I've been spending the last few days reading a book on motivational interviewing. One of the main problems I see in medicine is communication, and one of the things in which we aren't trained enough. In medicine and in my own life I've seen the weight of words. I have personal biases too, because having spent years writing essays about the choice of particular words and their context, I'm inclined to feel the nuances of everything that's said. This book is founded on the idea that while change must happen from a source internal to a person, the facilitation of the change very much depends on external factors, like how you talk to them about the change. I think this is all very true, that people are consciously and subconsciously affected by tone, syntax, vocabulary.
For that reason I try to take care with words; it's one reason I find it easiest to write rather than converse, when I have more time to consider. I've been told that this is a mode of filtering, that I'm being less honest because I don't just say what comes to mind. But for me I don't feel that my immediate words reflect my immediate feelings, mostly because I've barely figured out how I feel, not nearly enough to explain why I feel that way, and to explain it to convey it.
But it is hard, because language, even the same one, doesn't overlap from person to person. There are subtle differences in connotation and meaning for each person, and not only do you have to process what it means to you, but also what did the person mean, and which is more meaningful? Since I give it so much thought, I often forget that most people don't. And so, I shouldn't take things this way or that; that's not what was intended, and then following that things are said with clear meaning but that aren't meant. Too much care can be ultimately detrimental, and so balance is a goal in even something like that.
Friday, December 17, 2010
Wednesday, December 8, 2010
talking to each other
A very rough retrospective summary of happenings at the end of October, beginning of November--
*
When we first learn how to interview patients, we are taught to center our conversation around the patient’s chief complaint, with subsequent questions designed to elucidate its source and nature. Because people aren’t naturally inclined to speak following such structure, we’re taught to set an agenda early on in the conversation, to prevent unnecessary ramble and distracting tangents. Emphasize the main points and shed the rest to the sidelines. When a person comes in with a long list of concerns, we’re advised to ask the patient what is most personally important, while we silently also consider what may be most medically important. In this way we cut down and narrow for efficiency, but in doing so sometimes we also dilute, and make murky the source that we develop such intricate formulas to discern.
I’d seen several patients with chronic pain with Dr. McGarvey, and they often have multiple issues both within and outside the realm of physical pain. It can be overwhelming, and unrealistic, to address all of them. One woman, followed by Dr. McGarvey for pain and depression, comes to the clinic with concerns about head pain radiating down her arm, bilateral feet cramping, an episode where she felt sweaty and “drunk,” and sinus tenderness. These are what she names as most important to her, when asked to narrow her initial multitude of issues. She brings all her medications, and narrates a lengthy story about having stopped certain drugs after attributing her drunken sensation to her medications, and recent additions to her medications, and then having stopped all of them after visiting a native medicine healer, and not knowing where along this line lay the cause of her symptoms.
Armed with her bottles and stories, she is someone who may be quickly considered difficult and unreasonable by a healthcare provider meeting her for the first time, or one who has seen her often. But Dr. McGarvey uses his several year history with her to delicately untangle the threads of her state of health, taking each one in turn and stopping to examine the intersections where one crossed another. He translated the sweating and drunkenness that she described in association with her medications to diaphoresis and altered mental status, symptoms of a process called serotonin syndrome that may have been precipitated by a recent addition of trazodone to her usual sertraline, both drugs acting to increase serotonin in her system. This may also account for the cramping in her feet.
When she says that occurrences like these make her feel like she is taking too many medications, because she can never be sure what is acting on what, he doesn’t present the removal of trazodone as the only solution. Instead, he works with her to rework her medication regime. He groups them into drugs for pain, depression, and prevention and maintenance. He points out the few medications he felt were very necessary, and points out others that are more for long-term that may not be as crucial to take at this current moment. He knows her well enough to know to not overwhelm her now, and to know that she will be open to restarting these medications later. With the drugs for pain, he listens to which ones she feels help and which don’t, and rearranges things accordingly. The doctor having often talked through her medications before, the patient understands the details of her medications, and asks intelligent, thoughtful questions.
This is a routine that may be recurring, and that will never eradicate the continual pains and problems, but his care helps her take care of herself the best she can. For her there is no chief complaint, but a general sense of non-well-being, and a person in such a place often benefits from us broadening our view.
She pushes us to do so when she asks for a referral to the native medicine healer in the hospital. After checking in with the pharmacy to begin filling her prescriptions, I take her to the hogan where Larry, the native medicine healer, is working. A hogan is a traditional Navajo building, where families live and host ceremonies. It’s built in the shape of an octagon, and you enter the hogan in one direction and leave in the other, clockwise, to mimic the rotation of the earth around the sun. This one has a fireplace in the middle, rendering all the dimensions of the chimney completely visible until it reaches the roof.
Larry sits in one chair without a back, she sits on another chair with a back and so do I. While the light is still on in the hogan, he asks her what is plaguing her, and she tells him about her head pain radiating to her arm and her feet cramping. Then he takes out a small zippered pouch containing three crystals, a feather, an arrowhead, and a longer item I can’t identify. He’d received the set of three crystals from his grandfather, who had been a medicine man. He can’t say where they are originally from or how they came to be in his possession other than that they’d been passed on in the family for years and years. As a child, Larry followed his grandfather as he healed others, and when Larry was thirteen he perceived the light of the crystal while crystal gazing, the process which he is commencing now.
He lays out two square white cloths. One behind him, one in front of him. The one cloth behind him holds the items he will later place in his hand, and in her hand. On the one cloth in front of him, he places a small round glass bowl. He pours water from a water bottle into the bowl, and places one crystal and the arrowhead in the bowl after the water.
The feather he places in front of this cloth. He holds one crystal in his hand, gives one crystal for her to hold, as well as the item I couldn’t discern. He turns off the lights, turning to me and saying, “This is like an X-ray. It must be dark so that I may see through the body.”
They begin conversing in Navajo for a few minutes, and then he stares for a long time into the crystal. He speaks to her again for another few minutes. In the crystal he sees that in several years ago she had cut and burned the cactus around her home. This disruption of natural surroundings seeped into her body, and I wonder in what spaces—blood, bone, mind?
“You must communicate with all the elements: the sun you feel, the animals you eat, the trees you cut down to make a hogan. You tell them what you are doing with them, you ask permission. They talk to you too, if you listen.”
When there is a rearrangement of the state of things without conversation, the disorder is carried inside and manifests itself as illness. Other happenings like lightning and tornadoes can bring upon a person the aches of arthritis or a silent rise in blood pressure. I’m not sure if these natural occurrences are sources, or reflections, of disturbance.
Like others, this patient will need prayers, one which Larry chants now, and a ceremony in the future to fully recover. In her case, it will entail an offering to cacti and stages of placing sand paint, white for the new dawn and yellow for the closing evening, on her face and chest.
Ceremonies are performed for intervention in times of sickness, as well as for shaping in times of health. When girls experience their first menstrual period, they undertake the process of a kpuberty ceremony. Because a girl’s body is in a phase of change, everything about it is considered sacred; her spit is saved and used as medicine. Everything about it is also malleable. The ceremony lasts four days, and the girl runs at dawn and noon every day, each time going a bit further, to imbibe stamina for the rest of her life. She bakes a large cake for everyone from corn, which she is to grind herself from kernels to powder, using grindstones (one long stone and a bigger slab of stone), and she hand weaves the carpets and baskets used in the ceremony. These movements provide form, and she is also shaped by others in a process called molding, where she lays atop blankets as her skin is massaged by older women.
At the end of this ceremony, the patient drinks the water from the round glass.
“Where water comes together is birth; everything comes from water,” Larry explains.
I am a witness, as someone other than the giver and recipient of prayer must be present. If I had not been there, Larry would have used a long wooden stick he calls a ladder, as a witness. He would communicate with the ladder before beginning the crystal gazing, and then throughout the process, explaining what he sees and feels, just as he did with me.
Everything requires communication. When Larry offers to give me a travel prayer when I leave Arizona next week, I ask whether that it’s all right for someone from another culture to receive a prayer. With a short, light laugh he says, “Yes!”
“Before we start the prayer, I will tell the elements who you are, how you grew up, what your culture is. For those who believe in a Christian God, I will include this in the prayers too; for those who don’t, I don’t. I myself go to three different churches. I was raised Catholic by my mother, I go to Protestant church for the songs, and to Mormon church because my wife is Mormon. I feel the belief is all the same thing.”
“How important is belief to whether the prayer will work?”
“It works sometimes even for those who don’t believe. Belief is the thing, though.”
And so, on my last day on the Navajo reservation I’m blessed by Larry for safe travels. He uses a feather that was a gift given to him in Canada, where he took his wife once when she was feeling badly about her father’s death. At that time, seeing her grive, he had said to her, “Let’s drive North,” and that’s what they did. He brought back this feather that he uses often for prayers. He sings a travel song, and then prays, all in Navajo. The only thing he says in English is: “going to drive to Connecticut.”
He burns wheatgrass atop a burning coal. He gathers the smoke in the air with the feather, using the feather to wave the wafts around my body, then touching the feather lightly to my body: my feet, shins, knees, thighs, arms, chest, shoulders, cheeks, back.
When he says goodbye, he gives me a gentle hug sideways, stooping very slightly to meet me.
*
When we first learn how to interview patients, we are taught to center our conversation around the patient’s chief complaint, with subsequent questions designed to elucidate its source and nature. Because people aren’t naturally inclined to speak following such structure, we’re taught to set an agenda early on in the conversation, to prevent unnecessary ramble and distracting tangents. Emphasize the main points and shed the rest to the sidelines. When a person comes in with a long list of concerns, we’re advised to ask the patient what is most personally important, while we silently also consider what may be most medically important. In this way we cut down and narrow for efficiency, but in doing so sometimes we also dilute, and make murky the source that we develop such intricate formulas to discern.
I’d seen several patients with chronic pain with Dr. McGarvey, and they often have multiple issues both within and outside the realm of physical pain. It can be overwhelming, and unrealistic, to address all of them. One woman, followed by Dr. McGarvey for pain and depression, comes to the clinic with concerns about head pain radiating down her arm, bilateral feet cramping, an episode where she felt sweaty and “drunk,” and sinus tenderness. These are what she names as most important to her, when asked to narrow her initial multitude of issues. She brings all her medications, and narrates a lengthy story about having stopped certain drugs after attributing her drunken sensation to her medications, and recent additions to her medications, and then having stopped all of them after visiting a native medicine healer, and not knowing where along this line lay the cause of her symptoms.
Armed with her bottles and stories, she is someone who may be quickly considered difficult and unreasonable by a healthcare provider meeting her for the first time, or one who has seen her often. But Dr. McGarvey uses his several year history with her to delicately untangle the threads of her state of health, taking each one in turn and stopping to examine the intersections where one crossed another. He translated the sweating and drunkenness that she described in association with her medications to diaphoresis and altered mental status, symptoms of a process called serotonin syndrome that may have been precipitated by a recent addition of trazodone to her usual sertraline, both drugs acting to increase serotonin in her system. This may also account for the cramping in her feet.
When she says that occurrences like these make her feel like she is taking too many medications, because she can never be sure what is acting on what, he doesn’t present the removal of trazodone as the only solution. Instead, he works with her to rework her medication regime. He groups them into drugs for pain, depression, and prevention and maintenance. He points out the few medications he felt were very necessary, and points out others that are more for long-term that may not be as crucial to take at this current moment. He knows her well enough to know to not overwhelm her now, and to know that she will be open to restarting these medications later. With the drugs for pain, he listens to which ones she feels help and which don’t, and rearranges things accordingly. The doctor having often talked through her medications before, the patient understands the details of her medications, and asks intelligent, thoughtful questions.
This is a routine that may be recurring, and that will never eradicate the continual pains and problems, but his care helps her take care of herself the best she can. For her there is no chief complaint, but a general sense of non-well-being, and a person in such a place often benefits from us broadening our view.
She pushes us to do so when she asks for a referral to the native medicine healer in the hospital. After checking in with the pharmacy to begin filling her prescriptions, I take her to the hogan where Larry, the native medicine healer, is working. A hogan is a traditional Navajo building, where families live and host ceremonies. It’s built in the shape of an octagon, and you enter the hogan in one direction and leave in the other, clockwise, to mimic the rotation of the earth around the sun. This one has a fireplace in the middle, rendering all the dimensions of the chimney completely visible until it reaches the roof.
Larry sits in one chair without a back, she sits on another chair with a back and so do I. While the light is still on in the hogan, he asks her what is plaguing her, and she tells him about her head pain radiating to her arm and her feet cramping. Then he takes out a small zippered pouch containing three crystals, a feather, an arrowhead, and a longer item I can’t identify. He’d received the set of three crystals from his grandfather, who had been a medicine man. He can’t say where they are originally from or how they came to be in his possession other than that they’d been passed on in the family for years and years. As a child, Larry followed his grandfather as he healed others, and when Larry was thirteen he perceived the light of the crystal while crystal gazing, the process which he is commencing now.
He lays out two square white cloths. One behind him, one in front of him. The one cloth behind him holds the items he will later place in his hand, and in her hand. On the one cloth in front of him, he places a small round glass bowl. He pours water from a water bottle into the bowl, and places one crystal and the arrowhead in the bowl after the water.
The feather he places in front of this cloth. He holds one crystal in his hand, gives one crystal for her to hold, as well as the item I couldn’t discern. He turns off the lights, turning to me and saying, “This is like an X-ray. It must be dark so that I may see through the body.”
They begin conversing in Navajo for a few minutes, and then he stares for a long time into the crystal. He speaks to her again for another few minutes. In the crystal he sees that in several years ago she had cut and burned the cactus around her home. This disruption of natural surroundings seeped into her body, and I wonder in what spaces—blood, bone, mind?
“You must communicate with all the elements: the sun you feel, the animals you eat, the trees you cut down to make a hogan. You tell them what you are doing with them, you ask permission. They talk to you too, if you listen.”
When there is a rearrangement of the state of things without conversation, the disorder is carried inside and manifests itself as illness. Other happenings like lightning and tornadoes can bring upon a person the aches of arthritis or a silent rise in blood pressure. I’m not sure if these natural occurrences are sources, or reflections, of disturbance.
Like others, this patient will need prayers, one which Larry chants now, and a ceremony in the future to fully recover. In her case, it will entail an offering to cacti and stages of placing sand paint, white for the new dawn and yellow for the closing evening, on her face and chest.
Ceremonies are performed for intervention in times of sickness, as well as for shaping in times of health. When girls experience their first menstrual period, they undertake the process of a kpuberty ceremony. Because a girl’s body is in a phase of change, everything about it is considered sacred; her spit is saved and used as medicine. Everything about it is also malleable. The ceremony lasts four days, and the girl runs at dawn and noon every day, each time going a bit further, to imbibe stamina for the rest of her life. She bakes a large cake for everyone from corn, which she is to grind herself from kernels to powder, using grindstones (one long stone and a bigger slab of stone), and she hand weaves the carpets and baskets used in the ceremony. These movements provide form, and she is also shaped by others in a process called molding, where she lays atop blankets as her skin is massaged by older women.
At the end of this ceremony, the patient drinks the water from the round glass.
“Where water comes together is birth; everything comes from water,” Larry explains.
I am a witness, as someone other than the giver and recipient of prayer must be present. If I had not been there, Larry would have used a long wooden stick he calls a ladder, as a witness. He would communicate with the ladder before beginning the crystal gazing, and then throughout the process, explaining what he sees and feels, just as he did with me.
Everything requires communication. When Larry offers to give me a travel prayer when I leave Arizona next week, I ask whether that it’s all right for someone from another culture to receive a prayer. With a short, light laugh he says, “Yes!”
“Before we start the prayer, I will tell the elements who you are, how you grew up, what your culture is. For those who believe in a Christian God, I will include this in the prayers too; for those who don’t, I don’t. I myself go to three different churches. I was raised Catholic by my mother, I go to Protestant church for the songs, and to Mormon church because my wife is Mormon. I feel the belief is all the same thing.”
“How important is belief to whether the prayer will work?”
“It works sometimes even for those who don’t believe. Belief is the thing, though.”
And so, on my last day on the Navajo reservation I’m blessed by Larry for safe travels. He uses a feather that was a gift given to him in Canada, where he took his wife once when she was feeling badly about her father’s death. At that time, seeing her grive, he had said to her, “Let’s drive North,” and that’s what they did. He brought back this feather that he uses often for prayers. He sings a travel song, and then prays, all in Navajo. The only thing he says in English is: “going to drive to Connecticut.”
He burns wheatgrass atop a burning coal. He gathers the smoke in the air with the feather, using the feather to wave the wafts around my body, then touching the feather lightly to my body: my feet, shins, knees, thighs, arms, chest, shoulders, cheeks, back.
When he says goodbye, he gives me a gentle hug sideways, stooping very slightly to meet me.
Tuesday, November 30, 2010
back & forth
This fifth year, this in-between year of personal goals and time for self, has been a year of coming and going. Took a post-boards vacation in California, came back to living at the VA for my medicine subinternship, trekking cross country and living on a Navajo reservation for a month. Even having been back in New Haven for a couple weeks, the weekends have been spent elsewhere, in Boston then in Long Island/NYC. It was nice to dwell in bigger cities than New Haven, cities that are big parts of my past, and to share them with someone open to new sights and feelings. At the same time, because of the trips and because of the upcoming trip home for Christmas and because many friends are also coming and going and I see them in spurts of their being in New Haven, time in New Haven feels transitory, and the slight instability makes it hard to get down to the business of slowness. Instead of taking the time for what it is, it feels like filler until the next movement, when what I really do want is just to stay.
It's both helpful and frustrating to think of goals that stretch past these bumps in place. On the one hand, I find it really hard to work on things I know will have to be paused. On other hand, it's nice to have things to come back to, after an endeavor or a return home. Everything I want to do is a long-term pursuit, the pile of books to read and topics to read about, the work to run better after a setback from which I haven't recovered, maintaining friendships in the midst of a lot of transitions for all of us, being with him and exploring the newness of me and of my surroundings that he makes me feel, the list of stories I feel compelled to narrate. I want to give each of these things room, and it's hard when I keep moving around, but I'm trying not to so strongly associate internal and external spaces, to remember that what's best about these things and why I value them is their mobility.
It's both helpful and frustrating to think of goals that stretch past these bumps in place. On the one hand, I find it really hard to work on things I know will have to be paused. On other hand, it's nice to have things to come back to, after an endeavor or a return home. Everything I want to do is a long-term pursuit, the pile of books to read and topics to read about, the work to run better after a setback from which I haven't recovered, maintaining friendships in the midst of a lot of transitions for all of us, being with him and exploring the newness of me and of my surroundings that he makes me feel, the list of stories I feel compelled to narrate. I want to give each of these things room, and it's hard when I keep moving around, but I'm trying not to so strongly associate internal and external spaces, to remember that what's best about these things and why I value them is their mobility.
Tuesday, November 23, 2010
rearrangement
[October 20 & 26]
In the same way they teach us how to derive a differential diagnosis from a history and physical, they teach us how to interact with patients, in patterns and algorithms. I have a lot of respect for the critical thought that the development of these structures entail, and a lot of admiration for the beauty of the forms they produce. But they would feel a little suffocating, get a little boring, if not for the fact that they’re applied to people who aren’t static, who move, who each move with different fluidity even if in the same space as everyone else, and so who make you move too. In a place in the country that feels like another country, you instinctively let go of some of your ground, and become more open to continual rearrangement.
And even without the backdrop of an entirely different culture, there are characteristics that inherently place distance between people. There is a lot of stretching to be done, to talk to people at different poles of age and experience and expressiveness.
I spent one morning at the teen clinic at Chinle High School, where teenagers can make their own appointments and see primary care doctors during the school day. There is a security guard both at the parking lot and within the entrance of the school. Not unusually, they mistook me for a high school student. Despite looking so much like a sixteen year old, the clinic made clear how far from those years I am, how much intangible can happen in ten years’ time. I spent most of my time talking to the patients about sex, depression, and sports—many of them came for physical exams required to play sports; these were often the same patients with whom I ended up talking about sex and depression.
For me, it’s hard to assess what teenagers absorb from their surroundings, because I think their capacity to feel progresses more quickly than their capacity to express, or maybe their desire to express. They’re so different from people just a few years younger or older, making this period of time feel rare and fragile. The subtle changes we all experience from moment to moment are more pronounced in them, but with perhaps less self-awareness. All of this can be frustrating if you try to tackle things too quickly, and so they almost therapeutically push you to take time and care to read them. And if they open just a fraction, they can be in different phases of so many processes at once, many that lack obvious linearity. If you want to do anything with that, you have to be okay working in rough pieces without knowing their sources or trajectories, not immediately and often not in the near or distant future either.
It’s a challenge for me to speak to the quiet girl with skinny jeans, converse sneakers, black glasses and thick black eyeliner, and a short boycut with all the hairs angled to the left of her face, making her face look strikingly straight in comparison. She is one of the students who’s here for a sports physical; she’s playing softball in the spring. She pauses before answering any question, then answers with as few words and movement of her face as possible. The stillness isn’t effortful; it’s without thought, as though the moment her eyes and lips move out of place they naturally fall back to their original state of clear and mute.
All adolescents are asked to fill out a screening form before their visit, which asks them about school, diet, exercise, sexuality, mood, home life, and so on. On her screening form, the girl indicates that she has felt down for more than two weeks and has once thought about killing herself. Talking to her more, she has almost all the symptoms of major depression: decreased appetite, poor concentration, interest in activities she’d enjoyed before, bad sleep, and of course depressed mood. Her mother moved to New Mexico five months earlier, and she misses her a lot. She isn’t at all interested in talking to anyone about these things.
The screening form also asks if the patient has any questions about any of the following: diet, exercise, sexuality, school, relationships. She had circled exercise, and when I asked her what her questions were, she said that I’d already answered all of her questions during the visit. I asked her what kind of questions she had that I’d answered. She responded, “Oh about being bisexual.”
It took me a moment to go with that. I’m already too far removed from high school to understand how teenagers process their environment and relay what’s internal. And I think sometimes we try too hard to really understand; I respect the effort, but I think the subsequent discouragement that comes with failure can be harmful. We get tired and closed. Maybe we can just accept that we don’t know how a person gets from one place to another; maybe we’re closed off from that hallway, but once they’ve gotten to a place we can try to enter that.
So even though I wasn’t sure how we got to this point in the conversation, I took this comment as a gift from the guarded 14 year old. She then looked at me straight in the face, with eyes finally visible behind her glasses and hair even though neither had shifted position, and asked with such earnestness that the numbness of all her past sentences struck me: Is it okay to be bisexual?
I’m not at all equipped to answer this with the sensitivity and exactness that a fragile person deserves; I’ve never been asked that before. All I can do is hope to reciprocate her earnestness. She talks about having told a friend, who then told everyone, who then treated her badly. They tell her to go back from where she came from, and as she describes this, she looks genuinely confused; strange how her strongest expression of emotion is one of not knowing how to feel.
The doctor knocks on our door to retrieve us so that we can complete the visit together. I welcome this reminder that I’m a student, that learning is an explicit part of my role, but I wonder what to do with what I’ve learned. At first the girl doesn’t want me to tell the doctor about anything we talked about. When I talk to her privately about the reasons for speaking to her primary doctor about our conversation, she nods. When we are all in the room together, I tell her that I’m going to tell the doctor a little about what we talked about, that I know it’s personal, and that if she wants to tell the doctor herself that would be all right too; again she nods.
The girl refuses any sort of resource offered, and it’s hard to see her go without much more than she came with, and knowing I won’t see her again. It’s really hard. The doctor feels it too, but she makes the point that now it’s known somewhere whereas before it was only in the girl, and she knows she can come back. It’s one step; it’s a different place, even if a lot of doors are still closed to us.
The transition between places can be jarring even when elicited and anticipated. It can feel sudden when traveled gradually by this quiet teenage girl, or when it pours forth from the outgoing middle-aged woman whose slight change in the folds of her face make me lean forward and ask, precipitating a complete reworking of her face. This woman with strong features and build, a carpenter who can’t imagine not working with her hands, who has gone through rehab for alcohol use, who had her first cigarette in a long time yesterday because that was “just how I was feeling,” who comes to us with questions about a colonscopy that a woman at forty years old does not need, begins to cry. This time again I’m unsure how we arrived here; this time not because the concrete steps were unlinked, but because she moves so steadily on a new path that I lose track of the steps that initially brought her there, and again it seems more important to just continue.
She talks about how she has just moved here last night from her hometown of Ganado, how she doesn’t know if she can go back; she wants to go back but things won’t be the same; she needs work but she can’t go back to pick up her tools; it is hard to find work in a new place; her partner is a woman who abuses her verbally and physically; her family tells her to leave her; she thought she’d been strong; she hasn’t talked to anyone. We spoke for some time. When the doctor saw her a little while later, he provides her with some resources that she seems interested in pursuing and schedules her for a follow-up appointment, a streamlined process that seems a blur compared to what came before.
Watching her leave with an effortful smile and half of the demeanor she’d carried into the room, I’m reminded of something a resident told me on my psychiatry rotation. He’d said that after you’ve helped a person break down part of their exterior to expose other coves, and have dwelled there for awhile, you need to help build them back up before you leave them. With this woman I felt she left more exposed, without much protection for open patches, and so I feel that it’s not just closed spaces that are tenuous. These interactions can be difficult, and so when there’s movement there’s fulfillment, but no guarantee of safety. But to be so lucky as to be given a choice, it seems to me worth the risk.
In the same way they teach us how to derive a differential diagnosis from a history and physical, they teach us how to interact with patients, in patterns and algorithms. I have a lot of respect for the critical thought that the development of these structures entail, and a lot of admiration for the beauty of the forms they produce. But they would feel a little suffocating, get a little boring, if not for the fact that they’re applied to people who aren’t static, who move, who each move with different fluidity even if in the same space as everyone else, and so who make you move too. In a place in the country that feels like another country, you instinctively let go of some of your ground, and become more open to continual rearrangement.
And even without the backdrop of an entirely different culture, there are characteristics that inherently place distance between people. There is a lot of stretching to be done, to talk to people at different poles of age and experience and expressiveness.
I spent one morning at the teen clinic at Chinle High School, where teenagers can make their own appointments and see primary care doctors during the school day. There is a security guard both at the parking lot and within the entrance of the school. Not unusually, they mistook me for a high school student. Despite looking so much like a sixteen year old, the clinic made clear how far from those years I am, how much intangible can happen in ten years’ time. I spent most of my time talking to the patients about sex, depression, and sports—many of them came for physical exams required to play sports; these were often the same patients with whom I ended up talking about sex and depression.
For me, it’s hard to assess what teenagers absorb from their surroundings, because I think their capacity to feel progresses more quickly than their capacity to express, or maybe their desire to express. They’re so different from people just a few years younger or older, making this period of time feel rare and fragile. The subtle changes we all experience from moment to moment are more pronounced in them, but with perhaps less self-awareness. All of this can be frustrating if you try to tackle things too quickly, and so they almost therapeutically push you to take time and care to read them. And if they open just a fraction, they can be in different phases of so many processes at once, many that lack obvious linearity. If you want to do anything with that, you have to be okay working in rough pieces without knowing their sources or trajectories, not immediately and often not in the near or distant future either.
It’s a challenge for me to speak to the quiet girl with skinny jeans, converse sneakers, black glasses and thick black eyeliner, and a short boycut with all the hairs angled to the left of her face, making her face look strikingly straight in comparison. She is one of the students who’s here for a sports physical; she’s playing softball in the spring. She pauses before answering any question, then answers with as few words and movement of her face as possible. The stillness isn’t effortful; it’s without thought, as though the moment her eyes and lips move out of place they naturally fall back to their original state of clear and mute.
All adolescents are asked to fill out a screening form before their visit, which asks them about school, diet, exercise, sexuality, mood, home life, and so on. On her screening form, the girl indicates that she has felt down for more than two weeks and has once thought about killing herself. Talking to her more, she has almost all the symptoms of major depression: decreased appetite, poor concentration, interest in activities she’d enjoyed before, bad sleep, and of course depressed mood. Her mother moved to New Mexico five months earlier, and she misses her a lot. She isn’t at all interested in talking to anyone about these things.
The screening form also asks if the patient has any questions about any of the following: diet, exercise, sexuality, school, relationships. She had circled exercise, and when I asked her what her questions were, she said that I’d already answered all of her questions during the visit. I asked her what kind of questions she had that I’d answered. She responded, “Oh about being bisexual.”
It took me a moment to go with that. I’m already too far removed from high school to understand how teenagers process their environment and relay what’s internal. And I think sometimes we try too hard to really understand; I respect the effort, but I think the subsequent discouragement that comes with failure can be harmful. We get tired and closed. Maybe we can just accept that we don’t know how a person gets from one place to another; maybe we’re closed off from that hallway, but once they’ve gotten to a place we can try to enter that.
So even though I wasn’t sure how we got to this point in the conversation, I took this comment as a gift from the guarded 14 year old. She then looked at me straight in the face, with eyes finally visible behind her glasses and hair even though neither had shifted position, and asked with such earnestness that the numbness of all her past sentences struck me: Is it okay to be bisexual?
I’m not at all equipped to answer this with the sensitivity and exactness that a fragile person deserves; I’ve never been asked that before. All I can do is hope to reciprocate her earnestness. She talks about having told a friend, who then told everyone, who then treated her badly. They tell her to go back from where she came from, and as she describes this, she looks genuinely confused; strange how her strongest expression of emotion is one of not knowing how to feel.
The doctor knocks on our door to retrieve us so that we can complete the visit together. I welcome this reminder that I’m a student, that learning is an explicit part of my role, but I wonder what to do with what I’ve learned. At first the girl doesn’t want me to tell the doctor about anything we talked about. When I talk to her privately about the reasons for speaking to her primary doctor about our conversation, she nods. When we are all in the room together, I tell her that I’m going to tell the doctor a little about what we talked about, that I know it’s personal, and that if she wants to tell the doctor herself that would be all right too; again she nods.
The girl refuses any sort of resource offered, and it’s hard to see her go without much more than she came with, and knowing I won’t see her again. It’s really hard. The doctor feels it too, but she makes the point that now it’s known somewhere whereas before it was only in the girl, and she knows she can come back. It’s one step; it’s a different place, even if a lot of doors are still closed to us.
The transition between places can be jarring even when elicited and anticipated. It can feel sudden when traveled gradually by this quiet teenage girl, or when it pours forth from the outgoing middle-aged woman whose slight change in the folds of her face make me lean forward and ask, precipitating a complete reworking of her face. This woman with strong features and build, a carpenter who can’t imagine not working with her hands, who has gone through rehab for alcohol use, who had her first cigarette in a long time yesterday because that was “just how I was feeling,” who comes to us with questions about a colonscopy that a woman at forty years old does not need, begins to cry. This time again I’m unsure how we arrived here; this time not because the concrete steps were unlinked, but because she moves so steadily on a new path that I lose track of the steps that initially brought her there, and again it seems more important to just continue.
She talks about how she has just moved here last night from her hometown of Ganado, how she doesn’t know if she can go back; she wants to go back but things won’t be the same; she needs work but she can’t go back to pick up her tools; it is hard to find work in a new place; her partner is a woman who abuses her verbally and physically; her family tells her to leave her; she thought she’d been strong; she hasn’t talked to anyone. We spoke for some time. When the doctor saw her a little while later, he provides her with some resources that she seems interested in pursuing and schedules her for a follow-up appointment, a streamlined process that seems a blur compared to what came before.
Watching her leave with an effortful smile and half of the demeanor she’d carried into the room, I’m reminded of something a resident told me on my psychiatry rotation. He’d said that after you’ve helped a person break down part of their exterior to expose other coves, and have dwelled there for awhile, you need to help build them back up before you leave them. With this woman I felt she left more exposed, without much protection for open patches, and so I feel that it’s not just closed spaces that are tenuous. These interactions can be difficult, and so when there’s movement there’s fulfillment, but no guarantee of safety. But to be so lucky as to be given a choice, it seems to me worth the risk.
Monday, November 22, 2010
first day meeting open space
Have finished my primary care rotation in Chinle Arizona on the Navajo Indian reservation, and am slowly backtracking in writing about the experiences. It will probably take awhile, but here are some thoughts of the first day.
*
[October 19]
I approached Chinle Hospital in the dark, turning left onto the first paved road after a long stretch of lightless highway. The past hour and half encompassed nothing behind or ahead, focusing on the few feet of sight afforded by my headlights and hoping hard that my car wouldn’t break down or run into livestock. I’m relieved to see a sign, and a building in the distance; my fingernails released slightly their hold on my steering wheel. The directions written by one of the physicians noted that we would pass over three cattle grates on the road to the hospital. I didn’t know what these were, but I soon learn that when the sounds of the ground and feel of my seat beneath the car’s wheels changed, that meant I’m going over said cattle grates. This is how I came to know Chinle, in pieces of sensations. In the dark, the expanse is immeasurable; the next morning, the immeasurement is visible.
When parking my car facing the hospital, the sky stretches behind. Every morning the clouds are a different kind of spectacular, still and nonchalant. When I ask employees who had grown up there where they were from, they point to specks in the landscape: that peak next to the dipping crests, this bend in the road. On runs and drives along the two roads that take me from my housing to the hospital and back, looking at what’s straight ahead is like looking down from above; this and the sharp cold reminds me of the 5000 feet elevation. On one day, a cluster of green trees on the side of the road are burning in transitional sunlight, between the day’s rawness and the modesty of dusk. The space above the grove is encased in thick creamy gray cloud, such that you have to face the other side of the road to find the source of the yellow cloaking the trees.
Against the open space, I slip into the interior of the hospital a little off balance. There I am surprised to find that at first the inside here is not so different from the inside back elsewhere. There are aisles of patient rooms equipped with computers, otoscopes and ophthalmolscopes, and hand sanitizer. I recognize these sights, but I’m newly aware of the air surrounding them. The first day of clinic is muffled, faintly familiar with a lot I couldn’t quite understand. The medical problems are not dissimilar from what I have seen: diabetes, hypertension, hypothyroidism, back pain, joint aches; nor were the services rendered: routine physicals, medication changes, laboratory tests. Despite the intimacy of our relation to our blood and hormones, it is normal to disengage them from ourselves to form concepts of illness. Reading the medical chart before entering the patient room, I feel no hitch in turning the wheels of listing these problems and considering treatment of them. But once inside, I’m struck in that compact space, as I was in the emptiness of Arizona desert, by a depth made foreign not only by its thickness but also by the texture of it layers.
Meeting a homogeneous patient population connected by their residence on the 26,000 square mile Navajo reservation, where the distances between homes are far in miles and close in experience, I’m worried that it is at first too easy to perceive things in broad strokes. I’m surprised to find that the backdrop doesn’t blur individual outlines; instead it places details in relief, some of which do converge into a large perception.
The town of Chinle holds a little under 5000 people; this had seemed small when I read it on paper, but encountering a dozen patients in a day feels the same here as it does in a city of 500,000. The patients I see on the first day of clinic make me wonder at how many people exist, how much experience lies in what’s considered a gap in life when driving across country.
On the first day there are several people who individually move me, and as a group make me question our separation of illness and person. Not separation in the sense that we forget there is a person experiencing the illness; we know this happens often and the danger of this kind of thinking is familiar to us. Separation in the sense that illness happens to a person by outside forces, and thus can then be taken away by outside forces. The people I meet today attribute so much of what they feel physically and emotionally to themselves, and this philosophy and practice of internalization is new to me, as someone who learned about disease first as subjects in school, then as objects people have the way they might own a winter coat, something not readily shed but is in principle detachable.
There is a 13 year old girl with very long, straight hair obscuring her pretty features, with glasses and crooked teeth still too large for a mouth still adjusting to the shape of her face. The oldest of six children, she is unsure of how she should stand. She’s tall, but skinny too such that she easily folds herself over at the waist and looks small. She’s here for her annual physical exam, and tells us that she often contemplates suicide. She admits to cutting her wrists, a process I hear a relative lot about over the rest of my time here. It’s hard for her to express why, her feelings spanning a spectrum broader than her vocabulary. On the teenage questionnaire that asks if you could change one thing about your life and yourself, she responds that she would choose to “be brave and emotionless.”
There is a middle-aged man who is here for management of his chronic lower back pain. He wears glasses too, but they don’t overwhelm his face the way the teenager’s did. He yells at himself when the pain is too much to take, because he knows he’s to blame for the source of it. Years ago, he fell off a ladder while intoxicated, and the impact to his back has continually flared since then. He yells at himself outside, away from his children, and defers from repeating his words here in the office. He doesn’t want counseling; he has had it in the past and does not think he is in a place where counseling is necessary. He is reluctant to pursue surgery for his back, because he won’t be able to take care of his children, and his wife who left him a year ago will then take them from him.
There is another middle-aged man with a cowboy hat, checkered blue shirt, and heavy brown boots, compliant with his medications and without any complaint other than fatigue after a bout of cryptogenic organizing pneumonia on top of severe heart failure. He says that a native medicine healer told him that this was due to his practice of killing and burning snakes during his childhood. The defiled spirit of the snakes has encroached upon his own, causing him physical illness. When asked why he killed and burned snakes, he replies that he was scared of them. He says that the healer believes this is also the reason why his face has been more swollen recently. It’s hard to be Navajo, he says to me. He says it not for his sake but for mine.
Each person responds differently to their respective self-blame: the girl tells herself cutting is stupid, the first man resorts to alcohol to soothe the injury first induced by alcohol, the second man participates in a ceremony to remove from himself the spirits of snakes killed. Successfully or not, they carry and shift and distribute the weight of whatever is disturbing them, in a way that I haven’t recognized before. I’m not sure how this new awareness, still a vague theory without real understanding, will help in handling the weight. But learning to be open to its presence and to the process of building a sense of its character made for a fitting first day.
*
[October 19]
I approached Chinle Hospital in the dark, turning left onto the first paved road after a long stretch of lightless highway. The past hour and half encompassed nothing behind or ahead, focusing on the few feet of sight afforded by my headlights and hoping hard that my car wouldn’t break down or run into livestock. I’m relieved to see a sign, and a building in the distance; my fingernails released slightly their hold on my steering wheel. The directions written by one of the physicians noted that we would pass over three cattle grates on the road to the hospital. I didn’t know what these were, but I soon learn that when the sounds of the ground and feel of my seat beneath the car’s wheels changed, that meant I’m going over said cattle grates. This is how I came to know Chinle, in pieces of sensations. In the dark, the expanse is immeasurable; the next morning, the immeasurement is visible.
When parking my car facing the hospital, the sky stretches behind. Every morning the clouds are a different kind of spectacular, still and nonchalant. When I ask employees who had grown up there where they were from, they point to specks in the landscape: that peak next to the dipping crests, this bend in the road. On runs and drives along the two roads that take me from my housing to the hospital and back, looking at what’s straight ahead is like looking down from above; this and the sharp cold reminds me of the 5000 feet elevation. On one day, a cluster of green trees on the side of the road are burning in transitional sunlight, between the day’s rawness and the modesty of dusk. The space above the grove is encased in thick creamy gray cloud, such that you have to face the other side of the road to find the source of the yellow cloaking the trees.
Against the open space, I slip into the interior of the hospital a little off balance. There I am surprised to find that at first the inside here is not so different from the inside back elsewhere. There are aisles of patient rooms equipped with computers, otoscopes and ophthalmolscopes, and hand sanitizer. I recognize these sights, but I’m newly aware of the air surrounding them. The first day of clinic is muffled, faintly familiar with a lot I couldn’t quite understand. The medical problems are not dissimilar from what I have seen: diabetes, hypertension, hypothyroidism, back pain, joint aches; nor were the services rendered: routine physicals, medication changes, laboratory tests. Despite the intimacy of our relation to our blood and hormones, it is normal to disengage them from ourselves to form concepts of illness. Reading the medical chart before entering the patient room, I feel no hitch in turning the wheels of listing these problems and considering treatment of them. But once inside, I’m struck in that compact space, as I was in the emptiness of Arizona desert, by a depth made foreign not only by its thickness but also by the texture of it layers.
Meeting a homogeneous patient population connected by their residence on the 26,000 square mile Navajo reservation, where the distances between homes are far in miles and close in experience, I’m worried that it is at first too easy to perceive things in broad strokes. I’m surprised to find that the backdrop doesn’t blur individual outlines; instead it places details in relief, some of which do converge into a large perception.
The town of Chinle holds a little under 5000 people; this had seemed small when I read it on paper, but encountering a dozen patients in a day feels the same here as it does in a city of 500,000. The patients I see on the first day of clinic make me wonder at how many people exist, how much experience lies in what’s considered a gap in life when driving across country.
On the first day there are several people who individually move me, and as a group make me question our separation of illness and person. Not separation in the sense that we forget there is a person experiencing the illness; we know this happens often and the danger of this kind of thinking is familiar to us. Separation in the sense that illness happens to a person by outside forces, and thus can then be taken away by outside forces. The people I meet today attribute so much of what they feel physically and emotionally to themselves, and this philosophy and practice of internalization is new to me, as someone who learned about disease first as subjects in school, then as objects people have the way they might own a winter coat, something not readily shed but is in principle detachable.
There is a 13 year old girl with very long, straight hair obscuring her pretty features, with glasses and crooked teeth still too large for a mouth still adjusting to the shape of her face. The oldest of six children, she is unsure of how she should stand. She’s tall, but skinny too such that she easily folds herself over at the waist and looks small. She’s here for her annual physical exam, and tells us that she often contemplates suicide. She admits to cutting her wrists, a process I hear a relative lot about over the rest of my time here. It’s hard for her to express why, her feelings spanning a spectrum broader than her vocabulary. On the teenage questionnaire that asks if you could change one thing about your life and yourself, she responds that she would choose to “be brave and emotionless.”
There is a middle-aged man who is here for management of his chronic lower back pain. He wears glasses too, but they don’t overwhelm his face the way the teenager’s did. He yells at himself when the pain is too much to take, because he knows he’s to blame for the source of it. Years ago, he fell off a ladder while intoxicated, and the impact to his back has continually flared since then. He yells at himself outside, away from his children, and defers from repeating his words here in the office. He doesn’t want counseling; he has had it in the past and does not think he is in a place where counseling is necessary. He is reluctant to pursue surgery for his back, because he won’t be able to take care of his children, and his wife who left him a year ago will then take them from him.
There is another middle-aged man with a cowboy hat, checkered blue shirt, and heavy brown boots, compliant with his medications and without any complaint other than fatigue after a bout of cryptogenic organizing pneumonia on top of severe heart failure. He says that a native medicine healer told him that this was due to his practice of killing and burning snakes during his childhood. The defiled spirit of the snakes has encroached upon his own, causing him physical illness. When asked why he killed and burned snakes, he replies that he was scared of them. He says that the healer believes this is also the reason why his face has been more swollen recently. It’s hard to be Navajo, he says to me. He says it not for his sake but for mine.
Each person responds differently to their respective self-blame: the girl tells herself cutting is stupid, the first man resorts to alcohol to soothe the injury first induced by alcohol, the second man participates in a ceremony to remove from himself the spirits of snakes killed. Successfully or not, they carry and shift and distribute the weight of whatever is disturbing them, in a way that I haven’t recognized before. I’m not sure how this new awareness, still a vague theory without real understanding, will help in handling the weight. But learning to be open to its presence and to the process of building a sense of its character made for a fitting first day.
Wednesday, October 13, 2010
northeast to southwest
On a cross country drive there's a lot of time to think about why you're doing what you're doing. In the larger scheme of things, but also in the moment--like, why are we driving all day long? I think that that thought is one of the reasons to love long drives. Caitlin, my partner on the road, mentioned a meditative exercise where you sit and concentrate on sensation starting from your toes moving up, so that you become acutely aware of yourself piece by piece. Watching long stretches of road feels similar. You notice sudden and subtle changes in the landscape, and in the position of your arms and legs, and in how much sun is coming through the window to warm your skin. There are moments too when you lose attention altogether, which is nice too.
Caitlin and I both have clinical rotations on Indian health reservations in the Southwest for the month of October. She's doing ob-gyn in Gallup New Mexico, and I'm doing primary care in Chinle Arizona. Both places are in the middle of nowhere, hours from the nearest airport in Albuquerque. The cities are two hours from each other, and we planned on driving from Connecticut to the Southwest together since the end of summer, though most of our few concrete plans were made in the week before leaving. Another thing to love about drives, the freedom and flexibility and living out of the car and not having to carry stuff and worry too much about packaging.
The drive took us way down south on 95 (I had no idea 95 went so far), into regions of the country I'd never seen before. I've wanted to see the South for awhile, not because I had any appealing images of it but because I had no images of it at all. After a night in Maryland we drove through North Carolina, stayed along the coast in Charleston South Carolina and Savannah Georgia, saw Alabama and Mississippi through the car windows, spent a full day in New Orleans, drove along an L-shaped route through Louisiana to reach Dallas for a night, drove across a lot of nothing to get to the next Texan city of Amarillo, and completed a drive across the whole of Texas and the beginnings of New Mexico to arrive at Albuquerque.
To describe the South is hard, after such sensory overload in a new place; and unfair, after such a brief glimpse. But with those caveats, I think it's worth sharing. Driving from Maryland and Virginia into the Carolinas, the weather changed palpably from cold rain to warm yellow. I saw cotton fields for the first time; in Georgia we stopped to pick some, probably illegally; in Texas we were surprised to see miles of cotton and picked those as well. Caitlin had said they smelled like earth, and she was right, and Georgia earth smelled different from Texas earth. Against all overexposure and desensitization, I always feel pleasant surprise at seeing pure white lying so low to the ground (snow, salt, cotton).
We met Charleston SC at nighttime, where the homes have long wide columns, side porches, gates guarding gardens and fountains, and painted family portraits visible through windows. The street and house lamps burn real fire, and the trees and gates stand close to the homes, creating quietly gorgeous shadows. After the night sun takes over for the fire, though they keep the fire during through daylight too. Savannah was more developed and less striking than Charleston, but we did find plenty of magnolia trees, oak trees, and Spanish moss hanging off the oak trees. The drive through Georgia was populated by peach tree orchards, baby pine farms, and lots and lots of cotton.
I fell asleep for a good chunk of the drive through Alabama, due to the sun and to the Faulkner audio book playing in the car (Light in August: worthy to read and very Southern, but listening to books read aloud by strangers hasn't grown on me yet). I went to my first Waffle House in Alabama, and I remember Mississippi being very pretty with its water and expansive fields, and I also remember this day being a daze of a drive. Once in New Orleans, Caitlin snapped me out of it with rapid fire commentary on every street, home and billboard in her hometown. She took me round to all the good eats (crepes, beignets which I called French doughnuts which offended someone, ice cream, burgers & milkshakes), and drove me down St. Charles and her favorite street and Bourbon St in the French Quarter, stopping every few moments so I could take pictures of the incredible houses and balconies. She also introduced me to her tall kind lovely parents, showed me turtles in her favorite park, had our hair cut at her go-to hair salon, and had our pictures taken in a photobooth at a local bar; these parts were best for being specific to her and her home.
From there we had a long drive to Dallas; we didn't have much time to see the city, but we had our own kind of experience through Texas as we drove from there to New Mexico. Between Dallas and Amarillo there is a whole lot of nothing, and it was the first time on the trip that we felt like we were in the middle of nowhere, with mostly trucks on the road and no rest stops for a hundred miles at a time and speed limits of 80 and skies absolutely clear (we saw exactly one cloud). There is something really calming about driving across entire states, sensing both the immensity of things and the fluidity of lines. This made for the best day of the trip, with a soothingly empty landscape of concentrated red dust on either side of us, sometimes suddenly broken by unusual beauty--small sunflowers growing like weeds, a cluster of leaveless trees with gnarled branches, a dilapidated farm house, a field of what we'd call ranch country, stretches of what we called prairie grass--lightly tinged at the top with maroon and purple in a way that seemed unreal, in the way that its faint color could make you feel so much. There was also an adult video store every so often, standing on its own with nothing for miles before and after, because as Caitlin said, even the middle of nowhere needs that.
Once we arrived in Amarillo, we had our Texan experience over the course of five miles and an hour, none of which had been planned (we'd only known that Amarillo was the only city besides Dallas that showed up on our Google map route). This included a huge tacky road-side shop with a sign claiming "everything really is bigger in Texas" and a huge cowboy boot for evidence; breezing through a big warehouse of cowboy boots; a glance inside Hooters (neither of us had been to one and thought TX was a fitting place for our first venture); and a stop at Cadillac Ranch, a public art installation of ten Cadillacs vertically half-buried into the ground that people are free to spray-paint with whatever they fancy as they road-trip across Texas.
Then we were off for more flat landscape (this was our longest day, roughly 12 hours from start of driving to end) until we entered New Mexico, where the land changed dramatically to flat-topped canyons and crumbly ground sprinkled with little bushes. We arrived little before sunset, and drove until dark when the sky became dense with stars, and the outlines of mountains blended into black so that you had to squint to see if they were there. I've been to New Mexico before, but entering it this way felt new. We drove fast in the dark blasting pop songs, and when we got into a neighborhood we stopped at a stop sign and got out of the car to dance outside barefoot (until a car came up behind us and we raced back).
I looked back at something I wrote on the cross country trip I took a few years ago: "When in your life you feel both brave and unsure and open to emptiness, drive across your country with your Thelma." Still believing this to be true, I know I'm lucky to be able to 1) feel this way, and 2) act on it; to not be stuck or closed in feeling or movement. We ended our trip with the hot air balloon fiesta in Albuquerque, getting up at 3 AM to catch the balloons inflating and rising from the heat of fire. It was funny to watch things float and fly after so many days on ground, funnier that I was content to stay in place. Until we left again.
Caitlin and I both have clinical rotations on Indian health reservations in the Southwest for the month of October. She's doing ob-gyn in Gallup New Mexico, and I'm doing primary care in Chinle Arizona. Both places are in the middle of nowhere, hours from the nearest airport in Albuquerque. The cities are two hours from each other, and we planned on driving from Connecticut to the Southwest together since the end of summer, though most of our few concrete plans were made in the week before leaving. Another thing to love about drives, the freedom and flexibility and living out of the car and not having to carry stuff and worry too much about packaging.
The drive took us way down south on 95 (I had no idea 95 went so far), into regions of the country I'd never seen before. I've wanted to see the South for awhile, not because I had any appealing images of it but because I had no images of it at all. After a night in Maryland we drove through North Carolina, stayed along the coast in Charleston South Carolina and Savannah Georgia, saw Alabama and Mississippi through the car windows, spent a full day in New Orleans, drove along an L-shaped route through Louisiana to reach Dallas for a night, drove across a lot of nothing to get to the next Texan city of Amarillo, and completed a drive across the whole of Texas and the beginnings of New Mexico to arrive at Albuquerque.
To describe the South is hard, after such sensory overload in a new place; and unfair, after such a brief glimpse. But with those caveats, I think it's worth sharing. Driving from Maryland and Virginia into the Carolinas, the weather changed palpably from cold rain to warm yellow. I saw cotton fields for the first time; in Georgia we stopped to pick some, probably illegally; in Texas we were surprised to see miles of cotton and picked those as well. Caitlin had said they smelled like earth, and she was right, and Georgia earth smelled different from Texas earth. Against all overexposure and desensitization, I always feel pleasant surprise at seeing pure white lying so low to the ground (snow, salt, cotton).
We met Charleston SC at nighttime, where the homes have long wide columns, side porches, gates guarding gardens and fountains, and painted family portraits visible through windows. The street and house lamps burn real fire, and the trees and gates stand close to the homes, creating quietly gorgeous shadows. After the night sun takes over for the fire, though they keep the fire during through daylight too. Savannah was more developed and less striking than Charleston, but we did find plenty of magnolia trees, oak trees, and Spanish moss hanging off the oak trees. The drive through Georgia was populated by peach tree orchards, baby pine farms, and lots and lots of cotton.
I fell asleep for a good chunk of the drive through Alabama, due to the sun and to the Faulkner audio book playing in the car (Light in August: worthy to read and very Southern, but listening to books read aloud by strangers hasn't grown on me yet). I went to my first Waffle House in Alabama, and I remember Mississippi being very pretty with its water and expansive fields, and I also remember this day being a daze of a drive. Once in New Orleans, Caitlin snapped me out of it with rapid fire commentary on every street, home and billboard in her hometown. She took me round to all the good eats (crepes, beignets which I called French doughnuts which offended someone, ice cream, burgers & milkshakes), and drove me down St. Charles and her favorite street and Bourbon St in the French Quarter, stopping every few moments so I could take pictures of the incredible houses and balconies. She also introduced me to her tall kind lovely parents, showed me turtles in her favorite park, had our hair cut at her go-to hair salon, and had our pictures taken in a photobooth at a local bar; these parts were best for being specific to her and her home.
From there we had a long drive to Dallas; we didn't have much time to see the city, but we had our own kind of experience through Texas as we drove from there to New Mexico. Between Dallas and Amarillo there is a whole lot of nothing, and it was the first time on the trip that we felt like we were in the middle of nowhere, with mostly trucks on the road and no rest stops for a hundred miles at a time and speed limits of 80 and skies absolutely clear (we saw exactly one cloud). There is something really calming about driving across entire states, sensing both the immensity of things and the fluidity of lines. This made for the best day of the trip, with a soothingly empty landscape of concentrated red dust on either side of us, sometimes suddenly broken by unusual beauty--small sunflowers growing like weeds, a cluster of leaveless trees with gnarled branches, a dilapidated farm house, a field of what we'd call ranch country, stretches of what we called prairie grass--lightly tinged at the top with maroon and purple in a way that seemed unreal, in the way that its faint color could make you feel so much. There was also an adult video store every so often, standing on its own with nothing for miles before and after, because as Caitlin said, even the middle of nowhere needs that.
Once we arrived in Amarillo, we had our Texan experience over the course of five miles and an hour, none of which had been planned (we'd only known that Amarillo was the only city besides Dallas that showed up on our Google map route). This included a huge tacky road-side shop with a sign claiming "everything really is bigger in Texas" and a huge cowboy boot for evidence; breezing through a big warehouse of cowboy boots; a glance inside Hooters (neither of us had been to one and thought TX was a fitting place for our first venture); and a stop at Cadillac Ranch, a public art installation of ten Cadillacs vertically half-buried into the ground that people are free to spray-paint with whatever they fancy as they road-trip across Texas.
Then we were off for more flat landscape (this was our longest day, roughly 12 hours from start of driving to end) until we entered New Mexico, where the land changed dramatically to flat-topped canyons and crumbly ground sprinkled with little bushes. We arrived little before sunset, and drove until dark when the sky became dense with stars, and the outlines of mountains blended into black so that you had to squint to see if they were there. I've been to New Mexico before, but entering it this way felt new. We drove fast in the dark blasting pop songs, and when we got into a neighborhood we stopped at a stop sign and got out of the car to dance outside barefoot (until a car came up behind us and we raced back).
I looked back at something I wrote on the cross country trip I took a few years ago: "When in your life you feel both brave and unsure and open to emptiness, drive across your country with your Thelma." Still believing this to be true, I know I'm lucky to be able to 1) feel this way, and 2) act on it; to not be stuck or closed in feeling or movement. We ended our trip with the hot air balloon fiesta in Albuquerque, getting up at 3 AM to catch the balloons inflating and rising from the heat of fire. It was funny to watch things float and fly after so many days on ground, funnier that I was content to stay in place. Until we left again.
Tuesday, September 28, 2010
editing
My few weeks of nothing is coming to a close, as I ready for a cross country drive to Arizona, where I'll be doing a primary care rotation for a month. Probably because my mind is preparing and no longer in cruise control, I've come to the realization that these past weeks were more editing and maintenance than writing and moving forward.
In one respect, I enjoyed that a lot. Often I relish editing someone else's words more than forming my own. It's less taxing in a lot of ways that writing can be frustrating, and it can also be its own sort of challenge, as I found anew while working with the patient for my project on her personal story. On first read, you might think that it required a lot of reworking, both structurally and textually. In terms of structure, it wasn't something I could shape just by removing repetitions and grouping similar details. That's the first step, but just a concrete one, and if anything solid is to come from that, I had to understand what the author wanted to say. The same goes for nuances of text, choosing words etc. But in terms of that, I found it a really interesting and satisfying endeavor to keep her words while trying to manipulate the presentation of the words to better convey what she wanted. Again, on first read the story would be taken as undeveloped in terms of style, but I found myself falling in love with her simple narration, very much a mental print of memories as they came to her. I liked the sense that this was her, and didn't feel compelled use or add different words, which would change this sense.
Figuring out what she wanted of course was the most important, and this isn't straightforward. I can most definitely relate to writing without consciously knowing my purpose. So this grew out of a lot of conversation, questions, and reading versions of the story as things were concretely refined. And in those, I found that her words supplied both structure and text, and overall purpose. Everything added was added in the raw form that she gave it, and then it was a matter of placement and detail.
She had begun the story all because of the fact that she had known this person, and she ended it feeling that she hadn't really known the person at all. To go through that process with her and be able to document and express that process, it made me feel again how natural it is to want to shape narratives, how complex and fulfilling the effort can be.
It was also a pleasure to speak to someone who has experienced worlds and lands so vastly different from the ones she occupies now; to see in one person how much can be had in a life. It makes me feel less caught up in doing the things I wanted to do during these weeks, makes me feel all right with letting experiences happen and unfold as they come, to feel less lame for expending energy on simply maintaining the things in my life that take me places without actually going any place (car, camera, body). Just continuing can bring newness and fullness, and even though I've done almost no writing at all in this period, maybe sometime in the near future my words will come as simply and clearly as hers.
In one respect, I enjoyed that a lot. Often I relish editing someone else's words more than forming my own. It's less taxing in a lot of ways that writing can be frustrating, and it can also be its own sort of challenge, as I found anew while working with the patient for my project on her personal story. On first read, you might think that it required a lot of reworking, both structurally and textually. In terms of structure, it wasn't something I could shape just by removing repetitions and grouping similar details. That's the first step, but just a concrete one, and if anything solid is to come from that, I had to understand what the author wanted to say. The same goes for nuances of text, choosing words etc. But in terms of that, I found it a really interesting and satisfying endeavor to keep her words while trying to manipulate the presentation of the words to better convey what she wanted. Again, on first read the story would be taken as undeveloped in terms of style, but I found myself falling in love with her simple narration, very much a mental print of memories as they came to her. I liked the sense that this was her, and didn't feel compelled use or add different words, which would change this sense.
Figuring out what she wanted of course was the most important, and this isn't straightforward. I can most definitely relate to writing without consciously knowing my purpose. So this grew out of a lot of conversation, questions, and reading versions of the story as things were concretely refined. And in those, I found that her words supplied both structure and text, and overall purpose. Everything added was added in the raw form that she gave it, and then it was a matter of placement and detail.
She had begun the story all because of the fact that she had known this person, and she ended it feeling that she hadn't really known the person at all. To go through that process with her and be able to document and express that process, it made me feel again how natural it is to want to shape narratives, how complex and fulfilling the effort can be.
It was also a pleasure to speak to someone who has experienced worlds and lands so vastly different from the ones she occupies now; to see in one person how much can be had in a life. It makes me feel less caught up in doing the things I wanted to do during these weeks, makes me feel all right with letting experiences happen and unfold as they come, to feel less lame for expending energy on simply maintaining the things in my life that take me places without actually going any place (car, camera, body). Just continuing can bring newness and fullness, and even though I've done almost no writing at all in this period, maybe sometime in the near future my words will come as simply and clearly as hers.
Thursday, September 23, 2010
perspective
This morning I walked home with my pockets empty, no keys to let me in my house. Luckily my roommate was home, and at the time I figured I had left my keys and the attached red pouch, with my license, credit cards and ID, inside. But once inside, they were nowhere to be found: purse, backpack, desk and countertops scoured without find. I remembered that I had used the keys to lock the door, then had returned to grab something from my room, so I knew that if I'd left the keys in the house after the return, they would be either in 1) the door, or 2) somewhere visible I would've tossed them, like a table or dresser or the bed. They were in none of these places.
Which left my trajectory from after leaving my place to returning to it. After the keys' last use, I got on the handlebars of his bike; he thought it was safer than walking in the dark with the bike. I had a bookish childhood in which I never learned to ride a bicycle, much less ride on the handlebars, and I was hesitant. The streets were newly damp from fresh rain, still warm in the late summer/early fall. It smelled clear, but the air had the presence of humidity dissolving after the rain, one of my favorite weathers. I leaned back for more balance, and braced my face against his. It was late with pockets of quiet, and pockets of silent sirens where streetlights had gone out, so that his breaths felt close. I'm so used to the New Haven street wanderers and police cars that the visuals of danger don't incite much, and I felt safe flowing by in a breeze.
Not being able to find my keys and wallet the next day, the only other possibility was that they had fallen on this ride. Despite not being fazed by red and blue lights, I knew that if they had fallen in this part of New Haven they were pretty much lost to me. But I tracked my way back, this time on foot, and when strangers tried to make conversation with me (I learned that the large man who sits on the porch of the big green house is Aaron), I even asked them if they'd seen my keys. I went back to his house and rummaged those rooms too, and then scanned the streets again on my way back. Nothing. On the way back, I stopped at the Yale Security Office, who gave me the number to the central security office, who gave me the number to the Yale police, who gave me the number to the New Haven police--all of whom were very nice, none of whom had seen my stuff.
So I came back home with my roommate's keys. I called my friend who has a copy of my car key. I brought these to the locksmith kitty corner from our place, who said they wouldn't be back until 12:45. So I went back home, and canceled my credit card and my ATM debit card. I looked up how to get another driver's license, and realized that it's a bitch to do from across country, and called home to ask my parents to go to the DMV in California, and see if they could fill out the forms there for me. I went back to the locksmith, still closed at 12:45, and decided to go to our landlord down the street to see if I could get a copy of our house keys. I could, for $25. I headed back to the locksmith for my car key, still closed at 1:00. So I walked to campus to get a new Yale ID, for $20, paid for by cash borrowed from my friend. Walking back I passed the locksmith, who was finally open, but who could not copy my car key because it has a chip in it. Instead, I had to go to a locksmith in West Haven, 15 minutes away. After calling them first to make sure they could make a copy of my key, I drove over there, where they made me a copy for $35. I handed them the one credit card I had that hadn't been in my nowhere-to-be-found wallet, and they handed it back to me: "Um, this is expired." Only $7 in cash left, no other cards, no friends nearby--shit shit shit. I got back in my car, maneuvered it in the small awkward parking lot, called Bank of America who told me to get a temporary ATM at the bank, then backed my car back up into a spot, and went back to the locksmith to ask if there was a nearby Bank of America. I drove several minutes down to it, where they told me I couldn't get a temporary card since my account had been open in CA, and here we are in CT. But I could still get cash with a photo ID and my SSN; I had an old license that has expired, but luckily now I also had a new Yale ID. So I withdrew some cash, went back to the locksmith, and got my new car key.
On the drive home my parents called and told me they couldn't get a license for me; I had to be present at the DMV in California, so that they could take a new photograph and attain my fingerprints. I won't be back in CA until December, and I'm driving cross country and back before that happens; a license would be useful.
I came home, and sighed.
The one thing I couldn't recover was the least important, the coffeeshop card with which I'd ranked up almost enough coffees to get a free one. After the day's escapades I escaped to the coffeeshop, told them I'd lost the card and could I get a new one? It turns out they had my name in the computer, with my records and that this coffee would be my free one. So I upgraded from small to large, and told them that this was the first thing I'd lost that I'd gotten back without effort or expense.
As I settled down with my large drink to write about this, I received a call from my other roommate. I had called her in the morning to see if she'd seen my keys in the door. But I didn't see them anywhere in the house where she might have placed them, and she hadn't called me to tell me she'd found them, so I figured this hadn't happened. It turns out that it had; she had found them in the door, taken them with her, and wasn't able to call me until later this evening. After I spent the day replacing things I don't even really want back but "need" in some form.
If someone were to ask me hypothetically, whether I'd go through all that, to have wasted over four hours and eighty dollars, all because I sat atop handlebars of a bike ridden by a silly sweet boy whose face I could feel the whole time, I (like anyone else) would say no. And it's not something that logically follows; I didn't need to lose all my things, scrounge to replace them, eventually find that I'd never lost them--none of that needed to happen in order for me to have that ride. It could've happened, and I could've kept my stuff at the same time. But the comparison changes perspective. Having a nice moment is one thing, and having its niceness sustain itself through moments of not-so-niceness is another. Knowing how little the inconvenience of those four hours of wasted time and money will matter to me tomorrow, and feeling how those four minutes with him will last, I would have to say yes, it was worth it, to really feel what's close to me and what's not.
Which left my trajectory from after leaving my place to returning to it. After the keys' last use, I got on the handlebars of his bike; he thought it was safer than walking in the dark with the bike. I had a bookish childhood in which I never learned to ride a bicycle, much less ride on the handlebars, and I was hesitant. The streets were newly damp from fresh rain, still warm in the late summer/early fall. It smelled clear, but the air had the presence of humidity dissolving after the rain, one of my favorite weathers. I leaned back for more balance, and braced my face against his. It was late with pockets of quiet, and pockets of silent sirens where streetlights had gone out, so that his breaths felt close. I'm so used to the New Haven street wanderers and police cars that the visuals of danger don't incite much, and I felt safe flowing by in a breeze.
Not being able to find my keys and wallet the next day, the only other possibility was that they had fallen on this ride. Despite not being fazed by red and blue lights, I knew that if they had fallen in this part of New Haven they were pretty much lost to me. But I tracked my way back, this time on foot, and when strangers tried to make conversation with me (I learned that the large man who sits on the porch of the big green house is Aaron), I even asked them if they'd seen my keys. I went back to his house and rummaged those rooms too, and then scanned the streets again on my way back. Nothing. On the way back, I stopped at the Yale Security Office, who gave me the number to the central security office, who gave me the number to the Yale police, who gave me the number to the New Haven police--all of whom were very nice, none of whom had seen my stuff.
So I came back home with my roommate's keys. I called my friend who has a copy of my car key. I brought these to the locksmith kitty corner from our place, who said they wouldn't be back until 12:45. So I went back home, and canceled my credit card and my ATM debit card. I looked up how to get another driver's license, and realized that it's a bitch to do from across country, and called home to ask my parents to go to the DMV in California, and see if they could fill out the forms there for me. I went back to the locksmith, still closed at 12:45, and decided to go to our landlord down the street to see if I could get a copy of our house keys. I could, for $25. I headed back to the locksmith for my car key, still closed at 1:00. So I walked to campus to get a new Yale ID, for $20, paid for by cash borrowed from my friend. Walking back I passed the locksmith, who was finally open, but who could not copy my car key because it has a chip in it. Instead, I had to go to a locksmith in West Haven, 15 minutes away. After calling them first to make sure they could make a copy of my key, I drove over there, where they made me a copy for $35. I handed them the one credit card I had that hadn't been in my nowhere-to-be-found wallet, and they handed it back to me: "Um, this is expired." Only $7 in cash left, no other cards, no friends nearby--shit shit shit. I got back in my car, maneuvered it in the small awkward parking lot, called Bank of America who told me to get a temporary ATM at the bank, then backed my car back up into a spot, and went back to the locksmith to ask if there was a nearby Bank of America. I drove several minutes down to it, where they told me I couldn't get a temporary card since my account had been open in CA, and here we are in CT. But I could still get cash with a photo ID and my SSN; I had an old license that has expired, but luckily now I also had a new Yale ID. So I withdrew some cash, went back to the locksmith, and got my new car key.
On the drive home my parents called and told me they couldn't get a license for me; I had to be present at the DMV in California, so that they could take a new photograph and attain my fingerprints. I won't be back in CA until December, and I'm driving cross country and back before that happens; a license would be useful.
I came home, and sighed.
The one thing I couldn't recover was the least important, the coffeeshop card with which I'd ranked up almost enough coffees to get a free one. After the day's escapades I escaped to the coffeeshop, told them I'd lost the card and could I get a new one? It turns out they had my name in the computer, with my records and that this coffee would be my free one. So I upgraded from small to large, and told them that this was the first thing I'd lost that I'd gotten back without effort or expense.
As I settled down with my large drink to write about this, I received a call from my other roommate. I had called her in the morning to see if she'd seen my keys in the door. But I didn't see them anywhere in the house where she might have placed them, and she hadn't called me to tell me she'd found them, so I figured this hadn't happened. It turns out that it had; she had found them in the door, taken them with her, and wasn't able to call me until later this evening. After I spent the day replacing things I don't even really want back but "need" in some form.
If someone were to ask me hypothetically, whether I'd go through all that, to have wasted over four hours and eighty dollars, all because I sat atop handlebars of a bike ridden by a silly sweet boy whose face I could feel the whole time, I (like anyone else) would say no. And it's not something that logically follows; I didn't need to lose all my things, scrounge to replace them, eventually find that I'd never lost them--none of that needed to happen in order for me to have that ride. It could've happened, and I could've kept my stuff at the same time. But the comparison changes perspective. Having a nice moment is one thing, and having its niceness sustain itself through moments of not-so-niceness is another. Knowing how little the inconvenience of those four hours of wasted time and money will matter to me tomorrow, and feeling how those four minutes with him will last, I would have to say yes, it was worth it, to really feel what's close to me and what's not.
Thursday, September 16, 2010
what i'm doing
I've finished my month of subinternship and am in the midst of a month in between rotations. I'll be starting a primary care rotation in October, but in the meantime, when people ask what I'm doing, I usually say, nothing. Which is both true and not true. It's true that I'm not assigned a particular rotation, don't have a routine schedule, and don't have any concrete tasks to accomplish each day or even by the end of the month that anyone is going to check on. And it's true that I've prioritized getting enough sleep, food, exercise, and time with people above all else, which can generally qualify as what's commonly regarded as nothing, as it's not work. But it's not true that I don't have goals to work towards during this time. This block of time was blocked off for research and writing, both endeavors with less concrete goals than this past month.
The last month of being in the hospital was absolutely worth the time and work (of which there was an incredible amount), and I loved it more than I thought I would (in the beginning I was mostly terrified). The structure, mindset, and general atmosphere are very different than my current state, though. Being in the hospital is about treating acute problems, accomplishing tasks: figuring out a diagnosis, ordering the right medicine, filing out the right paperwork, presenting numbers. You work patients up for their problems, you try your best to make them better, and then you discharge them from the hospital. In the gaps and in the broader scheme there are all the other things that make a good doctor, that are more abstract and less straightforward, but the day to day is about getting stuff done.
Which isn't the case with research and writing, both of which I've been working on this past week, without much visible to show for it.
In terms of research, I developed a project that is more about knowing patients than attaining data, which is a difficult thing to 1) do and 2) measure. The general gist is that I want to speak to terminally ill patients who have transitioned from care with goals of cure, to care with goals of quality of life. In the hospital we're good at acute care and quantifiable results, but not as good with transitions that happen over time and aren't easily communicated. I think it's important to know what factors play into patients being ready for this transition, so that we know when and how to talk to them about it, so that care is focused on minimizing suffering, not so much maximizing breathing time.
The first patient I interviewed is dying from lung cancer and had been admitted to the hospice unit of the VA. He was very open to speaking with me but was breathing so heavily, with few gaps between large gasps, that he couldn't talk for longer than a few minutes. When I came back the next day, it was only worse. So nothing came about from those efforts, in terms of my project. But it reminded me of what it's like to see someone actively dying, and of what I want to learn in this process.
My second interview was an actual interview, with a lovely 88 year old woman with lymphoma. She had very developed thoughts about her life and death, and was very comfortable talking about them, so the outcome was completely different from my previous attempt. Another thing I wanted to explore was personal writing, and to have patients journal about their experiences at the end of life, because that can be so different than what someone is able to share in a conversation with a doctor. So at the end of the interview I asked the woman if she'd be interested in participating in something like that. She said that she can't really write due to arthritis, but she had been working awhile ago on a story about her childhood. She brought out several pages of yellow lined paper, and asked if I wanted to read it. We talked about typing it up and having me help her finish it.
So I took the pages home to read and transcribe. Several of them are numbered the same number, such that the order was hard to determine, and as I read through them I realized that's because she had written several different beginnings. Throughout there are some anecdotes told in slightly different ways, so that in typing up the story, I had to maneuver some passages, putting the similar ones side by side, so that she could decide which parts of the same story she wanted to keep, discard, combine. During some particularly difficult parts to decipher, where reading continuously didn't seem to give a sensible narrative, I saw that she'd written in every other line, and in the lines in between added other parts of the story. All of this required some rearranging as I read and typed, and I liked indulging in both the neurotic need to organize and the creative desire to piece things together. The story has nothing to do with my research, but it does have to do with what a lot of people seem to want, a desire to record certain memories, something that resonates a lot with me personally.
I really appreciate the flexibility of this time, that allows things to happen that don't fit a mold of efficiency or list of things to do, where I'm led not by steadfast goals but by natural happenings and my natural responses to them.
And this woman's story comes to me during a time when I've been working on a story about my childhood too. The writing part of this time off is even more vague than the research. I have a list of things I want to write about, which is a little overwhelming, and even when I focus on one, I'm not quite sure what I want to say or how to say it. All I'm sure of is that I feel compelled to write about them, but having the time to do it means being faced with why, and that has resulted in major writer's block. I could spend an entire day on something without much to show for it, and the lack of proportion can be disorienting. But I'm endeared to writing in the way that it's not science and things don't logically lead to other things, and it is amazing to wake up each day with the freedom and privilege to just try, with no expectations, to feel that that's enough, for now.
And so instead of explaining to every person who asks, I say I'm doing nothing. It gets somewhat tiresome, because we're not used to nothing being okay. I'm not traveling anywhere, so it's not like a vacation. The few times I've tried to go more deeply into it, I usually just confuse the person and I'd rather have them think I'm doing nothing of significance instead of misunderstanding something of personal significance. Besides, everyone takes nothing in their own way, and I think we could all use more of it.
The last month of being in the hospital was absolutely worth the time and work (of which there was an incredible amount), and I loved it more than I thought I would (in the beginning I was mostly terrified). The structure, mindset, and general atmosphere are very different than my current state, though. Being in the hospital is about treating acute problems, accomplishing tasks: figuring out a diagnosis, ordering the right medicine, filing out the right paperwork, presenting numbers. You work patients up for their problems, you try your best to make them better, and then you discharge them from the hospital. In the gaps and in the broader scheme there are all the other things that make a good doctor, that are more abstract and less straightforward, but the day to day is about getting stuff done.
Which isn't the case with research and writing, both of which I've been working on this past week, without much visible to show for it.
In terms of research, I developed a project that is more about knowing patients than attaining data, which is a difficult thing to 1) do and 2) measure. The general gist is that I want to speak to terminally ill patients who have transitioned from care with goals of cure, to care with goals of quality of life. In the hospital we're good at acute care and quantifiable results, but not as good with transitions that happen over time and aren't easily communicated. I think it's important to know what factors play into patients being ready for this transition, so that we know when and how to talk to them about it, so that care is focused on minimizing suffering, not so much maximizing breathing time.
The first patient I interviewed is dying from lung cancer and had been admitted to the hospice unit of the VA. He was very open to speaking with me but was breathing so heavily, with few gaps between large gasps, that he couldn't talk for longer than a few minutes. When I came back the next day, it was only worse. So nothing came about from those efforts, in terms of my project. But it reminded me of what it's like to see someone actively dying, and of what I want to learn in this process.
My second interview was an actual interview, with a lovely 88 year old woman with lymphoma. She had very developed thoughts about her life and death, and was very comfortable talking about them, so the outcome was completely different from my previous attempt. Another thing I wanted to explore was personal writing, and to have patients journal about their experiences at the end of life, because that can be so different than what someone is able to share in a conversation with a doctor. So at the end of the interview I asked the woman if she'd be interested in participating in something like that. She said that she can't really write due to arthritis, but she had been working awhile ago on a story about her childhood. She brought out several pages of yellow lined paper, and asked if I wanted to read it. We talked about typing it up and having me help her finish it.
So I took the pages home to read and transcribe. Several of them are numbered the same number, such that the order was hard to determine, and as I read through them I realized that's because she had written several different beginnings. Throughout there are some anecdotes told in slightly different ways, so that in typing up the story, I had to maneuver some passages, putting the similar ones side by side, so that she could decide which parts of the same story she wanted to keep, discard, combine. During some particularly difficult parts to decipher, where reading continuously didn't seem to give a sensible narrative, I saw that she'd written in every other line, and in the lines in between added other parts of the story. All of this required some rearranging as I read and typed, and I liked indulging in both the neurotic need to organize and the creative desire to piece things together. The story has nothing to do with my research, but it does have to do with what a lot of people seem to want, a desire to record certain memories, something that resonates a lot with me personally.
I really appreciate the flexibility of this time, that allows things to happen that don't fit a mold of efficiency or list of things to do, where I'm led not by steadfast goals but by natural happenings and my natural responses to them.
And this woman's story comes to me during a time when I've been working on a story about my childhood too. The writing part of this time off is even more vague than the research. I have a list of things I want to write about, which is a little overwhelming, and even when I focus on one, I'm not quite sure what I want to say or how to say it. All I'm sure of is that I feel compelled to write about them, but having the time to do it means being faced with why, and that has resulted in major writer's block. I could spend an entire day on something without much to show for it, and the lack of proportion can be disorienting. But I'm endeared to writing in the way that it's not science and things don't logically lead to other things, and it is amazing to wake up each day with the freedom and privilege to just try, with no expectations, to feel that that's enough, for now.
And so instead of explaining to every person who asks, I say I'm doing nothing. It gets somewhat tiresome, because we're not used to nothing being okay. I'm not traveling anywhere, so it's not like a vacation. The few times I've tried to go more deeply into it, I usually just confuse the person and I'd rather have them think I'm doing nothing of significance instead of misunderstanding something of personal significance. Besides, everyone takes nothing in their own way, and I think we could all use more of it.
Tuesday, August 17, 2010
subintern
I've just returned from my first day as a medicine subintern. It was about as overwhelming and exhausting as the hype goes, but the core of it was intensely gratifying. And that's not rationalization of the semi-blind choices I've made and difficult path I've chosen, and it's not making the best of things. It's something I feel in my tired chest (why is it that fatigue localizes there, as though our beats and breaths really do consume us). Why else would I be staying up to write this, in a partly delirious state, after having slept less than two hours in the past thirty-two hours? There's so much to say.
A subintern functions much like an intern, which is the first year you legitimately call yourself doctor, except nothing about it feels legitimate. This means that every four nights, you are on-call at the hospital. This means that you work a 30-hour shift. During this time, you see patients who come to the hospital, try to figure out what they have, and try to treat them. You also take care of the patients who are already in the hospital, who are getting better, worse, or staying the same. It's an incredible jump in responsibility, and work hours, from being a student to subintern. I was terrified, and after the first day, still am.
My first day of being a subintern also happened to be my first day on call. So not only did we have to learn the ropes of this new role with parameters wider than my mind could wrap around, but we had to do it for 30 hours straight. Naturally I had a lot of fears about all this. Fears of incompetence, of willpower giving way to fatigue, of being lost in what's supposed to be our space. All of these fears came true. I must say that I did a horrible job on my first day and call. I didn't get morning labs scheduled on time, I didn't think of multiple tests needed for my patients, I made several unnecessary calls and missed other necessary ones, I didn't know how to find new patients in the emergency department, my admission notes were short not for conciseness but for lack of comprehensiveness, my morning oral summaries of the patients were choppy, I didn't gather enough information from past records, I didn't perform complete physical exams on my patients. On and on and on.
It's natural to feel a little frustrated with failure, but what I found myself thinking more than shit, I'm doing such a bad job was, I really WANT to do a good job. For the first time in awhile, I felt want in the purest form. I didn't want it out of frustration from doing badly or because we're always being evaluated, but because I realized 1) just how damn difficult it is to be a good doctor, and 2) how worth it is to be a good doctor. I was lucky to be working with doctors who are good in such complete sense--smart and efficient with the science, smart and kind with the people. People acknowledge that both of these areas take training and effort, but personally, it goes far beyond what I imagined. On the science end, there is an incredible amount of information to gather and most importantly, analyze, apply and synergize. There's the story of symptoms, the methods of the physical exam, the interpretation of numbers, the understanding of images, and how all these complexities interact. And for many patients at once, juggling the components of one patient and then juggling multiple patients--it's dizzying. There is so much to know, and the knowledge isn't empty. Lab values and squiggly lines might appear dry, but when you consider how they are created representations of raw happenings in your body, it's pretty amazing. The indirect ways we've designed to figure ourselves out--I respect them, and I want to know that language in the same way I value language in its conventional definition, as a means of communicating ourselves and something bigger than ourselves. It's never quite the thing itself, but is our approach to it, and a whole other thing on its own. Of course, much (sometimes the majority) of it can be logistics and errands, which I can foresee becoming old fast. But it also appeals to my nerdy, neurotic self and also to a human part of wanting to build when immersed in an environment where people are not rarely falling apart. In both science and logistics I don't pick up things that quickly, and so I know I'll be lost for quite some time, but that's not a source of bitterness--I'm glad to be pursuing something that doesn't come easily.
And I'm glad that the challenge isn't simply for the sake of challenge. Besides the natural appeal of science and systems, there are the patients, and there is the learning of how to be with patients. People think that this isn't as hard as learning all the other stuff; I used to think that way too. But I've learned that while being nice is easy, connecting takes as much of your mind and effort as knowing the science. More often than not I'm not very good at it. I get mixed up with my words and with my silence, I'm bewildered as how to translate my intentions, I find myself painfully aware of my simple experience. The workings of another person can be as foreign as the mechanism of an antibiotic, and I know it's a corny parallel, but the truth is, I often feel myself encountering the same boundaries and confusion with a person as with a drug. But just like with the science, the feelings of stumbling make me feel how much I want this, how much I want to be good at this because I believe in its worth as a goal. I've seen other doctors show such grace at it, and I want that.
It's one of the things I love most about medicine, the way it forces you to interact with people you would never, ever know otherwise. Even as the VA gets the reputation of catering to old men with similar shadings of gruff salted life, each of them carries biting character. The lack of teeth, the sweetness of ninety years of age, the inhibition of schizophrenia, the depression of age, the depression of a hard life, the response to talk about pain, the blue blue eyes, the contortions of wrinkles going this way and that, the leg no longer there, the missing fingers, the natural questions, the natural anxiety. There is such pleasure in coaxing out qualities, of trying hard to see what you can and respect what you can't. And there are fleeting moments where you stop discriminating, when the harsh becomes as welcome as the welcoming, because it's another thing to absorb, another way to hold quality. Of course you'll get mad and annoyed when someone makes things difficult for you; when you're tired and responsible, you aren't looking for this extra baggage and I know I'll never be immune to impatience. But still, isn't baggage the reason we do all this in the first place.
A subintern functions much like an intern, which is the first year you legitimately call yourself doctor, except nothing about it feels legitimate. This means that every four nights, you are on-call at the hospital. This means that you work a 30-hour shift. During this time, you see patients who come to the hospital, try to figure out what they have, and try to treat them. You also take care of the patients who are already in the hospital, who are getting better, worse, or staying the same. It's an incredible jump in responsibility, and work hours, from being a student to subintern. I was terrified, and after the first day, still am.
My first day of being a subintern also happened to be my first day on call. So not only did we have to learn the ropes of this new role with parameters wider than my mind could wrap around, but we had to do it for 30 hours straight. Naturally I had a lot of fears about all this. Fears of incompetence, of willpower giving way to fatigue, of being lost in what's supposed to be our space. All of these fears came true. I must say that I did a horrible job on my first day and call. I didn't get morning labs scheduled on time, I didn't think of multiple tests needed for my patients, I made several unnecessary calls and missed other necessary ones, I didn't know how to find new patients in the emergency department, my admission notes were short not for conciseness but for lack of comprehensiveness, my morning oral summaries of the patients were choppy, I didn't gather enough information from past records, I didn't perform complete physical exams on my patients. On and on and on.
It's natural to feel a little frustrated with failure, but what I found myself thinking more than shit, I'm doing such a bad job was, I really WANT to do a good job. For the first time in awhile, I felt want in the purest form. I didn't want it out of frustration from doing badly or because we're always being evaluated, but because I realized 1) just how damn difficult it is to be a good doctor, and 2) how worth it is to be a good doctor. I was lucky to be working with doctors who are good in such complete sense--smart and efficient with the science, smart and kind with the people. People acknowledge that both of these areas take training and effort, but personally, it goes far beyond what I imagined. On the science end, there is an incredible amount of information to gather and most importantly, analyze, apply and synergize. There's the story of symptoms, the methods of the physical exam, the interpretation of numbers, the understanding of images, and how all these complexities interact. And for many patients at once, juggling the components of one patient and then juggling multiple patients--it's dizzying. There is so much to know, and the knowledge isn't empty. Lab values and squiggly lines might appear dry, but when you consider how they are created representations of raw happenings in your body, it's pretty amazing. The indirect ways we've designed to figure ourselves out--I respect them, and I want to know that language in the same way I value language in its conventional definition, as a means of communicating ourselves and something bigger than ourselves. It's never quite the thing itself, but is our approach to it, and a whole other thing on its own. Of course, much (sometimes the majority) of it can be logistics and errands, which I can foresee becoming old fast. But it also appeals to my nerdy, neurotic self and also to a human part of wanting to build when immersed in an environment where people are not rarely falling apart. In both science and logistics I don't pick up things that quickly, and so I know I'll be lost for quite some time, but that's not a source of bitterness--I'm glad to be pursuing something that doesn't come easily.
And I'm glad that the challenge isn't simply for the sake of challenge. Besides the natural appeal of science and systems, there are the patients, and there is the learning of how to be with patients. People think that this isn't as hard as learning all the other stuff; I used to think that way too. But I've learned that while being nice is easy, connecting takes as much of your mind and effort as knowing the science. More often than not I'm not very good at it. I get mixed up with my words and with my silence, I'm bewildered as how to translate my intentions, I find myself painfully aware of my simple experience. The workings of another person can be as foreign as the mechanism of an antibiotic, and I know it's a corny parallel, but the truth is, I often feel myself encountering the same boundaries and confusion with a person as with a drug. But just like with the science, the feelings of stumbling make me feel how much I want this, how much I want to be good at this because I believe in its worth as a goal. I've seen other doctors show such grace at it, and I want that.
It's one of the things I love most about medicine, the way it forces you to interact with people you would never, ever know otherwise. Even as the VA gets the reputation of catering to old men with similar shadings of gruff salted life, each of them carries biting character. The lack of teeth, the sweetness of ninety years of age, the inhibition of schizophrenia, the depression of age, the depression of a hard life, the response to talk about pain, the blue blue eyes, the contortions of wrinkles going this way and that, the leg no longer there, the missing fingers, the natural questions, the natural anxiety. There is such pleasure in coaxing out qualities, of trying hard to see what you can and respect what you can't. And there are fleeting moments where you stop discriminating, when the harsh becomes as welcome as the welcoming, because it's another thing to absorb, another way to hold quality. Of course you'll get mad and annoyed when someone makes things difficult for you; when you're tired and responsible, you aren't looking for this extra baggage and I know I'll never be immune to impatience. But still, isn't baggage the reason we do all this in the first place.
Saturday, August 7, 2010
parenchyma
While cramming for my board exams, I found myself tucking away medical terms like crackers. A big part of doing well on these exams has to do with associations; read nitroblue tetrazolium and think chronic granulomatous disease. At one point I learned the details of what the former and latter actually mean. These days I retain a general sense, but a lot of the finer points that would help form a concrete image are lost in the process of remembering the words. Things have become more and more familiar to me, but I don't know them more deeply.
Despite learning so much, the time has been so compact that I can still remember what it was like in the beginning. I distinctly remember feeling as overwhelmed as I still do, but also completely bewildered (as opposed to 89% so, currently). I remember sitting in front of the computer with my classmate, going through learning exercises on our school website. I remember looking at pictures of the lungs, and looking at each other, and wondering, "What's parenchyma?"
Wikipedia told us that parenchyma is the "bulk of a substance." This wasn't quite clear to us. I was used to science depicting arrows to things and giving them names, names that you could then translate into something you could point to. Over the past few years, we've learned that learning science isn't so much about precision as much as it is generalities for the details we don't know yet or can't know. Over the same past few years, the term parenchyma has been thrown around so often in relation to so many organs that we feel we know it. We know it not by memorized definition but by sense and familiarity. We can't point it out but we can nod when we hear the word. I feel this way about a lot of things in science and medicine, but parenchyma specifically crossed my mind a couple of weeks ago, and yesterday a friend of mine brought it up as an example of something he still doesn't really understand.
It's not that I think our knowledge is hollow. Every so often when I study, I'm stopped by the sudden rediscovery of how smart people can be. Sometimes words are gloss-overs, but often they are substantial representations of observation and logic. But I do feel we know less of the bulk of substances than we like to admit. After all, it's supposed to be a catch-all term for the essence of something, and we throw it around like it's something we can hold, and we dismiss the fact that we don't have precise means to define it. But if it's kind of the essence of the thing, shouldn't we take more care with that? Shouldn't we want to express it more clearly, know it better? At the least, give credit to its depth by confessing that our hands are too slippery and clumsy for it?
Writing is important to me for being a way to give more substance to our vague sense of substance. Even though it doesn't give the step by step explanation that we seek and sometimes miss from science, it acknowledges the fact that it can't. The bulk of a substance might be heavy, but weight can make things more elusive, and it seems right that this is so. For all the parts of life we know and handle, we rarely absorb it as a whole. I don't think it's meant to be fully known (or maybe it's just not possible), but I do think we're meant to seek it out (or maybe we just want to).
Despite learning so much, the time has been so compact that I can still remember what it was like in the beginning. I distinctly remember feeling as overwhelmed as I still do, but also completely bewildered (as opposed to 89% so, currently). I remember sitting in front of the computer with my classmate, going through learning exercises on our school website. I remember looking at pictures of the lungs, and looking at each other, and wondering, "What's parenchyma?"
Wikipedia told us that parenchyma is the "bulk of a substance." This wasn't quite clear to us. I was used to science depicting arrows to things and giving them names, names that you could then translate into something you could point to. Over the past few years, we've learned that learning science isn't so much about precision as much as it is generalities for the details we don't know yet or can't know. Over the same past few years, the term parenchyma has been thrown around so often in relation to so many organs that we feel we know it. We know it not by memorized definition but by sense and familiarity. We can't point it out but we can nod when we hear the word. I feel this way about a lot of things in science and medicine, but parenchyma specifically crossed my mind a couple of weeks ago, and yesterday a friend of mine brought it up as an example of something he still doesn't really understand.
It's not that I think our knowledge is hollow. Every so often when I study, I'm stopped by the sudden rediscovery of how smart people can be. Sometimes words are gloss-overs, but often they are substantial representations of observation and logic. But I do feel we know less of the bulk of substances than we like to admit. After all, it's supposed to be a catch-all term for the essence of something, and we throw it around like it's something we can hold, and we dismiss the fact that we don't have precise means to define it. But if it's kind of the essence of the thing, shouldn't we take more care with that? Shouldn't we want to express it more clearly, know it better? At the least, give credit to its depth by confessing that our hands are too slippery and clumsy for it?
Writing is important to me for being a way to give more substance to our vague sense of substance. Even though it doesn't give the step by step explanation that we seek and sometimes miss from science, it acknowledges the fact that it can't. The bulk of a substance might be heavy, but weight can make things more elusive, and it seems right that this is so. For all the parts of life we know and handle, we rarely absorb it as a whole. I don't think it's meant to be fully known (or maybe it's just not possible), but I do think we're meant to seek it out (or maybe we just want to).
Wednesday, August 4, 2010
radio
I don't listen to the radio much except for when I'm at home. In addition to the perfect temperature of the sun, and the easy wide roads, and the hills, the radio is why I love driving in the Bay Area. Besides the current pop (it was unexpectedly satisfying to crank up "California Gurls" in California), the stations here take me back to junior high dances and even further back to playing in the aisles of my dad's store with nineties soft rock in the background, and to being driven around by my brothers in their eighties cars to the tunes of eighties new wave. I blast a lot of bad, catchy music. It's stuff I never hear elsewhere, stuff that I haven't heard in years, like old school Mase (words I still know) or that one beautiful Donna Lewis song (I Love You Always Forever) that made me buy the entire album but only listen to that one song. Now that I've sold that CD away years before iTunes import was invented, the only time I might ever come across the song again is by chance on the kind of radio station they use at the dentist, the kind of station programmed in the car along with pop, hip hop and oldies.
It was in this house and in this place that I listened to my first radio, sometime in elementary school. The beer and cigarette companies my dad would purchase his store's goods from would send him little gifts with their brands all over them, like bags and cups and one time, a radio. It was from Camel cigarettes. It was a blue and yellow handheld radio, in a rectangular shape, with a camel on it, and an antenna. I sat on the carpet of my parents' bedroom, turned it on, and became mesmerized for the next four hours. I heard the same top forty songs cycled through the afternoon, and it's my first memory of discovering music. I became familiar with the concept of a radio station, and especially when I've been away for a long time, the pureness of that discovery comes back when I drive here to the radio. There's something about all this that makes nostalgia fresh, and the layers of everything around so light without losing substance. And it's just fun to dance and sing loudly, badly, and honestly in the car.
It was in this house and in this place that I listened to my first radio, sometime in elementary school. The beer and cigarette companies my dad would purchase his store's goods from would send him little gifts with their brands all over them, like bags and cups and one time, a radio. It was from Camel cigarettes. It was a blue and yellow handheld radio, in a rectangular shape, with a camel on it, and an antenna. I sat on the carpet of my parents' bedroom, turned it on, and became mesmerized for the next four hours. I heard the same top forty songs cycled through the afternoon, and it's my first memory of discovering music. I became familiar with the concept of a radio station, and especially when I've been away for a long time, the pureness of that discovery comes back when I drive here to the radio. There's something about all this that makes nostalgia fresh, and the layers of everything around so light without losing substance. And it's just fun to dance and sing loudly, badly, and honestly in the car.
Monday, August 2, 2010
goodbyes
[begun July 17]
A lot of people in my life have left New Haven, in a cluster over the course of a couple days. I've always found it funny how things coincide, either naturally or through my mind's doings or some mix of the two, or a mix between things beyond my control and things directed loosely by the directions I choose in my life. Today I said goodbye twice, to people who have left the city permanently.
[currently]
I didn't give myself any time to process those goodbyes, and it felt a bit like betrayal to myself. I wanted to cry but I wouldn't, because I knew how all consuming it would become. I wanted to sit on my bed and listen to music all day, but I couldn't give myself that space amidst all the things to do, and I didn't want to falter. I'm not sure if it was right, but at the time I didn't feel I could function well otherwise. And, the only thing really is to do it now.
One farewell was to one of my best friends in med school, one I'd met on my first day at school three years ago, with whom I spent many a day. The other was to a family I'd met a couple months ago, who I saw every weekend for about an hour and a half. They each deserve writings about them, one of which I have done a bit of before and the other which will be coming. But there is something about goodbyes themselves, and the relationships that make them hard, that warrants words.
Relationships are funny in the way they incorporate such different ingredients and take such different forms, yet converge into similar general feelings. There are of course nuances, but I felt a parallel heaviness with both goodbyes; maybe it was partly because they happened in the same period of time, but I think it was also because when it comes down to it, it's about connecting to a person, and change.
With one, I was hit with the awareness of the luck and good chance that my experience fell into place with the experience of someone who gives so much to respect, admire, and love. As a friend, classmate and person, his presence so defined my time and growth here, with such gradual steadiness that its substance molded itself naturally into the walls of my life. Time is so constant that I sometimes forget what happens in its context. Even though there were many moments I was conscious of how lucky I felt for his friendship and existence, it wasn't until he was going away that I understood how lucky I felt for not just moments but the proximity and closeness of our lives, how easy it was to seek him out and be sought out. And for not just moments but what grew through and in between them, how incredible it is what develops with time. Time is so crazy. I saw him pack up the last of his empty apartment, and I drove him to the train station. His bus was coming soon and he needed to get food before it came, so the final goodbye was of the quick see you later quality, and it's apt in a way. I'll see him again soon. He's not that far away. But his place in relation to mine has shifted.
With the other goodbye, I was struck by how affected I was by a connection with such lack of detail, so few moments, so little time. The family didn't speak English well and we couldn't communicate well. Somehow, the limited expression made clearer their depth. Recently I've been told often by someone to speak without filters, and I always think that for me it's not so much about filters as it is about finding the most accurate words because I feel so messy that I don't know exactly how to explain things. But when you have so few words, there is no way to filter, no way to dilute or complicate. When there are no other ways, people capitalize as much as they can on the simple means they have to convey kindness and openness, and the purity of that carries force. When they first told me they'd be leaving, and in just a few weeks, I was completely surprised and I felt sudden sadness in throat and eyes, which also surprised me. It wasn't until then that I recognized what our short time had led me to envision; I had been under the impression that there would be long to go, that the small space we had formed would fill and fill. Ultimately, I'm amazed at the deep impact of surface interactions, and how the nature of an interaction can account for just as much as how long it has been in place.
It hurts very much to know, while they are still there, how much you will miss them. To know that that can come from something cultivated in time, and also from something more fleeting, makes me think that nothing is too bound or static, and these goodbyes aren't demarcations but more part of a larger mold. Still, they pierced a defined day in my life, and I'll remember it as such.
A lot of people in my life have left New Haven, in a cluster over the course of a couple days. I've always found it funny how things coincide, either naturally or through my mind's doings or some mix of the two, or a mix between things beyond my control and things directed loosely by the directions I choose in my life. Today I said goodbye twice, to people who have left the city permanently.
[currently]
I didn't give myself any time to process those goodbyes, and it felt a bit like betrayal to myself. I wanted to cry but I wouldn't, because I knew how all consuming it would become. I wanted to sit on my bed and listen to music all day, but I couldn't give myself that space amidst all the things to do, and I didn't want to falter. I'm not sure if it was right, but at the time I didn't feel I could function well otherwise. And, the only thing really is to do it now.
One farewell was to one of my best friends in med school, one I'd met on my first day at school three years ago, with whom I spent many a day. The other was to a family I'd met a couple months ago, who I saw every weekend for about an hour and a half. They each deserve writings about them, one of which I have done a bit of before and the other which will be coming. But there is something about goodbyes themselves, and the relationships that make them hard, that warrants words.
Relationships are funny in the way they incorporate such different ingredients and take such different forms, yet converge into similar general feelings. There are of course nuances, but I felt a parallel heaviness with both goodbyes; maybe it was partly because they happened in the same period of time, but I think it was also because when it comes down to it, it's about connecting to a person, and change.
With one, I was hit with the awareness of the luck and good chance that my experience fell into place with the experience of someone who gives so much to respect, admire, and love. As a friend, classmate and person, his presence so defined my time and growth here, with such gradual steadiness that its substance molded itself naturally into the walls of my life. Time is so constant that I sometimes forget what happens in its context. Even though there were many moments I was conscious of how lucky I felt for his friendship and existence, it wasn't until he was going away that I understood how lucky I felt for not just moments but the proximity and closeness of our lives, how easy it was to seek him out and be sought out. And for not just moments but what grew through and in between them, how incredible it is what develops with time. Time is so crazy. I saw him pack up the last of his empty apartment, and I drove him to the train station. His bus was coming soon and he needed to get food before it came, so the final goodbye was of the quick see you later quality, and it's apt in a way. I'll see him again soon. He's not that far away. But his place in relation to mine has shifted.
With the other goodbye, I was struck by how affected I was by a connection with such lack of detail, so few moments, so little time. The family didn't speak English well and we couldn't communicate well. Somehow, the limited expression made clearer their depth. Recently I've been told often by someone to speak without filters, and I always think that for me it's not so much about filters as it is about finding the most accurate words because I feel so messy that I don't know exactly how to explain things. But when you have so few words, there is no way to filter, no way to dilute or complicate. When there are no other ways, people capitalize as much as they can on the simple means they have to convey kindness and openness, and the purity of that carries force. When they first told me they'd be leaving, and in just a few weeks, I was completely surprised and I felt sudden sadness in throat and eyes, which also surprised me. It wasn't until then that I recognized what our short time had led me to envision; I had been under the impression that there would be long to go, that the small space we had formed would fill and fill. Ultimately, I'm amazed at the deep impact of surface interactions, and how the nature of an interaction can account for just as much as how long it has been in place.
It hurts very much to know, while they are still there, how much you will miss them. To know that that can come from something cultivated in time, and also from something more fleeting, makes me think that nothing is too bound or static, and these goodbyes aren't demarcations but more part of a larger mold. Still, they pierced a defined day in my life, and I'll remember it as such.
Sunday, August 1, 2010
climbing
Doing nothing is glorious, and amidst the backdrop of home, it feels even more fully nothing because this is a place where I just am--not a place I worked to get to, not a place I remember adjusting to, not a place I had to populate with furniture. My little over a day back has been spent eating, sleeping and driving. Fremont is a beautiful town with its neat green trees and long stretches of fences shielding yellow fields from the school roads. It's a suburb, with nothing of note to show a newcomer; it's not a destination for anyone; it's just a sequence of events that made it so I would know its beauty. The sun drenches through all openings in our house, and somehow the sun feels different in different places, such that nothing makes me feel quite the same way I feel when my mom pulls the blinds up so the kitchen is bright so she she can make soy bean milk from real soy beans. I love to drive here, with the easy streets and the comfort of windows down. The mangoes are sweet.
Doing nothing really does feel like breathing, after such concentrated time of working hard for concrete things, and for looser periods of time of living for generalities. After this vacation, I will be rusty at that underlying gradually forward progression, but I think too I'll be a little stronger, because constant movement, however balanced and however enjoyable, needs rest.
It's odd how even as much as we need it, our bodies sometimes give us a hard time for taking a break. My roommate and I started rock climbing a few months ago, and it's hard. It's not as easy as it looks to climb a wall; it's also more satisfying than it looks. A lot of it is about building through continuous tries, and we've improved in tangible ways. But once, we returned after a two week hiatus, and found ourselves struggling with what had been easy before. It sucked. I turned to her and asked, why can't it ever just be enough? Why do we always have to keep trying? She laughed, looked at me and said, are you still talking about climbing?
As achievers we run on having something to achieve, and so there is always something more to work for. And having done something once isn't always a guarantee that it will be easy the next time, when you've a gap in between the times. It can be alternately trying and refreshing to never have an end, and I like how climbing combines these sensations and the combination is visceral and mental, and as a result, filling. Part of this is because there are little ends that you can see; each climb ends somewhere and sometimes you make it. When your arms exhaust themselves, which always happens sooner than you realize, and each move is a struggle and every try is only making you weaker and less likely to reach the next hold--you don't make that end, but in those cases, you're glad to know it's not the end.
The moments of completing this climb and of trying for more aren't always clearly defined, and that seems to make sense. And while too long between tries can be hard, so is too little time, as I remember from the day after two consecutive climbing days, when doing absolutely nothing made my arms scream with ache. Perhaps as we get better, the threshold for too short will get slimmer, for too long wider. In things that are continuous, I find a lot of flexibility in the boundaries, and there's a lot to be had in all parts of it.
Doing nothing really does feel like breathing, after such concentrated time of working hard for concrete things, and for looser periods of time of living for generalities. After this vacation, I will be rusty at that underlying gradually forward progression, but I think too I'll be a little stronger, because constant movement, however balanced and however enjoyable, needs rest.
It's odd how even as much as we need it, our bodies sometimes give us a hard time for taking a break. My roommate and I started rock climbing a few months ago, and it's hard. It's not as easy as it looks to climb a wall; it's also more satisfying than it looks. A lot of it is about building through continuous tries, and we've improved in tangible ways. But once, we returned after a two week hiatus, and found ourselves struggling with what had been easy before. It sucked. I turned to her and asked, why can't it ever just be enough? Why do we always have to keep trying? She laughed, looked at me and said, are you still talking about climbing?
As achievers we run on having something to achieve, and so there is always something more to work for. And having done something once isn't always a guarantee that it will be easy the next time, when you've a gap in between the times. It can be alternately trying and refreshing to never have an end, and I like how climbing combines these sensations and the combination is visceral and mental, and as a result, filling. Part of this is because there are little ends that you can see; each climb ends somewhere and sometimes you make it. When your arms exhaust themselves, which always happens sooner than you realize, and each move is a struggle and every try is only making you weaker and less likely to reach the next hold--you don't make that end, but in those cases, you're glad to know it's not the end.
The moments of completing this climb and of trying for more aren't always clearly defined, and that seems to make sense. And while too long between tries can be hard, so is too little time, as I remember from the day after two consecutive climbing days, when doing absolutely nothing made my arms scream with ache. Perhaps as we get better, the threshold for too short will get slimmer, for too long wider. In things that are continuous, I find a lot of flexibility in the boundaries, and there's a lot to be had in all parts of it.
Tuesday, July 27, 2010
so soon
On the eve of my board exams, a super hasty post about how I cannot wait to go home, for some calm and perspective. I'm as excited to go to Fremont, California as I was for Greece or Vietnam; in some ways, the feelings are even deeper. As usual I've let many things accumulate, things to save for home, the little and the closer to heart. There are errands: passport renewal, car registration, shoe returns, health insurance, travel and work for the next year. There are things I want to do everyday--run, write, sit on the couch with my parents. In my head I have a pile of unstarted entries about science, goodbyes, people--the thought of bumming around in the city and on the beach to plow through them is driving me crazy, it's so close. There are a good number of people from past and present I will be so happy to talk to, do things with, see things with, just be with--my oldest friend, my best friends from high school, college roommates, friends here who are currently there, and people met in between. As hard as it at these times to be away from my family, feeling so strongly their pull makes me glad for that capacity and venue for feeling. My mom is making all my favorite foods and my brother is making reservations at all his favorite sushi restaurants. There will be ocean, hikes, hills, woods, climbs, and lots and lots of sleeping. Before I get there, I have two 9-hour exams, two flights and three days to get through. It is so good to know how heavily the after outweighs the before.
Wednesday, July 21, 2010
music
Spending the bigger chunks of my day studying means constant music. I really love music so much, and in the most recent immersion, I came to the thought that being with music is like being with a person. And not for memories associated with people, but because music is this living, organic thing to which you form real, heavy ties.
In listening to albums all the way through, and listening to multiple albums by the same musician, and seeing the same musician perform at different concerts in different venues, themes diffuse from the sounds to inside, and the layers shift and unveil. The National likes concepts surrounding lemons, geese, and years. There are a couple songs that Thao Nguyen always plays in concert, that I wasn't fond of before, but have grown to form a sort of attachment to because she's obviously attached, and because each time she plays them, they have a different feel, and I love that dynamic factor of moving art that people breathe.
It's funny, how despite all that movement, how much of the time when I listen to a song or album, I feel the same as I did when I first came to know it, no matter how much time and distance has grown since then. Listening to Plans (Death Cab) the other week, I felt the twinges of the summer when I first loved it, and not as a former remnant but as its complete whole, as if I was back in that carpeted room, stacking my CDs on the stereo playing those bittersweet songs, finding it insanely hard to move my hands because I was in such heartbreak over changes back then. I remember sitting at the office in Vietnam, when my co-worker played James Blunt, and I wanted to die, thousands of miles and two years away from when that song first made me feel and hurt. Regardless of listening to old music in new places, new periods of time, new places in life, how I knew it first always comes back.
In those ways and in other ways music is both less and more real than real life, and I like that funny, deeply strong state of feeling, even if it's more of an ache than anything else.
In listening to albums all the way through, and listening to multiple albums by the same musician, and seeing the same musician perform at different concerts in different venues, themes diffuse from the sounds to inside, and the layers shift and unveil. The National likes concepts surrounding lemons, geese, and years. There are a couple songs that Thao Nguyen always plays in concert, that I wasn't fond of before, but have grown to form a sort of attachment to because she's obviously attached, and because each time she plays them, they have a different feel, and I love that dynamic factor of moving art that people breathe.
It's funny, how despite all that movement, how much of the time when I listen to a song or album, I feel the same as I did when I first came to know it, no matter how much time and distance has grown since then. Listening to Plans (Death Cab) the other week, I felt the twinges of the summer when I first loved it, and not as a former remnant but as its complete whole, as if I was back in that carpeted room, stacking my CDs on the stereo playing those bittersweet songs, finding it insanely hard to move my hands because I was in such heartbreak over changes back then. I remember sitting at the office in Vietnam, when my co-worker played James Blunt, and I wanted to die, thousands of miles and two years away from when that song first made me feel and hurt. Regardless of listening to old music in new places, new periods of time, new places in life, how I knew it first always comes back.
In those ways and in other ways music is both less and more real than real life, and I like that funny, deeply strong state of feeling, even if it's more of an ache than anything else.
Saturday, July 17, 2010
empathy
Learned today about a phenomenon called sympathetic ophthalmia, which I initially thought would be more accurately called empathetic ophthalmia. Basically when one eye undergoes some kind of traumatic injury, weeks later the other eye will also become diseased, even without having been subjected to any injury. So this seems more like empathy, which involves experiencing on some level another entity's experience, instead of sympathy which is more like understanding from more distance. It also brings to the surface the self-detrimental component of empathy in its rawest form.
But there's more to it than that. The mechanism is thought to be that injury to the eye exposes the body to elements in the eye that it's not used to, so the body mounts an immune response against them. So this immune response attacks parts of the other eye, and it becomes inflamed and ill. I was struck by how the valiant inefficacy of this process. As so often happens, the ways our bodies try to protect themselves result in harm, and natural processes are ramped to the point to which they become unnatural.
It's also interesting how things exist in physical compartments in ourselves, such that one part of our body is completely foreign to another part. And kind of scared of each other, the way the body is freaked out by stuff in the eye that's always been there but that it's just never seen. A good chunk of diseases is about recognizing things that are simply in the wrong place; for example, nothing should cross the diaphragm that separates the chest from the abdomen. Sometimes when I'm learning about an organ I look down at myself and wonder at how close it is and yet how little I know about how it works and what it's doing at the moment.
With all the barriers, defenses, instincts, injuries, active and passive--empathy is not so easy, I think.
But there's more to it than that. The mechanism is thought to be that injury to the eye exposes the body to elements in the eye that it's not used to, so the body mounts an immune response against them. So this immune response attacks parts of the other eye, and it becomes inflamed and ill. I was struck by how the valiant inefficacy of this process. As so often happens, the ways our bodies try to protect themselves result in harm, and natural processes are ramped to the point to which they become unnatural.
It's also interesting how things exist in physical compartments in ourselves, such that one part of our body is completely foreign to another part. And kind of scared of each other, the way the body is freaked out by stuff in the eye that's always been there but that it's just never seen. A good chunk of diseases is about recognizing things that are simply in the wrong place; for example, nothing should cross the diaphragm that separates the chest from the abdomen. Sometimes when I'm learning about an organ I look down at myself and wonder at how close it is and yet how little I know about how it works and what it's doing at the moment.
With all the barriers, defenses, instincts, injuries, active and passive--empathy is not so easy, I think.
Wednesday, July 14, 2010
crown 14A
For the last two years, here lived three goofy guys, and here a part of me was made and kept. I know we'll continue to see each of you and all of you together, but not in this place and this space anymore. I will miss so much about this--
The dirty kitchen floors. The mismatched chairs taken from different rooms for gatherings, a chair without a back, a wheely desk chair, some with cushions. The South Asian spices, and the blender where anything goes, where juice can be bright purple (beets) or conventional. The impromptu fruit salads, multiple colors eaten with condensed milk; or an all-orange salad of oranges, mango, cantaloupe. And mm, cantaloupe juice. How they never let guests wash the dishes. The balcony, for eats and smokes. The made-up songs about fruits and family and inappropriate things, the electric guitar and the acoustic guitar and the belt-out voices. The room with the gadgets where the "practicing" of video games takes place. The rooftop with sunsets, on clear nights and foggy nights, where we sit on ledges and crouch in corners to escape drizzle. In the room with the balcony: how he was always rearranging the furniture, the posters of nature and quotes. The door open and the half-clothed tall boy walking by ("that's the apartment"). The laughs, how we grew to know and identify each one. The odd potlucks, delicious and distinct items, a glass jar of kimchee and a plastic jar of yogurt because he loves yogurt, and discussions like yogurt or cheese? The planned gatherings, the spur of the moment invites, the random passings-by. The meals that are made as he goes along and can't be replicated. The big pots of rice, corn on the cob dipped in salty water, the rows of yams in the oven. The long talks, the quiet naps. The honesty and vulnerability, the disinhibition. The addition of lemon to water, and to anything. The wind through the windows on hot days, and the sun warming couch and carpet on winter afternoons. The bareness of that room, the sparse bathroom. Taking off shoes, and the too-big sandals for guest use. That one day the room exploded with clothes, to be placed into piles and piles. The ready spaces to fill and the complete acceptance freely given. The no need for apologies and thanks, and the response of gratitude to gratitude.
Thank you. Thank YOU.
The dirty kitchen floors. The mismatched chairs taken from different rooms for gatherings, a chair without a back, a wheely desk chair, some with cushions. The South Asian spices, and the blender where anything goes, where juice can be bright purple (beets) or conventional. The impromptu fruit salads, multiple colors eaten with condensed milk; or an all-orange salad of oranges, mango, cantaloupe. And mm, cantaloupe juice. How they never let guests wash the dishes. The balcony, for eats and smokes. The made-up songs about fruits and family and inappropriate things, the electric guitar and the acoustic guitar and the belt-out voices. The room with the gadgets where the "practicing" of video games takes place. The rooftop with sunsets, on clear nights and foggy nights, where we sit on ledges and crouch in corners to escape drizzle. In the room with the balcony: how he was always rearranging the furniture, the posters of nature and quotes. The door open and the half-clothed tall boy walking by ("that's the apartment"). The laughs, how we grew to know and identify each one. The odd potlucks, delicious and distinct items, a glass jar of kimchee and a plastic jar of yogurt because he loves yogurt, and discussions like yogurt or cheese? The planned gatherings, the spur of the moment invites, the random passings-by. The meals that are made as he goes along and can't be replicated. The big pots of rice, corn on the cob dipped in salty water, the rows of yams in the oven. The long talks, the quiet naps. The honesty and vulnerability, the disinhibition. The addition of lemon to water, and to anything. The wind through the windows on hot days, and the sun warming couch and carpet on winter afternoons. The bareness of that room, the sparse bathroom. Taking off shoes, and the too-big sandals for guest use. That one day the room exploded with clothes, to be placed into piles and piles. The ready spaces to fill and the complete acceptance freely given. The no need for apologies and thanks, and the response of gratitude to gratitude.
Thank you. Thank YOU.
Friday, July 9, 2010
sharing
During a long conversation of several hours, the kind that's really a flowing string of prolonged jokes and many long conversations interspersed with small comments, the kind that happens over the course of time that stretches from a couch in a living room to non-matching chairs on a small balcony to standing on a rooftop against a wall on either sides of an open window--during one such conversation, there were thoughts like why writing, why paintings like Hopper's Room by the Sea and Wyeth's Christina's World, and why a song like Mad World by Gary Jules. In a stream of pockets between friends, there is fast and slow talk of how one person sees this ocean as warm and comforting and the other finds it cold and foreboding, and how the grass around Christina slightly darkens, and how we seek hauntingly dark songs for a spectrum of feeling. That song is so damn beautiful.
Some of that contributed to what I wrote about last time, some of the sense that there is too much; even when it's good, when it comes in layers and builds up into dense blocks it can be incapacitating. But that conversation(s) also made me excited about writing, because I was pushed to articulate what lies at the bottom of that urge to put things in words. Which is that when things are experienced and felt strongly, you want to share them. And this phenomenon is most reliable when it's beauty. The beautiful quality of beautiful things inspires the sharing of them. There are probably a million reasons underlying this and more reasons existing in its periphery, but this is the feeling undiluted by explanation and psychology.
Since that time, I've fought hard against the turbulence of last week that made me sluggish, and in that have naturally fallen into a flexible routine. Within that space there's been an immersion in small beautiful things.
Mornings are spent in the architecture library. I like entering the place with the neat columned wooden bookshelves and artwork above, like a picture to be taken (but I don't, because I go there every day). The deep orange carpet and long smooth tables are calming, and there's a vertical window from floor to almost ceiling across the way, to see people come and go in their own proportion. There are very few people there these days, and I stay there for a few hours before I go home for lunch.
This morning, in those hours, during a pause when I let myself savor a song and stare out the window, I thought about how you always want to share music that moves you. I was listening to The Antlers' Hospice. It's an album my oldest friend introduced me to, when I was studying for Step 1 of the boards--over a year ago. It touched me then, but over the year I've grown to really love it. I like listening to albums in their entirety, for the full stories, even songs to which I'm not partial (writing that sentence grammatically correctly is kind of lame). Sometimes songs just aren't good, but sometimes you get an album like Hospice, where some songs are difficult to get into, but over time you really listen and then one day every song makes whatever it is in us that feels, explode. And it does it not with easy tricks, but with real, honest sentiments that are sometimes so much harder to communicate. I like how often the words are incongruous with the melodies, in a way that isn't about conflict, but about many things existing at once. Seeing passersby as this washed over, I wanted every one of them to have it happen to them too.
I walk back home for lunch, and cook something easy that I can have for both meals of the day. It's amazing how different, concretely and otherwise, it feels to have fresh food in your fridge, and to eat your own food. I'm going to make my own food for the rest of my life for as long as I can, because in the midst of everything else, it's so satisfying to care for your basic needs, and to know that the taking care of them can be basic too.
After passing time to digest by studying a bit more at home, I go running. I've found that one thing I really love about this is that it coincides with my love of long stretches of time. Running for an hour gives time to listen to an entire album and then some, or to a smattering of songs when I feel like it, and to be immersed in movement. The gym is also pretty empty these days, especially in the mid-afternoon, and this is a welcome break in the day.
It's also nice to shower in the middle of the day. It's almost like starting again, and makes the studies feel not so prolonged. But the studies, for the most part, have been good. Going through a different area of medicine each day, I remember the actual experience of the rotation in the past year, which is something I haven't been able to draw upon in the past. It's not that I remember anything scientific or clinical better because of those experiences; it's that spaces are filled in and studying becomes three-dimensional. Studying ob-gyn, I remembered what it was like to first consider the physical experience of miscarriage, to witness how abortions were performed, to squeeze into the corner of a crash C-section, and all the life that happens. Studying rheumatology, I remembered what it was like to think about living with constant pain in your muscles and joints, to speak to the people who have molded their skins to accommodate their illnesses, to appreciate the care and tenderness with which my attending physician touched their hands and bones. Studying renal, I remembered when I first thought about how simple and creative dialysis as a concept is and how awful and foreign it can be for the person being dialyzed, and how I felt a visual miracle to see the kidney go from gray to pink during a transplant surgery. And throughout all of that, there's the science and body alone, how dynamic we are and how a lot of the way our body functions are weird phenomenons. That's a post for another time.
I get distracted easily, of course. Yesterday I looked at photographs of my brother's trip to Wyoming, and that led to an hour of daydreams of road trips and open spaces under big clouds. I immediately shared them, and our nature loving friend said, these pictures make me want to stab myself in the heart and explode. My favorite pictures are ones where the muted browns/grays of the rocky backdrop contrast with other vibrancy in the scene; natural things that exist as they should, vivid trees and bright sturdy houses, and a rainbow after rain. It's as though their color, and presence, don't quite belong, but they're there, a quiet surprise that just about made me want to die.
In the late afternoon and evenings, I take a pick of coffeeshops. In the evening I spend time with someone whose presence I enjoy; this can be anything from eating with wife or studying at The Study, a posh hotel lobby and restaurant, with a classmate who's also wearing shorts and also not buying anything. Or it can be an activity like climbing or dinner with friends, something to look forward to and something to remind that there's not only things worthy of sharing, but people worth sharing them with.
Some nights I sneak in a few pages of Murakami's Hard-Boiled Wonderland & the End of the World, a book that steadily flowed along and has spun into a heartaching last quarter. Murakami is something else I've consistently wanted to share, so much due to how much I feel he sees and shares. The part of the book in which I'm currently residing, shouts that conflict and imperfection and all this mix-up I feel is, if nothing else, honest and therefore, worth it.
Before sleep I feel things I try to hang onto upon waking, and these days it's been the sense that all these things add up to a minuscule percent of a percent of all that can be experienced. It's how heavy that feels, in our hands, and then how light it is buried at the bottom of what's been and what can be; this is why.
Some of that contributed to what I wrote about last time, some of the sense that there is too much; even when it's good, when it comes in layers and builds up into dense blocks it can be incapacitating. But that conversation(s) also made me excited about writing, because I was pushed to articulate what lies at the bottom of that urge to put things in words. Which is that when things are experienced and felt strongly, you want to share them. And this phenomenon is most reliable when it's beauty. The beautiful quality of beautiful things inspires the sharing of them. There are probably a million reasons underlying this and more reasons existing in its periphery, but this is the feeling undiluted by explanation and psychology.
Since that time, I've fought hard against the turbulence of last week that made me sluggish, and in that have naturally fallen into a flexible routine. Within that space there's been an immersion in small beautiful things.
Mornings are spent in the architecture library. I like entering the place with the neat columned wooden bookshelves and artwork above, like a picture to be taken (but I don't, because I go there every day). The deep orange carpet and long smooth tables are calming, and there's a vertical window from floor to almost ceiling across the way, to see people come and go in their own proportion. There are very few people there these days, and I stay there for a few hours before I go home for lunch.
This morning, in those hours, during a pause when I let myself savor a song and stare out the window, I thought about how you always want to share music that moves you. I was listening to The Antlers' Hospice. It's an album my oldest friend introduced me to, when I was studying for Step 1 of the boards--over a year ago. It touched me then, but over the year I've grown to really love it. I like listening to albums in their entirety, for the full stories, even songs to which I'm not partial (writing that sentence grammatically correctly is kind of lame). Sometimes songs just aren't good, but sometimes you get an album like Hospice, where some songs are difficult to get into, but over time you really listen and then one day every song makes whatever it is in us that feels, explode. And it does it not with easy tricks, but with real, honest sentiments that are sometimes so much harder to communicate. I like how often the words are incongruous with the melodies, in a way that isn't about conflict, but about many things existing at once. Seeing passersby as this washed over, I wanted every one of them to have it happen to them too.
I walk back home for lunch, and cook something easy that I can have for both meals of the day. It's amazing how different, concretely and otherwise, it feels to have fresh food in your fridge, and to eat your own food. I'm going to make my own food for the rest of my life for as long as I can, because in the midst of everything else, it's so satisfying to care for your basic needs, and to know that the taking care of them can be basic too.
After passing time to digest by studying a bit more at home, I go running. I've found that one thing I really love about this is that it coincides with my love of long stretches of time. Running for an hour gives time to listen to an entire album and then some, or to a smattering of songs when I feel like it, and to be immersed in movement. The gym is also pretty empty these days, especially in the mid-afternoon, and this is a welcome break in the day.
It's also nice to shower in the middle of the day. It's almost like starting again, and makes the studies feel not so prolonged. But the studies, for the most part, have been good. Going through a different area of medicine each day, I remember the actual experience of the rotation in the past year, which is something I haven't been able to draw upon in the past. It's not that I remember anything scientific or clinical better because of those experiences; it's that spaces are filled in and studying becomes three-dimensional. Studying ob-gyn, I remembered what it was like to first consider the physical experience of miscarriage, to witness how abortions were performed, to squeeze into the corner of a crash C-section, and all the life that happens. Studying rheumatology, I remembered what it was like to think about living with constant pain in your muscles and joints, to speak to the people who have molded their skins to accommodate their illnesses, to appreciate the care and tenderness with which my attending physician touched their hands and bones. Studying renal, I remembered when I first thought about how simple and creative dialysis as a concept is and how awful and foreign it can be for the person being dialyzed, and how I felt a visual miracle to see the kidney go from gray to pink during a transplant surgery. And throughout all of that, there's the science and body alone, how dynamic we are and how a lot of the way our body functions are weird phenomenons. That's a post for another time.
I get distracted easily, of course. Yesterday I looked at photographs of my brother's trip to Wyoming, and that led to an hour of daydreams of road trips and open spaces under big clouds. I immediately shared them, and our nature loving friend said, these pictures make me want to stab myself in the heart and explode. My favorite pictures are ones where the muted browns/grays of the rocky backdrop contrast with other vibrancy in the scene; natural things that exist as they should, vivid trees and bright sturdy houses, and a rainbow after rain. It's as though their color, and presence, don't quite belong, but they're there, a quiet surprise that just about made me want to die.
In the late afternoon and evenings, I take a pick of coffeeshops. In the evening I spend time with someone whose presence I enjoy; this can be anything from eating with wife or studying at The Study, a posh hotel lobby and restaurant, with a classmate who's also wearing shorts and also not buying anything. Or it can be an activity like climbing or dinner with friends, something to look forward to and something to remind that there's not only things worthy of sharing, but people worth sharing them with.
Some nights I sneak in a few pages of Murakami's Hard-Boiled Wonderland & the End of the World, a book that steadily flowed along and has spun into a heartaching last quarter. Murakami is something else I've consistently wanted to share, so much due to how much I feel he sees and shares. The part of the book in which I'm currently residing, shouts that conflict and imperfection and all this mix-up I feel is, if nothing else, honest and therefore, worth it.
Before sleep I feel things I try to hang onto upon waking, and these days it's been the sense that all these things add up to a minuscule percent of a percent of all that can be experienced. It's how heavy that feels, in our hands, and then how light it is buried at the bottom of what's been and what can be; this is why.
Monday, July 5, 2010
coming back
Since I returned to New Haven about exactly a week ago, I've been feeling out of sorts. The out-of-sorts feeling is out-of-sorts itself, as it's a fluid thing whose quality changes with the seconds, the temperature, the walls or windows, and with nothing at all. Its source and its course is never quite one thing for very long. A lot of things are happening or at least going on, and in the midst of it I feel messy and moody. Messy is status quo, but what's changed is that with it there is unease instead of easy acceptance, and moody is unusual. Writing about it will probably feel the same.
Leaving my family was difficult, even as I'll be returning to them in a few weeks. Even though my parents don't change much at all in the intervals between my seeing them, time always claims more weight when I see them. When I'm with them, I find myself wanting not vacation time but daily time, the kind that lends itself to stray stories and details of their lives that fall here and there. My mom is constantly losing her jewelry because she isn't careful with where she places her earrings and watches and rings after taking them off; I'm constantly telling her to simply put them back in the same place. As I help her search underneath the bed and by the sink, I miss her. When I come back to lose my own earrings, I miss her.
For some reason I wrestle with small decisions like spending the month of July at home or here. I had ultimately decided to study for Step 2 of the boards here in New Haven, instead of going home as I did for Step 1. Having to hop from place to place to study and with all the places closing early in the night for summer, I've missed my corner by the window with a steady view of Fremont hills and passersby. Leaving my family after our trip, and having it really hit me that I have two more years here, makes me wish I'd taken the opportunity to be home for a full month. At the same time, I appreciate having other things going on here for escape and a sense that I still function as a person outside of books. I know that I wouldn't have been completely satisfied at home either; still, this knowledge that I wouldn't have had a perfect decision in any case doesn't move the sense that this was an imperfect one.
A big reason for my staying was to spend time with a friend who will soon be leaving for most of the rest of the year, and in that sense I feel I'm in the right place. On my first real night back, we had an impromptu dinner at his place, as we've had sporadically over the past couple of years; a couple nights later we planned a potluck, as we've had sporadically over the past couple of years. This time it took place on the roof of the apartment building, with shadows a light black against the deep yellow that the sun becomes when it's retiring. The food was a hodgepodge, the cups included small bowls, and the girls wore oversized coats supplied by our favorite nature-lover who always has plenty of coats and who threw chicken bones over the side and who wanted to fly. The directions of New Haven sprawled as we ate and laughed, and I feel so lucky to have people who have so defined my time here.
How sharp that definition has been, surprised me a bit. A lot of my close friends are currently scattered about the world, and I can feel their absence. I also feel the absence of parallel doings; I'm the only one studying for my boards right now, and that has felt strangely strange. As I'll be spending most of my year off being the only of us to be doing whatever I'll be doing (an unstructured mix of writing, processing, and talking), it bothers me a little that I'm bothered by being alone in my endeavors. I had thought this solitude would be welcome. I'm finding that as much as I hate crowds sometimes, I really love individuals, and I've missed many of them upon my return to a place where they've been for so long. Of course they will come back, but they will come and go, as we are all forming our own structure right now.
And the challenge of that, for myself, is one that I hadn't fully recognized as such. I never acknowledged the change that is going from third year (the introduction to/immersion in clinical medicine, and our toughest year) to fifth year (a gap year where we choose pretty much what we want to do). I hadn't given much thought to what this freedom and self-guidance means, and more specifically, that it can be difficult. I completely set my own goals this year, and completely set my own ways to go about them, which is wonderful, and daunting. More than that, or more purely than that, it's different. The simple fact of change happened as I blinked, and the unawareness is another rarity, something that has made me feel not myself.
Not that I didn't think about this year's approach--when third year ended, I looked forward to time and space to digest all that's happened. I forgot that I first have to get through the harder parts of the year first, my board exam and my medicine subinternship, both intense endeavors that leave little room for the little things. I resent being restricted, when I feel flooded with things that want for my attention. Again I'm conflicted, as I'd looked forward to really getting down to it and consolidating all we've learned in the past few years that has accumulated in the clinical knowledge that'll be tested. And to be honest, it has felt good to study. I'm surprised by things I remember from studying for the boards last year, things like how the fungus malassezia furfur causes tinea versicolor and looks like spaghetti and meatballs under a microscope, and how rhizopus causes mucormycosis in diabetics (I think I just like the words). I like reading the questions, which are written as cases with symptoms and findings and test results, and I'm aware of each acronym and number I didn't understand just a year ago. Concentrating on the science for hours has also let me put other things, things that aren't so rational and organized, at rest for awhile.
There are a lot of those things. My hives, along with lip swelling, recurred intermittently over the past few weeks, and after several trips to the doctor I'm following a regimen of daily claritin for a month, to break the cycle of histamine outburst in my body. Other than the physical inconvenience, I don't like thinking about what internal happenings my body is reacting to. This past weekend emotional impulses and ruminating responses usurped my abilities to sleep and eat correctly. The fatigue and dizziness that followed was annoying less for the actual senses and more for the knowledge it was my own doing.
In less physical and equally consuming areas, I'm scared and excited about the prospect of spending this year writing. I have a pile of one-line stories, of experiences and things I want to record. I'm annoyed that currently, I can't get to them, and a small part of me is glad for some more delay as I struggle with fears of not-good-enough and not-sure-enough, and doubts about purpose and product.
In terms of life outside of lined paper and blank computer screens, I'm pretty sure it's impossible for me to have simple interactions, and while I know that misunderstandings and bumps in communication and nonlinear connections are always part of the space between people, I really do wish that sometimes I could find myself in something simple. And with that, I miss innocence. I miss when certain moments don't have to lead anywhere else, and when an accumulation of moments take you honestly and naturally to a place where pride and perceptions give way to vulnerability. I've found myself feeling deeply and strongly on one end of the spectrum to the other, in the course of days and nights, and in that yet another conflict, I've grown tired.
Immersed in this push and shove, and mix of so many components alternately distinct and connected, I've decided, both rationally and emotionally, to simplify for the time being. It's not how I approach things as a principle; I want to learn to face multiple complications and find balance. But right now, it's a bit too much.
For July I want to do the things that give good--and give it simply. As integral as they are to me, I'm going to avoid sources of complicated or layered good. I'm going to concentrate on learning as much medicine as I can, to do well on the exam and to prepare for my subinternship and to be a competent doctor. I'm going to go grocery shopping for what I'll need for the next few weeks, to cook and to eat well and to save money. I'll run most days and climb on the days I don't, to stay healthy and to have breaks in the day when I'm moving and to feel good. I'm going to be with friends, to laugh a lot and to have conversation and to have company. For all the rest, I'm letting it rest.
Leaving my family was difficult, even as I'll be returning to them in a few weeks. Even though my parents don't change much at all in the intervals between my seeing them, time always claims more weight when I see them. When I'm with them, I find myself wanting not vacation time but daily time, the kind that lends itself to stray stories and details of their lives that fall here and there. My mom is constantly losing her jewelry because she isn't careful with where she places her earrings and watches and rings after taking them off; I'm constantly telling her to simply put them back in the same place. As I help her search underneath the bed and by the sink, I miss her. When I come back to lose my own earrings, I miss her.
For some reason I wrestle with small decisions like spending the month of July at home or here. I had ultimately decided to study for Step 2 of the boards here in New Haven, instead of going home as I did for Step 1. Having to hop from place to place to study and with all the places closing early in the night for summer, I've missed my corner by the window with a steady view of Fremont hills and passersby. Leaving my family after our trip, and having it really hit me that I have two more years here, makes me wish I'd taken the opportunity to be home for a full month. At the same time, I appreciate having other things going on here for escape and a sense that I still function as a person outside of books. I know that I wouldn't have been completely satisfied at home either; still, this knowledge that I wouldn't have had a perfect decision in any case doesn't move the sense that this was an imperfect one.
A big reason for my staying was to spend time with a friend who will soon be leaving for most of the rest of the year, and in that sense I feel I'm in the right place. On my first real night back, we had an impromptu dinner at his place, as we've had sporadically over the past couple of years; a couple nights later we planned a potluck, as we've had sporadically over the past couple of years. This time it took place on the roof of the apartment building, with shadows a light black against the deep yellow that the sun becomes when it's retiring. The food was a hodgepodge, the cups included small bowls, and the girls wore oversized coats supplied by our favorite nature-lover who always has plenty of coats and who threw chicken bones over the side and who wanted to fly. The directions of New Haven sprawled as we ate and laughed, and I feel so lucky to have people who have so defined my time here.
How sharp that definition has been, surprised me a bit. A lot of my close friends are currently scattered about the world, and I can feel their absence. I also feel the absence of parallel doings; I'm the only one studying for my boards right now, and that has felt strangely strange. As I'll be spending most of my year off being the only of us to be doing whatever I'll be doing (an unstructured mix of writing, processing, and talking), it bothers me a little that I'm bothered by being alone in my endeavors. I had thought this solitude would be welcome. I'm finding that as much as I hate crowds sometimes, I really love individuals, and I've missed many of them upon my return to a place where they've been for so long. Of course they will come back, but they will come and go, as we are all forming our own structure right now.
And the challenge of that, for myself, is one that I hadn't fully recognized as such. I never acknowledged the change that is going from third year (the introduction to/immersion in clinical medicine, and our toughest year) to fifth year (a gap year where we choose pretty much what we want to do). I hadn't given much thought to what this freedom and self-guidance means, and more specifically, that it can be difficult. I completely set my own goals this year, and completely set my own ways to go about them, which is wonderful, and daunting. More than that, or more purely than that, it's different. The simple fact of change happened as I blinked, and the unawareness is another rarity, something that has made me feel not myself.
Not that I didn't think about this year's approach--when third year ended, I looked forward to time and space to digest all that's happened. I forgot that I first have to get through the harder parts of the year first, my board exam and my medicine subinternship, both intense endeavors that leave little room for the little things. I resent being restricted, when I feel flooded with things that want for my attention. Again I'm conflicted, as I'd looked forward to really getting down to it and consolidating all we've learned in the past few years that has accumulated in the clinical knowledge that'll be tested. And to be honest, it has felt good to study. I'm surprised by things I remember from studying for the boards last year, things like how the fungus malassezia furfur causes tinea versicolor and looks like spaghetti and meatballs under a microscope, and how rhizopus causes mucormycosis in diabetics (I think I just like the words). I like reading the questions, which are written as cases with symptoms and findings and test results, and I'm aware of each acronym and number I didn't understand just a year ago. Concentrating on the science for hours has also let me put other things, things that aren't so rational and organized, at rest for awhile.
There are a lot of those things. My hives, along with lip swelling, recurred intermittently over the past few weeks, and after several trips to the doctor I'm following a regimen of daily claritin for a month, to break the cycle of histamine outburst in my body. Other than the physical inconvenience, I don't like thinking about what internal happenings my body is reacting to. This past weekend emotional impulses and ruminating responses usurped my abilities to sleep and eat correctly. The fatigue and dizziness that followed was annoying less for the actual senses and more for the knowledge it was my own doing.
In less physical and equally consuming areas, I'm scared and excited about the prospect of spending this year writing. I have a pile of one-line stories, of experiences and things I want to record. I'm annoyed that currently, I can't get to them, and a small part of me is glad for some more delay as I struggle with fears of not-good-enough and not-sure-enough, and doubts about purpose and product.
In terms of life outside of lined paper and blank computer screens, I'm pretty sure it's impossible for me to have simple interactions, and while I know that misunderstandings and bumps in communication and nonlinear connections are always part of the space between people, I really do wish that sometimes I could find myself in something simple. And with that, I miss innocence. I miss when certain moments don't have to lead anywhere else, and when an accumulation of moments take you honestly and naturally to a place where pride and perceptions give way to vulnerability. I've found myself feeling deeply and strongly on one end of the spectrum to the other, in the course of days and nights, and in that yet another conflict, I've grown tired.
Immersed in this push and shove, and mix of so many components alternately distinct and connected, I've decided, both rationally and emotionally, to simplify for the time being. It's not how I approach things as a principle; I want to learn to face multiple complications and find balance. But right now, it's a bit too much.
For July I want to do the things that give good--and give it simply. As integral as they are to me, I'm going to avoid sources of complicated or layered good. I'm going to concentrate on learning as much medicine as I can, to do well on the exam and to prepare for my subinternship and to be a competent doctor. I'm going to go grocery shopping for what I'll need for the next few weeks, to cook and to eat well and to save money. I'll run most days and climb on the days I don't, to stay healthy and to have breaks in the day when I'm moving and to feel good. I'm going to be with friends, to laugh a lot and to have conversation and to have company. For all the rest, I'm letting it rest.
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