transgender

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

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

January

This month's update on my resolutions:

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

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

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

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

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

three day weekend

Saturday: Took the winding, foggy drive to Big Basin in the Santa Cruz Mountains. In parts the fog hugged the coast and drifted onto the ocean; in others, it blanketed our entire view. Hiked eight miles with towering redwoods shaping the sky ceiling, and ate lunch by a waterfall. We noticed the varying positions and states of the trees--how some had fallen, some had blackened from fire, some were hollowed out ("what do you think lives in there?" M asked). Over the years, we have come across the same beauties--the fog over the hills on Skyline Drive and coasting onto 280, the redwood forests, the integration of dirt, water and foliage. So a lot of feels familiar, tickling the pores of my skin as we pass through it. At the same time, the power of escaping the compactness of the city always feels fresh. And there is always the sense that there are new things; we've been to Muir Woods and Redwood National and State Parks, but not to Big Basin, and there are so many more trails to explore.

Sunday: Drove down the coast to Santa Cruz, where we have been many times before. Even though Santa Cruz isn't far, the roads leading there are rough to navigate, and maybe because of that path, despite being familiar with the city, I don't feel quite connected to it. And maybe because of that I'm always newly struck by how beautiful the ocean is there. Having watched waves so often with M, I'm better able to recognize differences between waves, and have new appreciation for the uniqueness of the breaks there, how long and high the waves ride. The water there is always glassy, and the sunsets always bring the kind of light that makes photographers swoon. We saw arches of stone form over the beach, wondered how they are made, and laughed at the dozens of dogs running free on the sand.

Monday: Woke up to one of our cars not starting, decided to leave dealing with it for later and drove to Sonoma for wine-tasting. It was a little harder to decide on which wineries to visit, as the wineries are a little more spread out than in Napa. We went to Benziger first based on an internet recommendation, and it was the perfect choice. We really liked each wine in the tasting, with four really amazing reds in a row, and the grounds were gorgeous. Wine country really brings out natural feelings of leisure, and the comfortably sunny weather complemented this internal warmth. At Benzinger we were given a two-for-one tasting coupon to another place, which turned out to be a cozy microwinery where a big golden retriever nuzzled up to the customers. We We met a woman who had grown up in Sonoma and who recommended VJB Vineyards up the street. By this time I was a little too buzzed to have much more (we'd had seven wines at the previous place), but I loved this Italian-inspired vineyard. It was a little plaza of a winery, deli and outdoor pizzeria, outlining an open courtyard. We had Italian champagne (Prosecco) which was delicious, and more delicious reds. We also had a flatbread pizza with the freshest ingredients, including housemade mozzarella, basil, avocado and tomato. Dessert was salted caramel gelato. Driving home didn't do much to work off the food, but was a perfect way to end the indulgent day, with views of rolling hills, a marsh whose water kept changing degrees of reflection as dusk settled, and my favorite: long fields of yellow wildflowers that stayed bright in the night, both from their natural vibrant color and from the waning sun that cast its light from far off in one corner across the entire span of the fields.

When weeks begin and life becomes more confined to rooms and buildings, it's nice to remember that these weekends are really where the full spectrum of life starts.

resolutions by number

1. Write at least ONE blog post a week, which can include an update on these resolutions (this is one of those every-year resolutions but I believe in repeated attempts, if only for intention)

2. Make TWO new meals a month (including inpatient months!)

3. Listen to THREE new albums a month (music, which used to be half my life, has evaporated and I'd like to make it solid again)

4. Read FOUR news articles daily from different sources (this is actually really hard for me as I prefer fiction to real life)

5. Do each of the FIVE following kinds of exercise each week: yoga, climb, run, swim, and bike (my most important one).

viruses

Swimming in vast oceans, looking up at the big night sky speckled infinitely with stars--things that normally make people feel small, that there exists so much beyond our grasp that it's mind-blowing how much and how little feeling we encompass in our tiny capsule in never-ending other capsules. Over the holidays, ending my 2014 and starting 2015, I found another such wonder: the virus. The so-called benign, self-limited bug that is too common, too fleeting, and too un-sexy to ever find residence alongside the ocean and the night sky.

But after last week, I can tell you that if ever something made me feel taken over by a power beyond my control, it is the virus called Coxsackie that causes hand-foot-mouth disease. I caught it from my nephews and niece, who from oldest to youngest caught it from each other in succession. The oldest cried for a day due to the sore throat and aches and recovered; the middle cried because she thought her rash looked dirty; the youngest didn't even know he had it. For me, decades older and weaker, each day of the week-long experience is seared in my memory.

The first day, the febrile fatigue hit me all of the sudden. We'd made plans to go the beach, and on our way there I started to feel sick-tired, the kind of unusual discomfort that doesn't stem from internal exertion or external tangibles, that you know is coming from something foreign. After the gradual beginnings, it hit me hard and I ended up passing in and out of sleep for a few hours in the car instead of going to the beach. Deep chills flared in my head and stomach and muscles and bones, despite layers of clothes, a fleece blanket, and car-powered heat. M drove us to the grocery store to get me sick-food and while waiting for him in the car, I almost despaired--so much was going in my body and I was at a loss as to how to make it better. It wasn't just temperature, or nausea, or anything concrete. It was the awful of a sickness you can't touch. I went home, M made me warm, comforting pasta with a lot of garlic, and I fell into a sleep thanks to Nyquil. I had to start work the next day, and for the next couple days of work, I continued to intermittently feel the chills and this vague but deeply uncomfortable sickness.

Then, I noticed a faint rash on my hands, and the second wave of the virus hit: spots spread over my face, hands, and feet and sores developed everywhere in my mouth and most noticeably in the back of my throat. I once told Jen that one of my top ten worst things in life were chancre sores. She laughed, saying, what about war and violence? These sores are right up there; they have that vile quality of being absolutely relentless. Probably for the first time I had a glimpse into what a constant physical pain might feel like--it burned all day and all night, regardless of whether I was eating or speaking, though those simple actions made it so much worse I avoided them. It wasn't the kind of sore throat that ice cream or soup would soothe--extremes in temperature worsened it. (Imagine the kind of evil that makes you turn on ice cream). This lasted for a few days and got so bad I took a day off work, nursing my throat with viscous lidocaine and killing my kidneys with ibuprofen, all of which took the sensation away only for moments and sometimes not at all.

By the time the throat healed, the blisters on my face (on my FACE, branding me and making visible the invasion of this microscopic power) and hands and feet started to hurt, mostly the ones on my feet, making it hard for me to walk. Even now, two weeks later, the skin is still recovering from the pockets of invasion. And so this is how I came to know the multiple stages of this attack by Coxsackie.

Also strangely and in stages, this sickness was bookended by more minor viruses. Before I got sick with Coxsackie, I had had another virus with a more conventional sore throat and mild cough that I fought off with tea, garlic, and cough drops and that had melted away for about a day before Coxsackie hit. Then soon after I recovered with Coxsackie, I had another episode of febrile fatigue in the setting of being sleep-deprived, that went away with more rest. We are so used to being agents that it really struck me how our bodies are vessels for other, tiny, impactful beings. It sounds so pathetic to compare my virus to the illnesses our patients face, but I do think the debilitating vulnerability and helplessness was a small window into understanding both how fragile the perceived strong are, and how strong the perceived fragile are. And that these things that we see as invading our bodies, so different from and foreign to us, are maybe just settling into similar territory. Us and viruses. Tiny. Impactful. Beings.