche, and then return to when you get older and learn that some times are just deserving of universal love.

We waited for an hour in the cold to get into the Van Gogh museum, and even though I knew it would, it was amazing how seeing his art in person oozes warmth back into your coldness. It was surreal to see the famous Sunflowers, Yellow House, The Bedroom, and Irises in person. I especially liked seeing these in person:

The Wheat field with a Reaper:

Van Gogh painted this from the view from the asylum where he admitted himself in the last year of his life. I’ve always loved his pictures of wheat, and of yellow things in general. It was his favorite color, and I think my love of yellow originated there as well (I’m not too original). I learned in the museum that he considered it the color of love. This picture always seemed so vibrant to me, and yet of course it has such dark and bittersweet undertones.

Red Cabbages and Onions:

I hadn’t seen this painting before, and I loved the textures and colors. This doesn’t do justice to the colors, either; and the real painting has also faded from the original purple hue of the cabbages to more blue, but the contrast between the blue and yellow is still really striking.

Gauguin’s Chair: I love this on its own, the weird and compelling mixture of colors and how he uses this object to represent his friend. I also like it as a comparison next to the painting of his own chair, which is less appealing to me as a painting and makes you think a lot about self-perception and judgment.

Seascape at Saintes-Maries:

This made me think of M. Van Gogh makes me think less of water and more of fields, so this painting was striking amidst the collection, and after my new experiences in the ocean thanks to M, I feel the waves in this more strongly. They really look how they feel.

I loved learning details of his life. I didn't realize he was so young when he died--thirty-seven. As my dad pointed out, he looks much older in his self-portraits. My favorite part was reading letters between him and Theo, his brother, and being able to see the fragile paper and handwriting in person. Sometimes, the skill with which he makes us connect to his images ironically makes him bigger than us. Learning about him as a person makes me remember that it's the expression of his feelings, not the feelings themselves, that are unique to him. And maybe the degree to which he felt things. But the base emotions--the desire to have his work be meaningful, his frustration with the struggle, his desire to host friends and be with others, the feeling of pride in certain successes--they are so accessible, palpable. As we ascended through the floors to the top floor that exhibited the work he made in his last year of his life while tucked away in an asylum, I felt so sad for his emotion and at the same time so grateful for his expression. And the latter, I think, is what he really wanted.

The Anne Frank House gave an even more visceral experience of being inside the physical place where such powerful writing happened. Similar to the Van Gogh house, we started at the base and ascended through the house, to the annex where Anne and her family were hidden for two years before they were caught and sent to concentration camps, where all but one died. I was pretty much bawling by the end of it. I read her diary in high school and identified strongly with sentiment of optimism and goodness in the face of such blackness. In the house I learned many more little details that made both her everyday humanness and her extraordinary power so poignant. I learned more about the extremes of people. The good: the four "helpers" who risked their lives every day to not only try to save their lives but to make their imprisoned lives more ordinary, devising ways to get the kids schoolbooks, and bringing them news of the outside world. The friend who tried twice to bring Anne a package to the camp. The bad: the woman who stole Anne's first package from her. Whoever it was who betrayed the family and sent them to their deaths. And how this all springs from the same roots, the same skin and bones that make all of us. Towards the end, in a display about the family's arrest, their individual portraits are posted and behind Anne's endearing face plays a small black and white film with images from Auschwitz--starved bodies died and others barely living. It is of course meant to evoke what it does, but it is also in the spirit of who she was--a bright spirit that wasn't immune to these horrors and not meant to cover it up, but to remind us of it and of what else exists.

The house remains unfurnished; it was the wish of Otto Frank, Anne's father, to remind us how empty these lives were made. The pictures that Anne pasted on her bedroom wall's remain, as do the pencil marks that track the heights of Anne and her sister while they were hidden. Also, there is the original bookcase that hid the entrance to their hiding home. I found that these inclusions were really fitting, and appreciated the amount of thought placed into what to keep, and what to remove. Anne's family didn't have that kind of freedom.

Again, I loved seeing the actual real pages of her diary. Paper can be so moving. Her handwriting was neat and in cursive. No one really writes like that anymore. I cried separate times on each floor of the house but like Anne wrote, as incredibly sad and hard and horrible it all is, the thing that remains heaviest is how much one person can affect others--"in spite of everything."

clinic tidbit

Yesterday I saw for the last time the very first patient I ever saw in clinic during my residency. I don't think she likes me all that much so it wasn't a particularly poignant farewell (Me: I know you don't like seeing the doctor, but I wanted to see you once before I left. Her: Okay. You're a doctor now?). But I love that after three years, I have a panel of patients who I know well, both medically and personally.

The other day in clinic, one patient gave me a stuffed animal and a silver dollar as a farewell gift, another brought me Filipino fried treats, and another asked to take a photograph together when I told him I was leaving. While the nature of this work relies on less concrete rewards, no one is immune to enjoying feeling appreciated.

stress rash

When I started my first month in the hospital as an intern, I developed a rash in multiple areas of my body. I'm pretty convinced that it was from the stress of the work, though at one point I was also worried like every other intern working at the county hospital about having gotten scabies from a patient. Luckily this wasn't the case, but this went on for several months and my skin started to darken where I'd been scratching a lot--over my back, thighs and ankles. I went to the dermatologist who didn't tell me much other than to use steroid cream to prevent scratching, because the darkening could be permanent, and that actually if the darkening hadn't gone away by now it was likely to be permanent. This bummed me out, as probably my favorite thing about my superficial self is my skin tone. But I didn't pay much attention since I don't see my back much, which is where most of the changes were. Recently I've noticed that my skin has returned to normal, so I suppose it just takes awhile to recover.

But in the meantime, as I near the end of my residency and just finished the two hardest months of my training, with 30 hour days and living like a vampire while working nights, I've re-developed this stress rash in a lot of the same places. I'm trying my best to de-stress and recover, but it takes time and I've continued to have the rash despite now being on a normal, human schedule. It makes me think a lot about well-being, and the importance of active self-care. Because during those hard months, you just tough it out and think that it will be over soon, but the effects can be sustained even after the struggle. Your skin might permanently change color from what you did to yourself for a short time.

As someone who does a lot of self-reflection and active planning, I tend to think that I can surmount most things with lists and motivation and hard work. As a result I often take on difficult things feeling like I can get through it and stay balanced and normal, be in perfect shape emotionally, physically, concretely and philosophically. Residency has humbled me a lot, showing me that it's important to be mindful of what I take on and how it's affecting me, because no one can balance their lives during residency. There are many moments where it will be pose barriers to your health, relationships, and self-image.

Moving forward, I think the most important things are: 1) treat your mind and body well after the rough times, to allow it to recover, and 2) look back and see the worth of the sacrifices, because despite the difficulties there is much, much good. So as I have faith that my skin will heal, I also know that any scars are remnants of my battles--battles with some false pretenses and empty goals, but also with deep learning and real effects on other people and my own growth.

stamina

Stamina is one of my skills. Speed and technique are gaps in my skill set, but I can do things for a long period of time, and sometimes this is adaptive and sometimes it's counterproductive. With one and a half more nights on my month of nights, I've pretty much run out of steam. But as I've been chugging along, I've spent some time every day looking back on what I've seen and done--reading about patients who I admitted to the hospital and seeing what happened to them after the one night that I spent with them. The list of patients is long, and I remember most of them well because I spent so much time gathering their histories and presenting their stories, and it's interesting to see how things continued after I initially saw them. As I go through the list, it reminds me of when I hiked Kilimanjaro after a month of an intense rotation admitting many patients. The last night of the hike was a 16 hour hike, with the first half being a night hike ascending to the peak. It was an eight-hour, slow and winding climb up the mountain, with everyone quiet and concentrating on their breathing as we battled the altitude, and to keep myself occupied I went through a mental list of every patient I could remember taking care of in the previous month. I thought about why they came to the hospital, their eventual diagnosis, how we treated them, how they left the hospital. This took several hours, matching the rhythm of our hike with the ticking off of patients in my head.

Thinking about it now, I think that everything we do is just about finding a rhythm to match the inherent rhythm of our lives moving forward. And like we often talk about, this can be arbitrary and probably no one pacing method is more valuable than another. To me it seems kind of just like a way to keep up with what's going to happen regardless of what we do. I don't know if it affects anything other than turning a monotonous, meaningless pace into something that can be measured, even if this measurement can be arbitrary. I think that even if it were true that there's no inherent value in any way we choose to live our lives, the reason we continue as individuals and as a species is that we find something to parallel each footstep we take.

inhumane nights

Most of my time in residency has been spent at our county hospital, with a few months at our university hospital. I love the county and it's where I feel most at home. This month, working mostly night shifts, I've spent most of my nights at the university hospital, which I also enjoy, for different reasons. It is pretty amazing how different the two hospitals are, and I feel lucky to be able to experience both. Because of how different they are, everyone has strong feelings about which hospital they prefer. Thinking about the comparison makes me reconsider our definitions of misfortune and suffering, and our subsequent responses of empathy and connection.

There are definitely things about university patients that make them more readily relatable. For the most part, they are what people call "normal." They are generally employed, have supportive family, and can tell you a coherent story about their symptoms and their medical history. This is what people imagine when they imagine patients. And here, many of them have life threatening illnesses--advanced cancer, organ transplants, rare immune disorders. Many of them have had vibrant, successful, active lives, with strong professional and familial ties; people who write, research, travel; who have been doing pilates and karate and go camping. They are most often kind to us, and grateful for our care. So it is always very sad to see them face an acute change. All of the sudden, a man stops being able to swallow solid foods and is diagnosed with cancer of his throat. All of the sudden, a woman loses her memory over the course of a few months due to a rapidly progressive dementia. For these people, we relate to the people they were before their sickness, and can imagine the difficulty they face, and for me they are the ones that instill a familiar ache in the center of the chest, wherein resides what's closest to us.

This makes me re-frame the patients at the county hospital. They are often difficult to attain information from; they are usually less functional, less engaged in society, or engaged in a part of society that their providers have never lived in. We often think of their ailments as self-inflicted, such as drug and alcohol use that then predispose them to infections and withdrawals. It's difficult for us to see the people they were before these gradual, chronic conditions. Seeing the same patient over and over in the hospital for the same thing makes us more familiar with the illness but more distant from the person, as we consider futility in a way that is different than caring for a person with life-threatening cancer. And it would be dishonest not to acknowledge that some of these patients are less pleasant to us and often present behavioral difficulties, and are less able to see how hard you are trying to help, and less able to understand our own challenges as they are facing theirs. It takes real, hard work to take care of patients, and we are overworked, and when you are both overworked and feel like there might not be much purpose to your work, this fosters anger and resentment and ultimately distance.

I don't deny the differences, or deny that I respond differently to these situations. I do want to challenge myself to consider the similarities, to consider that so many of the things that make our lives physically and mentally challenging are beyond our control, and that somewhere in life we are very similar. Some people diverge from general commonality before others, and sometimes the source and timing of divergence interferes with our ability to relate to them. This is sad to me, the loss of a person's potential to become tied to the rest to the world. There are a lot of barriers to feeling this loss in the center of the chest the way we do with others; very real, understandable barriers like harsh words and violent motions and inconveniences to our own lives.

So I recognize the tangible differences and feel viscerally the differences in how I emotionally respond, intuitively. I do think that our intuition can be malleable, and that with thought, exposure, and practice we will come to intuitively relate to others' suffering as what could be our own, despite how much separates us. This isn't to say that I'm immune to the barriers; anyone close to me can tell you how unstable, distant, irritable and devoid of empathy working these hours has made me. And so in some ways as I advocate understanding for others I'm also asking for some myself, and maybe that's the way to stay connected to a circle of commonality.

young

As I sit up at night, trying to adjust again to a night schedule after a couple days off, I feel the hours differently than the day. Overall this month has stretched out very slowly, and it's made me think about time more. Even though the time feels longer, it feels less full since I'm mostly just working and sleeping. So I thought it would be a good time to write about thoughts I had when my life was more full. I remember feeling great after coming home from a short trip to Denver this past winter, when I went snowboarding in beautiful mountains with my brother, and telling M that it gave me a real sense of three things that keep me feeling young as the years past--

Movement. I think feeling the power of your body to move, especially as your body experiences changes as you get older and you start trusting it less, really does keep you feeling young. As I get older I find myself trusting my body more. I know it better but I've learned to adapt to its changes as I go along, and this combination makes for an exploration that keeps me learning more about what I can do. And it makes you feel both undifferentiated and developed--undifferentiated in that you can do anything you choose, and developed in pursuing different paths.

Nature. Being in diverse natural environments brings a freshness that can be stolen from our reserves as we sit working inside. It's one thing I am consistently grateful for, the opportunity to really be surrounded, immersed, and loved. The strength and kindness of landscapes mirrors everything I want. And I love them all. Deserts. Mountains. Oceans. Streams. Forests. Caves, valleys, canyons, volcanoes. Snow, blossoms, foliage, dry branches. There's just so much, and I think that what really keeps you young is the depth of wonder.

Doing new things. I think this is something I really appreciated when I learned to bike and swim, not just because these things are associated with youth and that's when normal people learn them, but because as an adult I could really appreciate how new the experience was. And it made me feel young, completely apart from the association. The sensation of experiencing something really different from what you've done before again brings you back to that sweet spot between being undifferentiated and developed, that sense of potential and achievement and boundaries still untouched.

february

Last month's update on my resolutions, while trying to stay up and on my night schedule this month:

1. Blogging: This was the one resolution I was able to fully keep, and glad as it was a really important month for processing. There was so much more to write and process, but I'm glad that I didn't let the intense ICU experiences pass me without some recording. That was a singular month in my life, and even if experiences can never fully be encapsulated I'm grateful for the means to track some part of its trajectory.

2. Recipes: I wasn't a big fan of the two new recipes I tried this month, though M was. The first was a dessert that sounded like a dream to me: baked croissant french toast with lemon cream cheese(found here: http://www.everyday-reading.com/2015/02/baked-croissant-french-toast-with-lemon.html). It looked so good, and I made it for our anniversary. I found my result to be a little too soggy; luckily M thought it was delicious and finished most of it. I would try it again, making sure the croissants are more on the stale side and also actually following the directions about either refrigerating it or letting it sit for 30 minutes, because I think that would congeal things and make the bread less soggy. The second recipe I tried to make was an adaptation of a restaurant dish we absolutely love--the Cajun shrimp from Cha Cha Cha, a Cuban tapas place in the Haight. I found someone's attempt to recreate the dish: http://www.epicurious.com/recipes/member/views/cha-cha-cha-cajun-shrimp-50041610. I didn't think it tasted anything like the original, and this may be because I adapted the recipe a bit, but again Mark liked it a lot and said it did taste similar. I would try it again, making sure that I use sweet paprika (ours was smoked), and also a dark beer for the base (we only had a pale ale). I've still not quite learned that the details in cooking do matter, and that using substitutes requires a good understanding of what taste each ingredient is being used for, and the nuanced difference between ingredients used for particular bases and flavors. I think that's where the difference lies between a good and excellent cook, and while I'm content with being good enough to follow directions, I'd like to develop more of these skills. In any case I feel lucky to have tried two recipes at all, because I basically didn't cook at any other point in the month.

3. Albums: I didn't have much spare sitting time to listen to music, so a couple of these albums were half-hearted listens. But I did get to fully absorb Bjork's Vulnicura (was so happy to hear about this early release from wife). I think Bjork is the most creative artist ever. I still remember the moment I fell in love with her: seeing from a far distance her tiny energy bring to life a Coachella stage, amazed by how much power such a small woman could carry, and then going home to listen to all her albums, each one uniquely creative and inspiring. I can't even describe how much I admire her, how she instills this incredible sense of how amazing people and the world can be, by showing us what we are capable of. Anyway, so anything else really has no chance of standing out even if I had been in a more clear state of energy to listen. But I did try to give Lost in the Dream, from the War on Drugs, another chance because I've heard so many good things about it, and I can't say I'm that crazy about it. I think it's okay, but it hasn't blown me away yet. I also gave Viet Cong's self-titled album a quick listen, though I really hesitated about the name for obvious reasons. I cringe to think of what my dad would think, even understanding rationally that the name obviously isn't an endorsement of cruel communist politics. Anyway, they sound a lot like Interpol so I enjoyed it and thought it was a well-done album, though again didn't fall in love. There's always Bjork.

4. News: Just have to admit that it was no surprise to me that this fell completely by the wayside. I don't anticipate March, a month I'm working mostly nights, to be much better, but I will try.

5. Exercise: Sadly, I struggled with this one and it made me really grumpy not to have time to do the things I enjoy. I usually had to sleep soon after coming home from work most nights, and after 30-hour call days I never had any reserve to exercise. I managed to climb twice, go to yoga a few times, and run a few times. I only managed one week where I accomplished my resolution of biking, swimming, yoga, and climbing all at lest once in the week. And I'm pretty proud of achieving that once. Again, March doesn't seem optimal for this, given that being up at night and sleeping during the day gives you a unique kind of fatigue. But I did run home from work the other morning, and it felt good both during the run to actually be outside and seeing daylight (I miss light much when on nights), and the next day when at work I could feel the lightness of my legs that comes after a run, reminding me that I'm human and can move and be out and about, even when I'm stuck at the hospital.

It was a hard, rewarding month and even though it was impossible to keep up with all these resolutions, having them in the back of mind pushed me to do more of what I wanted than I would have otherwise, so grateful for the intentions.

the end of ICU

I came into my ICU rotation feeling like critical care is the opposite of primary care and what I want to do, but open to enjoying the experience. I knew I’d enjoy parts of it and learning the medicine and challenging myself with things that scare me. But I was surprised by how much I loved it. Intensive really is the most appropriate word for it, and I feel really lucky to have had such a uniquely intense experience.

There are so many things that make the ICU very different from everything else in medicine.

First, I’m struck by how close you become to people who you often never get to know. If people get better, and are able to interact more, we quickly transfer them out of the unit to make room for sicker patients and reserve our energy and space for the acutely ill. But you get to know the idiosyncrasies of their bodies—how they respond to changes in their respirations, how different medications improve their blood pressure, how their delirium develops in response to their environments. As we poured long days and weeks into thinking about how to care for people’s bodies minute to minute, our team grew close to people whose voices we never heard.

Second, there is more death, obviously. I’ve never had so many breaking bad news conversations. I won’t forget what it’s like to explain the unlikely recovery of a thirty year old man to a room full of his family, or to call a woman in the middle of the night to tell her what she already suspects when someone calls you at one in the morning. It was deeply rewarding to learn more deeply how to speak to people about such extreme illness and to understand their responses, which can often be harsh, and almost always heartbreaking. This was the first time I’d been a part of terminal extubations, something I never gave thought to when entering medicine. And that’s thing about this career. People talk a lot about how we idealize this field, and it’s true that a lot of the day to day work is not what most people would imagine. But there is an incredible amount that is so much more powerful than I ever anticipated.

The medicine is extremely complex, and interesting. I find acute respiratory distress syndrome (ARDS), where your lungs are flooded with inflammation, really interesting-- in that an illness in one part of your body can then trigger such a dramatic and life-threatening response from your lungs, even when your initial illness had nothing to do with your lungs. In medical school I struggled most with understanding the physiology of the lungs; it never came very intuitively and I had a lot of trouble visualizing the organ. Now I have a much better sense of how they work, how amazing and resilient and sensitive they are, and I really value having better understanding of what it is that enables us to breathe.

Another thing I loved about the medicine was trying to piece together stories of each person’s sickness. Very often, our patients came to us unresponsive and unable to tell us anything about how they’d been feeling up to that point, and very often we’d unearth things about them that they themselves didn’t know. A woman with unexplained low blood pressure, in whom we discovered widely metastatic cancer, we guessed from images of her heart, her need for oxygen, and her newly diagnosed cancer that she was suffering from large clots in her lung even though we weren’t able to see them. In another young man whose heart stopped inexplicably, we used his medical history, laboratory findings, and an exam of his stomach to learn that he likely used pain medications to treat the pain of an inflamed pancreas, causing his breathing to slow, aspirate contents into his lungs, causing less oxygen to reach his heart and a cardiac arrest. With the sudden collapse of a very young woman, I learned from toxicology that this was a common presentation of GHB overdose—a drug used for highs and also for date rape because it causes unresponsiveness without a change in your heart rate or blood pressure. I learned so much medicine as a result of trying to make diagnoses, as well as trying to manage the diseases: how severe an illness pancreatitis can be and how important early aggressive hydration is, how to use measurements of blood pressure to determine whether giving a person fluid will help them, how to evaluate whether an intubated patient has developed a pneumonia when they can’t tell you anything about their symptoms, how to predict whether an intubated person will be able to breathe on their own without the tube. I also loved how quickly we could gather information and learn in the ICU, because tests happen quickly, blood can be drawn at any time, vitals are monitored constantly.

One very concrete thing in the ICU that was different from other rotations is the fear it instilled in me, mainly fear of 1) procedures, and 2) emergency situations like codes. I’m happy to say that I’m not that scared of either of these anymore, which I really didn’t think would be the case. I’m not the best at either of these, but I feel at the very least competent. I did a lot of lumbar punctures, arterial lines, and central lines. I’m confident that I can place a central line (a catheter into the internal jugular vein, or femoral vein as I had the opportunity to do once), by myself, and because of that I’m not as worried about being on call overnight alone anymore. And as someone who isn’t very procedure oriented, I’m surprised by how much I enjoy having this skill. Likewise, I was surprised by how much I appreciated codes—situations where a patient has lost a pulse, or having unstable blood pressure/heart rate. I was part of one, and had to be the leader for another. The one that I mostly observed was a classic case (ventricular fibrillation, a deadly heart rhythm) with a defined algorithm, but complicated by its length and the difficulty in when to stop trying to resuscitate the patient. Amazingly, at the very moment when the decision was made to stop after another round of CPR and we stopped that round of CPR to check the patient’s pulse, it had returned. It amazes me on so many levels: 1) that after half an hour of being essentially dead, that a person could return to life; 2) we have the power to do that; 3) how tenuous and arbitrary the boundary is between living and dying, such that it comes down to an individual person’s evaluation of when to stop trying to resuscitate, and how if we’d given up (very reasonably) one minute earlier, things would be so different.

The other code, which I had to lead, was not as straightforward and I was so fazed by the suddenness of everything that it was hard to remember and think of everything I needed to. But I learned so much from just a few minutes of events, and now will likely never forget how to evaluate for causes of asystole (flatline, when your heart basically stops) and how to quickly manage it. I had a lot of help and played a small role in this, but nonetheless it feels good to be part of reviving a person. I still know that emergencies aren’t my style, but I also realized that often we think we dislike something that is inherently enjoyable because we’re scared of it, or aren’t naturally good at it. In this case, I think most people could enjoy the quick critical thinking and immediate cause-and-effect nature of codes.

And so that’s how a month whose beginning I dreaded became an experience whose end is bittersweet.

in the middle of ICU

It’s hard to know where to begin writing about experiences in the ICU, and it’s easy to not try because it’s so hard. It’s difficult to describe what it feels like, and so I thought I could just describe concretely what happens, but that’s also difficult. But I think it’s important to try. In the mornings we go from room to room, learning the details and mechanics of each person’s breathing and blood flow through their vessels. There is a ton of science and linking of every organ system. I like that breadth a lot, and I also like the detail more than I expected.

Then we enter the rooms and a lot of the time there is still a lot of science, but many times it becomes human. Yesterday, we spoke to a family who decided to withdraw care from their mother, a woman that before her illness had been a feisty, vibrant woman who traveled to Vegas and smiled gently at us when she was awake. When we first met her we thought she might be improving, even leave the ICU. Then things progressively worsened to the point that we weren’t sure she would recover, and if she did, surely not to her baseline. As the decision was made to make her comfortable and remove her breathing tube, I thought, I can’t remember the last time an entire team of interns, residents, fellow and attending cried with a patient.

Then we saw another patient’s family in tears. This patient had also been healthy and active, and had collapsed suddenly the day before, and found to have had a large heart attack. The family told us that their husband, their father, had woken up, could show them two fingers when asked to. And we cried a little again, this time not for letting go but for remaining connected.

Then we visited a young patient whose medical course has been up and down since he’s been in the ICU. He will seem like he’s getting better, staying stable, and then he’ll crash. His partner, a naturally sweet woman who is always so grateful and kind, asks if he is likely to get better or worse, and none of us know. In him I can feel the entire spectrum of upswing s and downturns that embodies the ICU.

starting ICU

On the day before starting my ICU rotation, which inspires a unique kind of fear, we received information about the current patients in the ICU. It's pretty amazing how sick these patients are. Even though I have no interest in doing critical care in the future, it's definitely a good experience to see how much people can go through and survive. Reading about one person with a urine that contained heroin, cocaine, benzos, and opiates, I think about all the toxins we accumulate in our lives, concrete and otherwise. It's both our absorption of these, and our resilience against them, that gives so much value in caring for critical illness.

Now on day three, I think back on what's happened:

Day one: Death A patient who collapsed in the morning was brought to the emergency room. She had one event after another in rapid succession throughout the day. In one day, her years of functioning came to an end. Piecing together what happened to her medically, imagining how she existed before this, communicating with her family--being in the ICU where things can evolve quickly means having entire narratives ravel and unravel over one day.

Day two: Achievement I don't have much experience with ICU-related procedures, in part because I haven't had much ICU experience and also because I'm known as what they call a white cloud, where I find myself just not having as many patients and many emergency situations as a lot of other residents, which can be a good thing but also means that I'm less prepared coming into this than everyone else. So our ICU fellow was very nice and approached me to do a procedure to get practice. Which I promptly failed twice. But when later that night I was by myself and had to do it again, I was able to do it on my own. I was proud of myself for braving it alone instead of immediately accepting that I wouldn't be able to.

Day three: Failure I made some poor decisions about a sick patient overnight that became much more evident in the morning to everyone else. There were several points where I could have done things differently, and I know that other people in my position would have done things differently. But I'm trying hard not to compare myself to others, and to remember that there are different strengths with different visibilities.

transgender

Our program started a curriculum on LGBTQ and transgender health these past couple of months. We've received lectures on the whole spectrum of definitions of gender identity, and yesterday we had an in-depth lecture on primary care for transgender patients. I was struck by how this obscure area of health (we don't receive much teaching or exposure to this in medical school and this is the first year it's been taught in our residency program) embodies so much of what I love in medicine. In particular, there is a huge amount of individual variability, both in physical and psychological health, such that it really emphasizes how important it is to get to know your patient. There is also a lot of personal evaluation and patient-centered decision-making because there is not as much research based evidence to guide clinical care. For example, a transgender woman may not need a mammogram as she doesn't have native breast tissue, but what about the fact that she may be receiving female hormones? Or what if she would like to receive the same routine care as another woman? How do you balance this with the high false-positive rates of mammograms for even cis women (women who are born as females)? How do you approach doing pap smears on a transgender man who may physiologically need one for cervical cancer screening, but who no longer identifies with that component of himself?

This is an area of healthcare I honestly haven't given much thought but now having been exposed to its complexities, I find it really interesting. I feel lucky to be in a program that considers the value of care for different populations of people. I also thought it was fascinating to learn about hormone therapy and reconstructive therapy, and how surgeries like hysterectomies (removing the uterus) and vaginoplasties (constructing the vaginal structures) can affect physical and psychological well-being. I think this area of medicine has so much depth, and shows how lucky we are to have opportunities to draw upon multiple components of who we are. This is something that requires skill in human relationships and learning about things that may be foreign to us, continued diligence in observing biological mechanisms in the face of a lot of uncertainty about what we know, and adapting as we go along. We have been having conversations lately about different kinds of intelligence, and I think things like this rely on the most admirable (to me) intelligence of synthesizing our knowledge of human experience and being open to what we haven't experienced and may never will.

January

This month's update on my resolutions:

1. Blogging: Despite having intermittently blogged since college, I haven’t really figured out what makes it sustainable, or what exactly the focus of my blogging should be. But I’m not trying to have high aspirations at this point in my life (eg, finishing residency), and right now I just want to get back into writing when I feel like something is worth recording. Whether those somethings are connected, is irrelevant to me right now. So in that respect, four entries in the past month is on mark with my goal to write one post weekly.

2. Recipes: This past month, I discovered polenta. I wasn’t really sure what to do with it at first. Reading about it, it seems that people use it often as a base for toppings. So I used it as a base for eggs (yolk in tact) and roasted sweet potatoes spiced with oregano and cayenne for breakfast, which was delicious. Especially if you cook the polenta in a little bit of butter. Another time, because I’d read that it goes well with pasta sauce, I used it as a base for the tofu tomato soy sauce scramble I make often when I need something easy and savory. My second recipe was an effort to vary how I eat tofu, and found a baked peanut tofu recipe that was perfect and that M liked a lot too: http://minimalistbaker.com/crispy-peanut-tofu-cauliflower-rice-stir-fry. I scaled back on all the times in the recipe so that it only took half an hour to make and it was still delicious.

3. Albums: This was my favorite resolution this month. I’ve been away from music for so long. During residency when I’ve tried to venture back, my finds have been lackluster. I’d forgotten how much continual listening it takes to discover the narratives that really move you. This month I had the luxury of listening enough to find three albums that I absolutely loved; in the future I suspect that I might settle for just listening to three new albums in general, but at present I feel lucky. After listening to Alt J, both An Awesome Wave and This is All Yours, I felt again the desire to listen to music not as a backdrop but as a sole experience. I also loved Angel Olsen’s Burn Your Fire For No Witness. Her vocals are both extremely bare and complex, a dichotomy that I think we’re drawn to by nature, maybe because there is constant conflict between our simple, fierce feelings and all the layers on top that we’ve cultivated and absorbed.

4. News: M predicted this would be hard for me, and it was at first. I haven’t been u p to date with current events since the beginning of medical school, so I really do fairly or unfairly attribute my ignorance to medicine. Which, like many things in the process of medical training, is ironic. Anyway, this resolution was a little difficult at first, but after getting into the flow of it, I’m finding it hard to not spend all my free time reading. I’ve gotten a subscription to the Economist, which I like for its big picture focus and ability to give equal weight to a lot of different topics, including ones that other sources wouldn’t find headline-worthy.

5. Exercise: I did pretty well with this one except for the swimming, which is hard logistically because I have to get to my brother’s gym to do this. Overall I am happy with January’s fitness, especially being able to go to yoga most weekdays. This does mean that my body will feel at a deficit when I start in the ICU next month, but I’ve started doing more yoga at home so this will still be feasible when my hours get awful. Climbing-wise, I would really like to pick up momentum at some point because I feel a strong plateau that likely won’t move without a lot more practice. I also feel a strong fatigue and burnout with running, which I think has to do with too little variation in my routine so I’d like to run more outside and on different routes. But these are all general thoughts, and my concrete goal to keep me grounded is that I just want to do each activity (yoga, run, climb, bike, and swim) once a week, so that I’m doing something active almost every day and that there’s enough variety to keep myself feeling buoyant.