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.
Tuesday, August 17, 2010
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.
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