second beginning

On Monday we start on the wards, and it's what we've been anticipating excitedly and in immense fear for quite some time. But unexpectedly, a lot of things began with Survival Fair two weeks ago. I know we complain about having to wake up early for lectures, long days of workshops, and some very dry sessions on legality, privacy, sexual harassment, and so on. It is a pain, but I've also learned a lot, medically and personally and while there's a lot I'd change about it and I could use another week to wind down, it's helped me.

We haven't had as much down time as I'd thought and wanted, especially this past week with afternoons full of advanced cardiovascular life support, phlebotomy, and a clinical skills session. We've learned the steps beyond CPR in resuscitating people, which include shocking them (or not shocking, depending on what's wrong with their heart) and a handful of drugs. We learned to draw blood for cultures, how to put in an IV, how to insert a catheter. Among these procedures, some of the hardest things are little steps that require a lot of attention. For example, sterility is a huge concern, and it's kind of interesting to think about how we are trying to avoid everything that surrounds us, like slipping in between slits of rain drops. There is a certain way to put on sterile gloves, to ensure that nothing gets "dirty," and you have to be constantly aware of your hands and body and what lies in a "sterile field" and what doesn't. It's pretty cool conceptually, to think of how we negotiate our environment, but it's also exhausting and prime ground for mistakes. So I enjoy the explanations, fumble around with my own imitations of what I saw, and come home crammed and tired.

In the midst of this, I am grateful to Yale for pounding into us the personal aspects of medicine, all the issues that we're going to face as people. Even as some of the topics can first come across as superfluous or obvious, like gender discrimination and power dynamics, much of it has been helpful in thinking about how to interact with people. More specifically, how to interact such as to bring greatest benefit to patients, stick to your principles, not cause drama, and avoid frustration. This is hard.

I've heard many things that connected to me, that I know will be hard to keep in mind; I can barely recall them now after a week of so many things. A lot of it helped me with some of the feelings I had from the last entry, and made me think about what to do in conflicts to benefit people most. I also learned to think about how circumstances influence my own feelings, and to remember that most things happen out of neglect rather than bad intentions, which includes a lot of my own negative responses. Another thing emphasized is the detachment of certain behaviors and feelings from individuals; for us to seek systemic reasons for why a person might do something we perceive as unkind or unjustified. Today was particularly powerful...oops, no pun intended. Our last day of orientation was called Power Day, and it was dedicated to thinking about potential abuses of power in the health profession. We read two stories where physician-writers narrated their own experiences of taking advantage of patients' vulnerability in order to enact what they felt was best care. The day started with a fabulous keynote speaker, a woman who had been my section leader for Public Health, who talked about the power dynamics of race and ethnicity.

She was amazing in several respects. Firstly, I think the majority of the audience loved her and it's hard to sustain the attention of any group of people and make yourself relatable to a diverse number. Secondly, she read us a couple journal entries she kept back in med school, which of course inspired me to write as much as possible. The entries themselves narrated powerful (again) experiences that were unique in how they explored the medical hierarchy, the divides between people in general, and language (even though this wasn't really mentioned). The first story dealt with a doctor's use of literature to degrade a med student (the speaker), and unraveled at a slowly building pace that made it seem natural that such a thing could happen not even fully understood by the student. It ended with a sentiment that it was nice to think about literature, a part of her brain that'd been suppressed in medicine, but that in the end literature had hurt her medical learning and herself. It's a longer story that can't be done justice by summary, only by her voice, but I appreciated this thought and remind myself that stories in my head are one thing and stories in front of me are another. The second entry the speaker shared with us dealt with a med student gracefully, creatively, and humbly standing up to a doctor who failed to address a patient's language barrier. In both stories, she noted a couple things that have been, in different lights, emphasized these past weeks: these powers and responsibilities we have and will come to have carry much weight, for both a lot of good and a lot of bad. In her first story, thoughtfulness and kindness from an unexpected source saved the speaker from her superior's racism, and in the second, strength and ingenuity came from the lowest rung on the totem pole. Of course there were "adversaries" in these stories, but she, like others, have encouraged us not to see them as such, to give more room for gray. Related to this, we're encouraged to see where the problems lie within the system, not the individual. For example, why was this allowed to occur in the first place, why wasn't the speaker comfortable reaching out to anyone about it, why didn't anyone else notice anything or if they did, why did they do nothing? In the other story, the med student took it upon himself to change the system that led up to miscommunication between doctors and patients, via a simple suggestion to place simple signs on doors of patients who couldn't speak English, to refer healthcare providers to interpreter services. This systemic approach was also brought up in a session on leadership and group dynamics, wherein we talked about distinguishing when individual behavior is indeed individual and when it is a reflection of group thought.

This is not to escape personal interactions, because that's where any systemic change occurs and that's also where we live. Even before starting on the wards, and way back since starting first year, I've been amazed at how many issues we discuss because medicine deals with countless aspects of life and not necessarily just in the patient encounter, how hard a lot of this can be and what rare challenges we experience and witness others experience, and how lucky we are to continually question and start.

no, really this time

So after I wrote that entry yesterday about appreciating our experience and privilege in the face of embarrassment, frustration, and indignation, I faced all of these today to the furthest extent as yet in med school (this threshold, I know, will continue to be pushed each day on the wards). And it was harder in practice to tell myself what I'd been thinking for the past week: that these incidents are challenges that push us to focus on why we're here, that roughness is rough but not crippling, and that our learning is on us. There were a couple things in particular I saw today that I didn't like and bothered me for quite some time afterwards, but after talking to a few friends I remember goals I've accumulated over the past week of Survival Fair. Don't dwell or complain (not in the moment and not too long after the moment either; everyone should give justice to their feelings, but in my case I need to recognize and move on, or it becomes consuming and unproductive). Use the energy to improve, instead, even if in the rare case the problem lay outside of myself. Let what I see change me in ways I would want, and come home as a person I still like. I didn't expect to need to remind myself so much before I even stepped inside the hospital, but better here than there. This year will be tough, and good.

surviving

I like to do my laundry and clean my room before I leave it on vacation (or in this case, Boards-study) so that its openness and togetherness welcomes me upon return. This time around, because my subletter hasn't completely moved out yet, my room is less able to fulfill its role, the cluttered surrounds mirror what this period of time has been.

Before we assume our roles as third years in the hospital (the wards), we have two weeks of "Survival Fair." We didn't know what it meant either, other than that it's an orientation designed to prevent us from being stupid on the wards. It turns out that the first week is mostly a warning: we will be stupid. We will be told so, made to feel so, and we are legitimately so.

I've never been so scared, so excited, or so scared and excited at once, to be beginning something. Part of this stems from the mystery that enshrouds medicine. Survival Fair consists of lectures, workshops and hands-on sessions that prepares us for 1) stress (details on what will stress us, how to cope) and 2) practical skills (putting in an IV, advanced CPR, learning the hospital computer system). I feel like a big number three is missing, the one that tells us what we'll actually be doing, what our responsibilities are. I know that this is hard, varies not just from department to department but from doctor to doctor. I also know that just as with our first two years of book learning, these next years are about figuring out for ourselves what we need to know and do. Still, somehow knowing we're about to descend into a black hole (in both positive and negative terms; I mean, it sounds bleak but it's kind of cool) without any remote idea of what makes it black is disconcerting. Though I guess that element is part of it.

As much as I don't like it, I admit it is probably good to coat this anticipation with a guard against the negative aspects of medicine. It seems we've been told over and over that we will be criticized, a lot; that people will be mean to us, a lot. It's been good advice to not take it personally because people are at their worst when stressed and sleep deprived, but among our class the natural response has been: why must this be true? I know that for myself I'm more easily irritated and more quickly take it out on people around me when stressed, and rather than falling back on that, I should avoid that crutch. I suppose that the warning to grow lizard skin is for the inevitable fallbacks.

But the nurse who taught us how to scrub in for surgeries left us with the advice to be nice. It goes without saying you should be nice to your patients, but she told us to be nice to everyone, to our doctors and medical teams and to each other. It also kind of goes without saying that you should be nice to your doctors, but I got the feeling she meant, nice in thought and not just in action-for-show. She herself was not about nice-for-show; she was rough when things were rough and kind when kindness was sincere.

Rough is necessary in surgery. I'm looking forward to being involved in them, but it's natural to feel more apprehensive. We had a two-hour session about how to prepare for one. Scrub your arms and hands for five minutes: 10 strokes on each side of your fingers, five across the webs in between, circular motions across both surfaces of your hands, turn the scrubber to the other side and continue the circles as you rotate your arm back to front, two inches above your elbows. We learned how to put on gloves (if you look this up on the internet, you'll find there is a five-step procedure for putting on gloves), how to put on a gown (this entails holding onto a tag at an exact spot and spinning around; I've already forgotten whether it's clockwise or counter). I learned that my glove size is the same as my shoe size. Then stand for upwards of 7-8 hours, half of which might consist of leaning over a patient holding an instrument in place and in place means in place, and remaining aware of what every inch of you is touching (lean on a patient out of fatigue and he may wake up with a hematoma). This indeed means holding your bladder for the duration of the operation. No scratching your face. If you sneeze, that will stay in your face mask until you're out. They've warned us back to back that we will be yelled at, blamed for everything we do wrong and for things not our fault. All while being asked questions to name what's before you, things that are less clear when real than when etched in a deliberate textbook.

In a timely turn of events I just read the Diving Bell and the Butterfly, the book whose words streamed from the blinking of a completely paralyzed man. He talks a little about his medical caretakers, and a lot about his world, the one which in our highest aims we seek to reach.

I haven't decided yet whether the negativity is a necessary tool or an unfortunate byproduct, or where it falls on the space between, but I do think that Survival Fair and third year in general is about pushing us to find ways to fight against it, and in the process, remembering or finding anew or finding for the first time what this is for. It's not for us, or at least not the majority of it. I don't intend to forget myself, though I know that may happen often. I want badly to take care of myself: write, drink milk, run twice a week, respond to emails, talk to people, eat fruits and vegetables. I'm trying my best to keep it simple and possible (I decided against making any resolution about cooking, even just once a month). We already know that there may be months when this list will be tough, but I know how much better I will feel to have things to control and give myself.

On the other end of that, like the operating room nurse told us, this isn't just about us. For the person whose literal cluttered insides are vulnerable and open, and not in the openness of a clean room but of an honest one, we go through what we do and we work to do the most we can. It shouldn't wear you away completely, but perhaps there is reason to wear a little. It wouldn't be realistic to bestow purpose to all negative; some crappy things are just crappy. But I think what drives us is the belief and hope that to see things as they are, messy or clean, is worth it.

prague

Gray skies shaded the muted colors lighter, but it stayed light until well after nine, the moon rising long before the sun set. On our first night we wanted to sleep at five in the afternoon; we stuck it out through dinner and slept at 9. The second night there was no sleep; there was absinthe dancing and a stage (earlier in the day: absinthe ice cream is good, though it burned Allison's throat and my stomach). Walking in the quiet mid-morning, it was strangely bright without any obvious sun. Saw the sun rise sitting atop a rooftop with an arm around my waist, that I let slip as easily as I let it rest there. The sun appeared suddenly as a gleaming disk, I mistook it for the moon until I remembered. It made a patch of sky blinding, and promptly disappeared into cloud with its ascent. The light stayed behind a while. In the morning, having checked out of our hostel, we stumbled our way around town searching for places to sleep. At one point we catnapped on a bench; upon feeling like bums we went inside to a coffeeshop where only one could sleep at a time. Allison opened her eyes and said, Let's go to the cinema. I was confused, then understood that a theater offered the luxury of letting us both close our eyes. Brilliant--but we stuck it out. After some more napping at an outdoors McDonald's.

All the streets I can remember were cobblestone. The Charles Bridge was crowded, and loveliest from afar. The castle sprawls. Upon huffing and puffing up a grassy park, red roofs abounded. Walking through the city to our bus, came across gorgeous vantage points like surprises. Buildings in the square seemed to press flat against the sky like a movie set. They were boxy in the middle, with lots of curls and odd corners at the edges.

Czech food is warm, meaty and good with beer (very cheap). Attractive waiters with sincere charm. Roast duck was particularly memorable, with savory sauce mopped up by bread dumplings. Allison had "the best croutons ever" in her garlic soup, and I enjoyed a good steak at a slightly medieval former-prison-turned-restaurant where bear hides clung to the walls and a group of burly men befriended a lone Asian traveler, the one guffawing with every sentence uttered by the other. A seafood lunch by the river in Cesky Krumlov, with another castle in view, a full trout with teeny bones and much flavor, laced with lemon juice. Home-made Korean food welcomed us in the mornings and evenings: kimchee, slices of pork wrapped in lettuce and unbelievable sauce, breakfasts of sushi and soup, fish and spring rolls. A welcoming pair of parents who reacted to our presence with smiles, always. Narae's energy kept us walking, eating, looking. We watched Star Trek (it was super cheap to watch movies and the movie was so good!) and rested at the worst Burger King in the world. Saw the castle at night, the lights more subtle than I anticipated; the river reflecting light without taking it all.

The bus station was chaotic; we went back and forth and maneuvered times and routes and stations, but after several trips became expert (kind of) navigators. The bus ride to Cesky Krumlov was filled with stops and locals, and a lot of green. Our hostel was a homey cave with walls painted yellow, lived-in kitchen and common room, and comforting to wake up in. Walked a straight road into town, with nonchalant viewpoints along the way, overlooking a small quaint town, loudly splendorous but humble. We perched on a bench to watch it grow dark (it takes a long time), the pink castle maintaining its pink from the day and gaining white light to define it against night, and talked for some time, getting cold. We talked a lot, falling asleep or staying up, in transit, during meals. Narae and I hiked our way to a hiking trail, and went back, stopping at points and consuming the afternoon in another yellow cafe, with mediocre food and drinks but glad to be sitting. The escalators in Prague are the fastest we'd ever seen; they are scary. Other -ests: biggest breakfast, cheapest (good) beers, most castles, more that I can't recall at the moment (should've recorded).

The ride to Vienna: vineyards, red flowers peppering grass every so often and then in bursts; mustard flowers showering large patches of fields. The ride back: the sky changed every few moments, like the way a movie flashes scenes one after another to show the passing of time. In Vienna, the escalators are normal, the castles and churches darker, in coloring or feel or both. Favorite was a thin white one with a jagged pattern, felt like an icicle piercing the surroundings. Fell asleep in a spot amidst much grass, trios of boys playing soccer, couples, people by themselves reading or watching or listening to music. A glorious nap, on the one day I wore a skirt. Night light brings everything to a glow, the rows of windows individually alight. Had a long dinner with appetizer, main course, and dessert. Walked by many stores, none of which were ever open (night, Sunday, etc). Tried schnitzel (once is enough). We sat outside the opera house, watching people walk out after the performance of My Fair Lady. Allison brought me breakfast in bed: strawberries and bread with prosciutto (I LOVE PROSCIUTTO) and cream cheese. Frolicked in rose gardens, posing by the flowers and decided our route by sight ("let's go toward THAT"). The next afternoon we spent in a pretty clean-cut coffeeshop and had a melange. The gelato in Vienna was especially good (Prague was also very good: a delicious raspberry; in Vienna, strawberry yogurt and kiwi and mango that tasted like biting into all of those things).

We had ice cream every day. Sometimes twice.

six weeks

Back in Connecticut, today was the first day of third year. We were advised to be present: to be aware of where we are in a moment and to stop thinking about where else we need to be or what we should do after this moment is over. During the lecture about how to manage stress, it was suggested to write things down as they happen, so they don't slip as days pile upon one another. I'd meant to catch up on some things during our trip to Prague, but that didn't work out for various reasons. One of the things that has frustrated me most in med school is not having time and energy to reflect in thought and writing all the things in which we're immersed. I recall clearly deciding to not spend my life writing because I had nothing to write about, to experience instead so that I'd have something to say; medicine has brought me closer to that, has given me much to say but in the process often takes from me the capacity to form sentences.

One piece of advice was to just get things down, even if incoherent. I used to do that often, but somewhere between that and now, have done it much less. The idea is to capture your immediate impression; that you can return to it later, give it real form and thought later. I worry very much that I never will return to it, that there's too much; that I can't fully describe how I feel in a moment without more time and energy, and so I should only write when I have all the time and energy I need, and since I won't settle for less, I end up doing nothing. While I'm somewhat proud of this stubbornness about taking care about completeness, I realize that in some circumstances you do have to work with limitations, not just ignore them.

In theory this would mean I would jot down the overwhelming amount of stuff thrown at us today, but there is a lot of past too and I'd like to share that first, even if insignificant. I know I can't spend my life catching up to myself, but for the next two weeks before we start in the hospital where I have to be present, I'd like to have that luxury.

So to go back to what feels like way way back, the six weeks I spent at home studying for the Boards was pretty wonderful. I'm not sure how the test itself went, and while I learned a lot, it didn't quite feel like enough. I'll talk about that whole process maybe later. But other things happened, and for those I'm proud and glad.

I ate all my meals with my parents, and my brothers came home on the weekends for the more elaborate meals my mom would make. The first few days I returned, Fremont was gray and green. I studied in a room with a window facing the street, and we live on a busy street. I had three second glimpses of people as they passed from the left edge of my window to the right, or the other way: teenagers walking home from school, missionaries going door to door, parents wheeling strollers, dogs on leashes, stray cats, a man collecting cans in a shopping cart, young couples, old couples, people talking to themselves and each other, various runners with different running styles, a woman singing and running into her notes as they flowed forward and she walked after them.

I ran a few miles every couple days, all on the treadmill after my first week at home, which I know surprises everyone because people think I'm really unathletic (which I am, except for in elementary school but no one believes me when I tell them I was good at sports back then) and because when I do run it's always outside. I started because it got too hot in the afternoons to go outside, and despite sleeping fine for the most part I was too tired to run in the mornings. So I grew to love the treadmill, which faces away from the screen door to our backyard, in our living room. I'd open the screen to make it feel more like outside, and I grew to love the mechanics of running on a machine, of focusing purely on movement (not even forward movement, obviously, just moving), rather than surroundings and surrounding feelings. I was disappointed to realize it'd take me much longer than I anticipated to work up to a decent pace, after many years of irregularity, but it did motivate me to continue. I also started to like milk (I do tally this on my list of accomplishments), because it was the only cold drink we had. It was really satisfying to have everything I needed to run at home. Just changed in my room, went downstairs to the living room for the treadmill, panted my way to the kitchen for milk, then back upstairs to shower.

I finished one book during Boards studying (in my small defense, it was a long one)--The Wind-Up Bird Chronicle by Murakami. It's up there with my favorites of his. Much of it was dark, and I'd go to sleep unsure. Through it all there was something to hang onto, as is usual with even his strangest contexts and characters most disconnected from things. And in this book amidst all the unbelievably expressive and knowing and detail, there were in particular two pages that I may hang onto the rest of my life.

I didn't get to see friends as much as I would've liked, only seeing my high school friends the day before I left for Prague. I did fly to LA for a day to see Iron & Wine at the Troubadour with my oldest friend. Awhile ago I posted about my top songs and none of them included Iron & Wine, even though he is one of my top artists. This is because what I love in his music runs through everything he writes, and the whole experience of hearing Iron & Wine with someone close to me who values that feeling, felt like that, where places and events and things lose definition and become vessels for something ineffable and common in all of them. He ended with Trapeze Swinger, which is a long song and one I'd been listening to often before the show. It's a beautiful beautiful song and one that will always make me think of that moment in the show, and also the walk in the cool night to the venue before the show, and the car ride afterwards which I remember as a long straight road punctuated by streetlights, though I'm not entirely sure it was that way the whole time.

I said goodbye to my great-aunt, and the funeral is something else I'd like to write about, and separately. I wasn't close to her, but I tried to stay close to what it meant. I can't say that I was always able to completely focus on it, with the hectic background of studying and other things, which forced me to consider balance and my role in that. It also made me glad to be with my mom, who is much nicer to me than I deserve and who did teach me to make a couple of her dishes. Not quite as many as I wanted, due to her cooking hours before I got up in the morning; by the time I was getting up early enough, I was trying to make up for lost time in studying. But now I can (theoretically) make my favorite spring rolls and savory crepes? pancakes? Not really like either, but yellow and crispy and eaten with fish sauce and lots of lettuce and herbs.

I also cut off about 12 inches of my hair. I needed 10 to donate to Locks of Love, so the hairdresser asked me if I wanted to keep that extra 2 inches, but I told her to just take it all. So instead of messy wavy hair down my back, I have manageable straightness to just my shoulders. Even though I don't like the look of the haircut much, it felt pretty good to make a dramatic change, after growing it out for two years. Other tidbits at home included getting my white coat tailored to my actual size, getting a new backpack, and finishing a roll of film.

Writing about things awhile after I've thought of them is hard, and dissatisfying in the knowledge that it's inadequate. The intersection of language, or my language, and feelings makes me feel that it's always inadequate, even when I write in the moment, but this feels more so. Still, I'm really very glad to be able to do at least this.