hurt

Found myself spending snips and chunks of today considering moments where I've felt extreme emotional pain. Don't worry (that's to you wife, who is the first and probably only person to read this), I'm not currently hurt. Only, I woke up this morning with a vague precursor of what it might feel like in the future, and it made me think of the past. If I had to narrow it down to the most excruciating, there would be six moments I'd put on my list of god-awful emotion, and mixed in with those are moments I'd pile in the same section of a fabric store, the kinds with similar threads even if they aren't the intense shades you immediately return to when perusing shelves of memory [a well meaning, pretentious person taught me that "peruse" is commonly mistaken to mean skim when it actually means to deeply delve. Since then, I debate how to use it, because if language is to communicate and that's how people interpret it, why not use it in the way people will take it? In this case, you can take it whichever way].

As a friend and a med student and other-relations-to-others, I've been privy to other people experiencing pain, just as most of us have. I could describe the expressions of those things, but when it comes down to the inside, we can only draw from ourselves. So from myself I draw the periods of time, short and long, where I was in sharp conscious unwavering pain. There was that time I ate nothing but cereal for weeks, and watched a lot of movies with sensory overload in the hopes of crushing inner workings to no avail. This was the most drawn-out, recurring pain. There was that other time I didn't eat anything for several days, didn't sleep either. I thought it'd be drawn-out and recurring too, but it wasn't, but it was damn intense in its compactness. There was that time I sobbed in a stranger's kitchen, for someone I knew and didn't really know, and then spent days in beautiful new places and felt tangibly less touched by the beauty, the pain coloring all else. This one comes suddenly into focus at moments that make sense and ones that don't, and fades. Then when I sobbed against my car in a cold snowless winter, for someone I kind of knew but didn't really know. This doesn't come back too often. Then when I felt shelter crumbling while wearing kid pajamas, when I sat holding the hand for someone older and in more pain than me. Then when I was the wielder of such pain, different than other cases because the person who bore it didn't choose it; this happened in a place away from home, and I came home and put the wrong on bare display for two people who love me and it hurt like all hell. All of these come back in the form of sadness more than pain, and in some ways you can't say that you'll never forget; there's always forgotten. Strangely it's not so bad to remember what parts of it I do.

bike riding

I've been in a moody rut since coming back from Vietnam, conceptual anchors loosening into the framework of physical disorientation. Things that normally ground me feel heavy. My knee throbbed after a run yesterday, climbs that used to come easily feel frustrating. Instead of being excited by the recent experiences that compel me to write, I'm paralyzed by the stack. I get even more easily upset than usual, wallowing in trivial petty things, and staying irrationally there. M tells me to give it time; I trust him and the sentiment, so I am letting things happen. This doesn't mean I overcome the moodiness, I let that happen too, but I trust that the stifling character will break, leaving a baseline moodiness which I can handle, and appreciate.

On Saturday, after a morning of moping in moodiness, we entered a a sunny crisp not-yet-spring day, and he said, let's get you on a bike for lesson #2. Lesson #1 entailed sitting on a bike for the first time and having him hold the bike and me up, running alongside as I got a feel for pedaling. It served several purposes. I learned that it's scary, and hard, to be on a bike for the first time. I fell, the scruff of my pants opening to scrape my skin; having been holding me, he fell too. We expected lesson #2 to proceed in similar increments of progress. I know he wanted me to move, to try something new, to make me feel better, and the thought was enough to slightly jar the heavy air fogging me. He said, even if you're just on it for five minutes, it'll make next time easier.

So we drove to get a bike pump, which didn't really work, but I got on the bike anyway. I pedaled in the parking lot of the mall, him again holding onto the handlebars and running alongside. The first thing he emphasized was to steer into my leans, because I'd lean to one side and would've fallen over and over if he hadn't been there to correct for me. It was too much for me to think about, to correct my leans and pedal at the same time (two things, too much). So because I couldn't, he steered for me as I pedaled. This let me focus on the motion of pedaling, and it also let me subconsciously absorb the hand motion of steering, to feel the handlebars under my fingers. Then he made me try to push off on my own, to start pedaling without him holding. I'd push off with my right foot, but wouldn't trust the bike enough to push hard enough to make it work. Each time I tried, I had to consciously breathe in and suck it up; sometimes the fake courage worked enough to push hard enough to bring the left pedal up quickly enough so that I would actually move forward. To our surprise, after some struggle with this, I could keep pedaling for a few seconds, before I leaned too much or pedaled too slow, and stopped myself.

We returned the faulty bike pump, drove to Wal-Mart to get another; he pumped the tires with success this time, and we started again in the parking lot of Wal-Mart. Realizing that I could continue after starting, he helped give me a push to start, and shouted to me from our starting point to keep going. Back and forth down the length of the parking lot, I stopped as I got scared or worried that this strange capacity to steer that I unconsciously acquired would slip. He made me keep going until I'd gone down the length of the lot, each way, without stopping, and I think we were both pretty surprised. I was surprised not just by the concrete happenings but by what it did for me.

The surprise, a childhood moment given to me as a near-27 year old, the dislodging of things in their proper place, facing loss of balance during a period of inward shakiness, the doing of something new--did me a whole lot of good. Being pushed to let go of ground, we find new holds, and that seems like good reason to keep traversing across moodiness.

recharging

In the past week, I've had to replace my phone charger, my iPod charger, and my computer adapter (though my computer just died altogether, so it may not have been the adapter that was the issue). My phone charger has been acting up in the past few months. I have to wiggle and bend and contort its attachment to the phone, to reach a precarious position where it will charge the phone. For awhile it only took a few seconds and a book for pressure, to get it working. And per usual this is an inconvenience I can willingly put up with indefinitely. But it got to the point where ten minutes of adjustment didn't do the trick, and even if it worked eventually, there was no standard way of adjusting; it'd be a different trick each time. I've been content charging my iPod via my iPod stereo or my computer, since the charger that came with the iPod broke a long time ago. This was back when Apple still gave a charger with the iPod (that's right, first generation iPod packaging). This also gives you an idea of how old everything technological I own is. Anyway, I would've been fine without a wall charger, except now my computer is dead and I can't go without charging my iPod for three weeks while abroad in Vietnam. And my computer has been having issues with its adapter, where none would charge it up anymore; I'd found a new one at home that worked for several months, then wasn't working; so I got another last week. But looks like the computer needs more than that, because it won't start up.

So as many have told me, it seems that I probably need new things, rather than continually trying to recharge old ones. But even if I replace everything, I'm left with my old sometimes worn self, and I'll always have to find ways to recharge. Thank goodness for running into people at exactly the moment I need cheer, for stubborn climbs, for him in the evenings and how he makes me value not just his presence but my own, and for new travel to old places.

hospice (ending)

I just finished my month-long hospice rotation at the Connecticut Hospice in Branford, which both gave more and took more than I anticipated. Perhaps because after a slew of clinical rotations, I've lost a bit of the expectant newness that used to come before each new venture, and so there wasn't much anticipation to begin with. I didn't think much about what hospice would be like before I started. Having had a strong experience that led me to being interested in the rotation in the first place, I think I unconsciously felt that I'd reached a certain level of intensity that would prevent me from being taken by surprise here, even as I approached this rotation as an opportunity for broadening experience, concrete and emotional. I'm glad to have been wrong.

I haven't felt this motivated to write about a medical school experience for a long time, but before doing it in a structured and comprehensive form, it feels nice to sit in bed and ramble about all the things that made it filling, and hard.

On my last day, an APRN asked me what was the most memorable event during the rotation. It would be hard, and probably not accurate, to choose one event or interaction or experience. Instead it was more generalities absorbed that most affected me. I told her that I'd take with me the calmness of the place, the simplicity of the medicine, and the kindness of the people.

Connecticut had the most snow in January on record since years and years ago. We had two two-feet snowstorms, a couple ice storms, and record below freezing temperatures. While I was used to this in Boston where the winter is more harsh than here, I'd never had to deal with the visceral challenges of snow and ice. For the first time in my life, I had to shovel my car out of the snow, had to try to drive it through the narrowly plowed driveway, had to shovel myself out of the driveway that wasn't plowed widely enough, had to shovel piles of snow off the entrance to the street where the tires would just spin in place, had to chip away at inches of ice off every window and off the roof of the car, had to see why getting ice off the roof is important as a I saw sheets of ice slip off cars on the highway, had to steer my car as it slid on unsalted iced roads, had to walk strategically to avoid puddles of slush and piles of iced snow. It was uncomfortable, and tiring to have to work so hard and think so hard about how to simply get somewhere.

There were also incredible vignettes of how pretty harshness can be, in the snowflakes that would freeze on my car windows to create a printed pattern I'd have to scrape away, in the ice that dressed bare tree branches making the forests on my drive looks like crops of glistening gray hair, and in the sheen of clean soft snow hardened on top like creme brulee, by the ice. There were incredible views from the windows, of big flakes falling against warm yellows and cold grays. There were the first falls, untouched, and the old snows, dirtied.

After the trek through all of that, I arrive at a workplace with windows in tandem, bookshelves, and fireplaces. Laid on the beds are crocheted blankets and patchwork quilts. Hand-painted signs of patient's names are hung in their respective spaces. Guitars strum, and every other day there are sweets from families or employees. It seemed to me I was lucky to have done this rotation during the onslaught of winter, to have to confront bitter elements with reason to escape to this cove. It's not often that you think of a workplace as soothing, especially not hospitals.

It's true that this atmosphere is partly due to the way that the rough edges of medicine are worn away a bit by the different goals and mindset of hospice. There is more thought to necessity, and the removal of what's not. In that sense, things feel simpler. There are no fancy tests to order; people often get sicker and instead of embarking on a diagnostic quest for etiology, we acknowledge the worsening condition and continue. There's still a lot of room for creativity in catering to individual needs. My attending pushed us to consider the best options for care, to not get stuck in status quo. But grounding all of that movement is a framework of simple stability. Not to say that dying is simple, but in the face its possible complexities, people's wants and needs become basic and streamlined to the core, without the excess that can often distort. After awhile the pharmacological treatments become routine, leaving more room to focus on non-pharmacological care, and hospice focuses on that much more than other areas of medicine. Its wholistic perception of people is reflected in its interdisciplinary approach to care; doctors aren't at the center, are instead an arm, of the scheme. There is constant, continual communication with the nurses, social workers, pastors, and family. And while there are many factors to consider, the way in which all these people work together to focus on each person's care, gives a simple sense of value.

I imagine that the comforts and simplicity help the staff as much as the patients, because as calming and welcoming a place it is, it is a hard place to be. Because of that, I think it attracts and seeks certain qualities in the people who work there, making for an incredible community. I've never met such a cluster of genuinely warm, kind, and strong people. The nurses, who are the heart of hospice care, made the biggest impression on me, but the kindness is palpable in every person encountered, from the person at the front desk to the person manning the cafeteria.

In the morning, the nurses and physicians round together, going over the care for each patient. The nurses are the ones giving report, which has never been the case for any other rounds I've seen. They make me remember why I want to be good at whatever it is that I do. They take care in the most whole way possible: delicate where people are fragile, tough and honest when needed. They advocate for their patients, they know their stuff, and they all have voice. It's this combination of warmth and strength that I admire most in women who give care, and every day it reinforced goals to work for.

On my last day I told a slightly demented patient of mine that it had been really nice to take care of her. She replied, "It was really nice to take care of you too." Even as her response was a rote one, I appreciate the truth in that. I think that at their worst these patients and their loved ones have given me more than I could give at my best. Each person copes differently, experiences different pains and discomforts. It would be misguided to say that all of them gave the same thing, but as a whole, it was valuable to witness their capacity to give when so much is being taken from them. There is a woman whose body has been distorted and disfigured by tumors, and as she struggles with grace and patience, she makes me think of how deep our reserves run, how much we can face without being torn. There is a man who has accepted that it will be difficult for him to breathe until he no longer has to, and his first thought in conversation is to answer all the questions he knows you'll ask before you ask them, without pause and without rest, with the creases in his face working with effort to give you all he can. There is a man actively dying before the eyes of his wife, who comforts me with stories of him before he was sick--redheaded, singing silly songs in the morning.

In conversation about this, it was pointed out that perhaps it is something about this stage in life, and not something intrinsic to these specific people, that make us that way. It doesn't matter to me too much from where the source stems. To see people in pain, so close to something unknown, be gracious and generous and sensitive gives me faith in the endurance of these qualities and makes me try harder for the patience to endure. And it's not to say that these people weren't struggling, weren't falling back in some ways, but that there seems to be a pull to hang onto the good when things are slipping away.

I can't say that I endured the past month of this rotation with the same kind of grace that I observed in my patients and their families. The rotation was hard for me. I was surprised by how quickly people transitioned from alert to unresponsive, how I could never get used to someone changing so much over hours or days from the way I first met them even for the ones I rationally knew had come to hospice to die. I missed the people they were as they were still breathing, and I wondered how it was for people who had been their lives. While the pace was unhurried and I was never overworked, and I loved most days there, at the end of them I felt tired.

And I was mean when tired, and the emotional stress of seeing and taking in this weighty process manifested in a lot of physical breakdown. Getting sick, breaking out with a cold sore, a couple allergic reactions, and developing various muscle strains, I was told that I was pushing myself too hard, that I needed to listen to my body. I think it is true that we should take care of ourselves, but I also find value in digging for the resilience that lies in vulnerability, and believe that this first means knowing what makes us weak. I didn't plan this of course, and it could be argued that I'm rationalizing the discomforts of the experience. But somehow, an intuitive, inexplicable part of me feels that there is good reason the weather was so harsh, the people so fragile.

hospice (beginning)

I'm a week into my rotation at Connecticut Hospice, the first hospice established in the States. It's located in Branford, about twenty minutes north of New Haven, and overlooks the Long Island Sound. The water is a wide expanse, with a wide expanse of ground from the building to the water, and every room has this view. Currently the ground is piled upon with snow, and unlike the snow of city and of routine living, this snow has remained white since its fall one week ago. There's little to disturb it other than the few who walk out from the building to the black fence outlining the beginnings of the water, and these steps add not color but a faceless depth. The sun rising and setting seeps into crevices of the water and clouds, in increments of half seconds, such that you get a sense of change without any motion.

With that backdrop, we have morning rounds, where the nurses (the heart of hospice) report on their patients and their daily plans are discussed. With that backdrop, we visit the patients and write notes on those visits. With that backdrop, we watch people die.

I hesitate with that line, hesitate to dramatize, but when thinking of the actual fact of things, that's just what it is. And some of it is as heavy as it sounds, and some of it floats away without much notice. As not just newbies seeing things for the first time, but as students whose role is to absorb as much as possible, the experience as a whole is quite a bit to take in.

In this short time, I've been struck by a number of things. For example, of how scared I was to see someone physically transition from life to death. Not out of empathy for the person who had not much life before that transition than after, but out of an instinctual aversion to seeing it happen and an awkward, sad sense of trivializing something by being there for the last breath of a person I didn't know.

I've been struck too by resilience, by how people give more at their most difficult times than I can at my best. At a time when I imagine people might feel compelled to turn inwards, they are instead touchingly sensitive to others. They continue on as the people they were--they want to take care of the families they've raised, they are insecure about how others perceive them in hospital beds,

And I've been struck by the variety of burdens, in quality and quantity. There's a lot to consider, besides the sufficient issue of absence. There's a man whose wife donated her kidney to him, there's an unresponsive woman whose 14 year old son reads her stories she'd read him, there's a man whose son and wife don't know how to speak to each other about the same thing, there's a 98 year old woman who says she feels full of emptiness like a room where sound echoes on and on, there's a woman whose understanding of her husband's pain is a more meaningful transition than his from life to death, there's an artist whose wife never let him draw her portrait until now and he draws a black and white picture of her face with her eyes closed. There is a 46 year old man who without telling his wife bought a sports car, who then crashed it while speeding, who then dies after months of his family tracking the movements of his left eye.

And I've been struck by the humor, and conventional routes to warmth paved in a place one might imagine as cold. I wrote my first prescription for a daily beer, frailty quickly turns into feist when a woman wants her nails polished and thinks you're the one who promised them to her, and you find that innocence doesn't need to be young, that the sweetness of wanderings renews itself with dementia. And it's things like all of these that bring awareness from knowing logic to feeling realness, like the sense that maybe death is an emptiness but one that's full.

language

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.

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.

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.

therapy

For my weekly outpatient experience for psychiatry, I spend half a day at the women's clinic at the VA. Given that I will have spent three months at the VA by the time I graduate, I thought it would be nice to interact with part of its population to whom I've never really been exposed. None of my patients on my medicine rotation at the VA were women. I was told that two years ago, the number of female veterans surpassed the number of World War II veterans, and women are currently the fastest growing demographic group in the military.

The sessions are essentially talk therapy, in which I have no training or experience. The psychiatrist often leaves me alone with the patients, which is both something I appreciate and something that terrifies me. Conversation I can do, but conversation in the setting of purpose is different, and I'm not sure it's my role to be attaching "therapeutic" to anything I ask or say. If anything, it's felt like much of third year, where we're given more than we give.

But this past week, I learned that that's the point. The psychiatrist explained to me that these sessions are based on logotherapy, a form of psychotherapy developed by Viktor Frankl. Frankl was a Holocaust survivor and psychiatrist who struggled afterwards to derive meaning in a world that had shown itself capable of such injustice, cruelty and suffering--things that these women know so intimately that it seems to sit in their skin. He believed that meaning existed in every existence, even one of pain, and that tragedy could serve as sources of good. Logotherapy focuses on helping people use their tragedies to form meaning in their lives; not to see the negatives as simply barriers to overcome but as means to create value.

The role of the student in these sessions exemplifies this philosophy. By sharing their stories, the patients give us an inexplicable amount of life. The women are tough with how their experiences have grown into them but are generously open with the layers they've developed. Each sentence, each shape their faces take, give texture such that I feel like I could hold the air between us. And this is a small part in acknowledging that their stories of pain have worth, that what's been taken from them doesn't have to perpetuate loss but can further growth.

At the end of the day I'm very tired, drained from absorbing the sadness of their stories. On some days I choose to sleep or listen to music without doing anything else or shower even if I'd already showered, to concentrate on a sole sensation because this is easier. I don't blame myself or anyone for retreating to this numbness for a short while; it's natural. And I like to think that it eventually leads to working to continue what these women started, not just absorbing their experiences but then using them. It's a weight, but not one to be sucked in or erase. It's something to take time to record, remember, share and integrate into how we process and experience our days. I'm a little tired now, but I think that will all come.

alone

Leaning against my car, I didn’t see any water. Void of any geographical sense, I wasn’t sure where the Long Island Sound was situated but I wasn’t really looking for it either. Though the space between, between where I was and where the bank of trees ahead lay, steeped down and gave a feeling of being higher up, the parking lot was likely not elevated enough to afford a view. It was cold, not bitingly so, just so to match the gray that comes too early in the day during months like December. The sky held a dull solid gray, the trees blended a hazy one.

It’d been a short and unfamiliar drive from New Haven to the Connecticut Hospice, and now that I’d entered and left the entrance of the building, it was easier to stay. The stray leaves clinging to deceptively precarious branches didn’t keep the trees from being bare, but made them feel heavy, and I tried to focus on the lean trunks. I tried not to choke on my heaving breaths. And to stop the flow of salt and water from my eyes to the air around, air that you could tell was dry by the way it soaked up the moisture layering my skin.

He’d been transferred from the hospital to hospice the day before. He hadn’t been happy about it, had responded with “horrible” when asked how he was doing, the last two syllables swallowed by the effort of the first. Often his breathing was too labored for fluency, and sometimes words took a long time, occupying a space that I didn’t realize was open until his voice closed them. Even though his voice sounded the same whether he was comfortable or uncomfortable, it moved more than anything else about him. It was never accented by the rest of his face; his lips didn’t migrate from the straight road they naturally formed, the taut white of his forehead never disrupted even while his lungs crumpled into rough coughs.

He lived in a bed next to the door in a room of three, and when we waved from the hallway he called out hello if he saw us. The wet brown of his eyes drew a full film from one corner to the other and felt protective of something, but they kept him from seeing his food well enough to eat. He didn’t want to eat anyway, and he directed his gaze towards the sound of the television, even when the hospital headphones slipped off his ears and forward onto his chest like a necklace. It made me think that hospital gowns don’t lend themselves to accessories.

He had been a patient on our list of patients to see every morning for almost a week before I really met him, when the physician taking care of him allowed another medical student and me to sit in on a conversation she had with him about his health. Earlier that day she had talked of him as a patient she knew would stick with her; “he’s sweet; you can tell life’s been unfair to him.” I’d felt somewhat guilty for not noticing, as once I sat down on his bed it was palpable through the blankets.

The doctor touched his shoulder, which was usually enough to rouse him if his eyes were closed (at this time they weren’t), and told him she wanted to talk to him about things.

She gently explained the state of his major organs and how in trying to support one, we hurt another. When things reach a balancing act where balance would be unstable, when piling or removing things from either end keeps hurting, we turn our attention to the fulcrum. Again nothing in his face moved, but he said he wasn’t ready. He’d have to talk to his wife. She didn’t visit because they didn’t have a car, and a taxi would be too costly for their resources. She didn’t like seeing him so sick, anyway. But Thanksgiving was coming up, and his nephews and nieces had cars that could carry his family, and turkey with cranberry sauce in plastic containers, to the hospital then.

I was also in the hospital on Thanksgiving, when his room went from three patients whose beds were separated by cloth curtains maneuvered by nurses and doctors, to a flock of relatives standing in their puffy winter coats that they didn’t remove once inside. His wife’s shape matched her voice on the phone but she looked much older than him, with the gray in her hair prominent since she’d let it go long while his hair was still brown, and the wrinkles I sometimes imagined to be hiding in his forehead openly lined her eyes. A teenager with glasses and thick strands of hair across his forehead, a nephew I presumed, brought him a walkman. The headphones that came with it weren’t any more stable around his head than the others, but he took them with him to hospice; we had to disentangle them from the other pair to make sure he had the right ones.

I said hello to the group forming a sort of semi-circle at the foot of his bed as though participating in an icebreaker, and saw the cranberry sauce. It is strange to meet people whose lives give a disproportionate amount of substance to yours when compared to vice versa. I wasn’t in the room when the doctors talked to them about the future. But I saw them leave the room and walk down the hallway in a choppy stream, some visibly upset and others subtly so.

His wife nodded as I passed and said that she would like him to be comfortable. I nodded back, and went into his room out of an invisible inertia, without thought to if I had anything to offer and if so what form that would take. And so I started as we did every morning.

“How are you doing?”

“Oh, half and half.”

“I saw your family in the hallway. It must’ve been nice to have them here.” I looked at his bedside table to see if he’d eaten, but I couldn’t really tell. It was only then that I heard what he’d said, which was something he would say often in the following days. When evaluating his physical state, the doctors taking care of him spoke of him as having good days and bad days. It is true that on some days his face looked cleaner and his lungs sounded clearer, and other days the crackles that our stethoscopes could hear would rattle his chest so that he looked limp and for some reason during those times, the crust that develops from standstill remained in his eyes instead of being washed with blinks. “Half and half?”

He nodded, which for him meant bringing his chin down to his chest. By the time he’d bring it back up, you may have forgotten the first motion.

“Did you talk to your family about things?”

“We’re looking for a place. There’s one near my house so my wife can walk there and see me.”

Surprised that the logistics of things had already been discussed, I nodded.

Back in the room with the computers where we typed records of how our patients were doing today versus yesterday, they tried guessing what would take him, eventually: his kidneys, said one; his lungs, said another. How does that work, when his cancer had started in his throat? He never asked, but I wondered and despite the daily updates on his physical state I never knew.

Later through a process of which I wasn’t aware but trusted, it was decided that he go to Connecticut Hospice in Branford, not to the place he mentioned in his town. We told him it would probably be better when he was settled into a place, in a room with more privacy. He asked whether he would be in his own room, and was told that it was likely to be shared but that the rooms were vast. Although he seemed to want his own room, he wasn’t eager to leave the company of the people passing his open door in the hallway, though he never stated either sentiment directly. “It’s nice to just see faces,” he said in what felt more like a confirmation than a confession.

On one Friday, after having seen him on our morning rounds every day he’d been in the hospital, I said I’d miss him over the weekend.

“Well, then you should work on the weekend.”

I paused. “I’ll come by to see you.”

There was no pause, and no movement of his eyes from their station. “That’s very nice, but you won’t.”

Our interactions were not scarce, but brief. We ran out of things to say. I didn’t find out much about his life before here, or his life at that time outside of that bed. The natural course of asking how he was would be to discuss the present and near future, and I didn’t know how to bring the past in relief. On days when he wanted to be in limbo or something more than that, he’d talk about the new cancer center and what his doctors had told them. On the days it was explicit, mostly he said he didn’t want to die. Asking why would have felt too easily misunderstood, but now feels too easily absent.

So the day he left for hospice was one of the half and half days; to his doctors it was a bad one. In the hours before the transport from hospice arrived, he was having trouble breathing, and when they arrived he was receiving a breathing treatment to help open the vessels in his lungs. The man and woman in uniform who had come for him stood by the window and told us to take our time; they were “in no rush.” When he finished breathing into the mask, they brought a thin stretcher alongside the hospital bed.

“We’re going to move you from there into this so we can drive you there, okay?”

“How far is it?”

“The ride will be over before you know it. Barely twelve minutes.” The woman’s conversation was proficient, and I became acutely aware that this was my first time seeing all this happen. Her hair was tight where her braid started to form and then throughout. Nothing about her gave way, but still she was kind in a way difficult to pinpoint with tone or act. Maybe it was this softness without known source that made me turn away when they put the rails down on his hospital bed.

But I watched as they gathered the sheet below him and swiftly transferred him to the stretcher. Narrow as he was, the stretcher still just accommodated him. The man and woman layered him with blankets that had the texture of towels.

“There will be a brief period, less than a minute, where you’ll be outside as we move you into the van. It’ll be cold, but we’re putting these blankets on you, and it’ll be very quick.”

His belly was large, but he was seamlessly consumed by a swarm of blankets. Once covered, his arms and legs disappeared. His small face lacked sharp edges and fell into underlying pillow without difficulty. There were hints of him against the sheet: the deep brown of his hair splayed in tufts, the red in his cheeks dissolving thinly out and down to his jaw and seeping into the pillowcase, the wet in his eyes making all else feel dull. This was all I could see of him; everything else was white on the black stretcher.

“We’re going to strap you in now, okay?”

He brought his chin down to his chest, and coughed, “Okay.”

The woman pulled on a black belt with a heavy buckle, stretched it to as far as her arm extended, and handed the other end across his body to the man, who pulled down and tightened it. This spanned his torso. They started another across his lower body but as the transfer of buckle was taking place, one caught the other’s eye and they paused. “It’s probably not necessary.”

I’d never seen him walk while in the hospital, though I knew he went to and from the bathroom on his own, but it wasn’t until now that it seemed that he couldn’t move, with or without the one buckle. He was breathing less heavily now and unlike when he was sitting up in bed with his gown in full view, as he lay there I couldn’t see his chest struggling.

“I hope you’ll come see me.” We’ve been advised never to promise anything, and despite instincts, we force ourselves to rephrase things into “I’ll try.” It was a Tuesday, and I told him I’d try my best to come see him, though it might not be until Thursday or so. I watched them wheel him through the door and down the hallway, no further though I could have rounded the corner to the elevators with them.

I’d never been to Connecticut Hospice but had heard it was beautiful, overlooking the water. I looked up its information on the internet on Wednesday morning. I called their number for his room number, and was given it, though they said I wouldn’t need it. The person at the front desk would help me once I got there.

It was late afternoon when I got there. Though the streets were a little confusing, I’d found the way fairly easily with my friend’s GPS. The parking lot was large and three fourths full. As I walked to the main entrance, I felt glad the transition had been made, and looked forward to seeing him in a brighter place, one designed for comfort. The front desk was where they said it would be, and I found myself thankful for the ease of things. The woman manning it wore a thick sweater upon which her light curls rested. When I gave her his name, she carefully scanned a list in front of her. As the seconds crawled, I regretted forgetting the room number I’d called for in the morning.

She picked up the phone to call for his room, and as I waited I watched others pass through the front desk and down a corridor past large glass windows, without stopping. She spoke softly, but I heard her say his name. Then, “oh,” to the phone and to me, “Are you a family member?”

“No. I’m a med student. We took care of him at the hospital.”

“Oh,” to me, and to the phone, “She took care of him at the hospital.”

I watched her nod several times at the phone, continuing to speak softly, and hang up. “Someone’s coming.”

“Thank you.” I waited and watched more people pass, without waiting.

Someone whose face and shape I don’t remember came. “Hello, are you a family member?”

“No. I’m a med student. We took care of him at the hospital.”

“Oh.” She nodded. I gave a small smile. She told me she was very sorry; he’d passed away that afternoon.

“Oh. That was fast.” So fast. Twelve minutes to get from the hospital to there. What happened in between? I’d called that morning. He’d had a room number. One with a letter, so he was sharing space. But it was more space. Blinking to buy time, I paused before it came to me to ask, “Was his family there?”

“No. We called his wife. She didn’t want to come.”

I nodded. “Thank you.” I wanted to give her more than that thank you, or to fully give the thank you, and paused. But it was too brief, and the sentiment too blurry. I turned slowly, maybe to match the stride of what had come before. But once out the door, the passing air that grazed my skin on its way to elsewhere held in it the shortness of my time inside, taking it for itself and carrying it away. Maybe because of that I stayed outside.

He hadn’t asked to be moved to a building with a view, or for much of anything other than our presence. It wasn’t much to give, and it wasn’t hard to want to give it, but in the end it was the most elusive. When asked about how he wanted to proceed, he’d defer to what we thought, saying we knew best. There were a lot of us: the respiratory team watching over his lungs, the oncology team monitoring his cancer, the renal team reminding us that his kidneys were failing, and the geriatric team checking every morning for a bad or good day. Each of them explained things, and asked questions to cater to his needs, trying to provide care in the niches they’d formed in training and in experience. Because the weight of confrontation and decision was too much for him, and because this weight had become a part of their anatomy, they let him give it to them, in the hopes that they could give something to him.

I thought this too, thought that though it felt viscerally out of place to attach him to that stretcher and move him, it would take him to a place that would be better, eventually. What happened in that transition to this place, that took from him the time required to make it better? We’d left him alone before.

Never having seen him in a new place, standing with the hospice in close distance I only saw him as he looked when I first knew him. After not too long I left for home, with the water still out of view behind the low level of trees.

angry

At the United States border, driving from Montreal Canada, a friendly man with a Southern drawl asks us where we lived, where we were coming from, what we did, and what we were doing. When I tell him we're students in Connecticut, he asks what we were studying. "Medicine." A slight grimace, and "...Why?" We break into real laughter, not of the oh-you're-funny sort, but of the oh-you're-right kind. "We've been wondering that the whole drive here."

I'm generally not that negative about the harder, less ideal aspects of medicine, mostly because 1) I keep hoping that we'll fight against them, and 2) even when that fails, I feel lucky to meet such variety of people, to witness and understand subtle individual qualities, to get strands of stories even as most are still wound tight. But this doesn't mean that I don't see the shortfalls of what we've seen of medicine, though I do worry that my modes of adapting to or coping with them will lead to passivity and unawareness.

Anyway, I get disconcerted and quietly mad throughout the days. Most days I see it and think about it and tuck it away, for storage and memory and recall and change. This keeps me sane, and optimistic even as I try to stay open to how that optimism may pan out (ie, it may not). Some days it's much harder; while the mad remains quiet, it's noticeably present to me and it gets to the point where hope gives way to worry and slight depression about why things are this way. A friend of mine who saw with me some of the saddest parts of medicine I've seen, asked me the other week to explain my distinction between sadness and depression. There's probably a lot to it that I feel and haven't yet expressed, but the best I could do at the time was that--I find sadness in loss that is natural, whereas unnatural loss brings depression. Disease and death is sad; injustice and undue unkindness or undue absence of kindness (more common than the former), depresses me. This hole amidst a profession of caretaking can really get to us sometimes.

At times like this I look around for the ground that we're supposed to stand in; at this point in our venture I don't mind if it's grass sunken from continuous downpour, if it's uneven pebbles that uncomfortably dig, even fresh tar that traps. But then there are those moments I look and there. is. nothing. We reach and reach, and we're left drifting in some two-dimensional space where the ground of taking care has been replaced with simple blank.

What to make of this, at the end of a day when I don't want to be helplessly angry? As with other modes of sustaining positivity, I'm not completely sure but hope that--in this fury we'll throw wide heavy blocks at this wall with no floor.

physicality

Hepatic sinusoidal obstruction. Encephalopathy. Hypoglycemia. Sepsis. Hypotension. Lactic acidosis. Intubation. Multiple organ failure.

Prepositions strung these words together, a litany of the goings-on in her body and what ultimately took her life. Having a slight sense of what these mean, the words were bullets. Instead of blood, they drew salted water. It can never be as visceral as it is for a person whose physical life is slipping, but it reminds us that it is visceral, and today I felt that maybe that's part of what they mean when they speak of all this as a gift. We tend to polarize, sometimes focusing on the science and other times emphasizing the emotions, with elbows nudging us to meld the two. In between lies something less lectured, less considered, equally present--physical sensations, from which so much flows.

I started my neurology rotation today, and we began by observing neurological exams on a couple of patients. Neurology more than other disciplines draws quite a bit from the physical exam; you can often localize what part of the brain has been damaged by what part and side of the body can't move, or what the person can't say. The brain is the center of complex feeling and thought; it's also the source of tactile sensation and bodily movement, and to me this can often be the most touching loss.

One test requires a person to close their eyes. Without visual balance, one should still be able to center themselves. When our patient closed his eyes, I heard a gasp slide from the classmate behind me. When our patient closed his eyes, he swayed to his right side, and had we not known this to be a possibility, he would have fallen. One way to treat his condition, which causes vertigo because deposits in the inner ear dislocate and end up in the wrong place, is to rotate your head and roll your body in various directions, to shift the deposits back into place. We marveled at this cure, so simple beside the antibiotics whose names I can rarely remember and the surgeries involving anatomy I often can't visualize.

A bit later we observed our first stroke code, meaning the standardized protocol when a person is suspected of suffering from stroke. Aside from the acute event, she had a past medical history of HIV, hepatitis C, breast cancer with metastases to the liver, COPD, and obesity. The four of us, students with nothing to do but watch, huddled in the corner but there was no way not to be in the way. Red stained needles and whatnots fell to the floor inches from us and we were benignly smacked as people went to and from a corner of the ED made flimsily separate with shoddy curtain. As all this went on, a doctor spoke loudly in the woman's ear: Close your eyes. Open your eyes. Stick out your tongue. Say your name. Lift your arm, and hold it there. There is a point system that adds up a person's ability to follow these commands and thereby determines how dire the state of a person's consciousness is. There's no modesty, much noise, and carved out among this are the listless failures of a body to move.

For fatal cancer, for benign vertigo, for someone in limbo--it can be these everyday sensations that are stolen, and sometimes never given back. A friend of Natasha told us in Natasha's words how she felt about her cancer, and she said this when she had relapsed: lucky, without regrets or a wish to turn back time and eradicate the experience. Because of it, she felt beyond what she called earthly, and I believe that must paradoxically be some kind of sensation too. We talk a lot about feeling happy, what seems a communal and obvious and ever elusive goal. It seems to me that between the innate and fragile capacity to feel the "earthly," and the "beyond" that we acquire and earn--there lies the most honest, coveted desire to merely feel.

failures

During the first two years of med school, we went to the hospital each week and interviewed a patient. I liked the conversation and experience, and disliked never seeing them again, especially since the interaction was purely for the purpose of teaching us; we weren't involved in their care in any way. So it always felt a bit one-sided, and I mentioned a few times to people that I disliked the drop-in feel to it. I interviewed one patient who asked me to come back and say hello; he came back to the hospital regularly for chemotherapy. Given this chance, I thought I'd actually have something to offer. So I had my first (and only, at least before the wards started) second visit with a patient; we talked for a bit and planned to talk again right before winter break. But when I came back with chocolates to share for the holidays, he wasn't there; the chemo must've been re-scheduled. I checked one more time the next morning, but wasn't there. That day I went home for a few weeks, immersed in chaotic family friends and studies, and came back to more chaos of second semester of second year. In the midst of it, I kept thinking I should go back and see how he was, knowing that he was supposed to undergo an operation right after break. But I was perpetually tired and busy, and in the moments in between that I was lazy. So I never did see him again, and since his cancer didn't have a great prognosis I'm left with mostly doubts. I still have the chocolates, keeping them as both a trivial means of assuaging my guilt and a reminder of my failure to actually take the opportunity to do what I say I'd like to.

I was reminded of this today, when I saw a teenager with strep. Despite my very recent post about how we should read patients' charts, especially in primary care which is ideally continuous care, and address chronic issues at each appointment--I've already fallen into the established routine, of reading the two-line chief complaint written in by the nurse upon the patient's arrival, and checking the chart and problem list only when seeking certain information. Despite my confusion about why we don't ask about a patient's depression each time they come in, for something like back pain, I don't think to consider that each new patient I see might have similar problems. Despite my discomfort with purely focused physical exams and our school's emphasis on observation, I get caught up in the problem at hand and today, the red throat caught my attention more than other concerning findings. It's not that I missed them; I saw them, and for whatever reason, made in a half-second the decision not to inquire further. After the patient had already left, I looked at her chart again and discovered that this was a recurrent, chronic problem. To be fair, it wasn't listed in her problem list, an issue I brought up before, so I had to write that in, but it was in several notes from her previous visits. This is the sort of thing I've so recently thought and wrote so much about, the need for follow-up and detailed, wholistic care. I neglected the opportunity to address it, and not because I didn't have time--as a student the only thing I have more of than doctors and nurses is time--but just because in three weeks of outpatient care I've fallen into a habit of sacrificing depth. It's not that there haven't been models of comprehensive care; I've found the PCPs to be incredibly caring and mindful. It's the pace of things, and the necessary narrowing of things, that pervades all of current healthcare that has become practice even despite my mental barrier to it.

I hope hard that these experiences remind me not to repeat the same mistakes, and push me to try harder, because I'm disheartened that they happened so early on when we're supposedly at the height of energy and time. And it's okay, don't comfort me! I know we're all hard on ourselves; this isn't so much for the present me as the future me.

In the end I wrote out my first prescription (penicillin), asked our social worker to give her a call and follow-up, and stared at her chart for half an hour. It felt about as empty as not eating the chocolate.

communication

In skimming a description of what babies look like if their moms have had alcohol during pregnancy, I came across the word "philtrum." Wikipedia tells me that the philtrum is the vertical groove between the lips and the nose. It "allows humans to express a much larger range of lip motions than would otherwise be possible, which enhances vocal and nonverbal communication." It's derived from a Greek word that means "to love, to kiss."

One thing I liked about anatomy was learning the words for things, even if it doesn't often enhance your understanding of it. It kind of made my day to learn what the philtrum is, partly for that reason and partly because I've been thinking a lot about communication lately, and had already planned to write about it today.

So much that's important to me comes down to communication. The things I've been in immersed in as of late have been crowding my mind, all for reasons relating to this. With patients, learning how to talk to people from different backgrounds and struggling to bring down to earth those loose commonalities of health, respect, empathy. With friends, feeling such love for the big and small offerings of ourselves that we swap. With myself, reminding every day to be honest. With the outside world, fighting against the perception of people as simple to know, the categories, the dismissal of depth.

There is amazing variety in the kind of interaction healthcare providers have with their patients, and from the small bite of exposure we've had thus far, I've been better able to formulate in words what makes for real communication between people. I've always been awful at verbal articulation, but it's even harder than I thought to carry on a conversation that conveys both information and feeling. This morning my preceptor spoke to a mother in Spanish, who responded to a PA in Portugese, who then translated in English. The woman's toddler howled in tears. As students we have the perspective of naive eyes, and with those I wanted to put down what not to forget when our eyes get tired--

*Really wait for the answers when asking questions. Then listen to the answers, and ask follow-up questions. We pay attention to the factual answers about symptoms, but we fill in a lot of the how-are-you's ourselves without waiting for the response. *Speak half as slowly as you think you should, and remember that even in English we need to translate. I have two years of medical education (maybe half a year if you consider how much I retained) over most patients, and I have so much trouble remembering what was said, what people really have and how they got it and how they'll get better. *Acknowledge everyone. I've been grateful for the kindness that comes with a glance my way, sincere greetings, the shifting of objects to accommodate another's path. I think feeling each other's weight makes us more aware of our own, in a way that lets my hermit self retain its shell but also keeps us grounded in something more expansive. *Write legibly. Seriously, what's the point of writing something no one can read? *Move deliberately, not hurriedly. There's some illusion of efficiency dangling before all of us time-crunched busybees, the one that whispers to us to flip pages loudly, plop folders on the counter, walk briskly out rooms without closing doors, to speed-talk, to write illegibly, because it saves seconds, precious seconds. It might, but I've seen the steady hand say more and last longer.

These things can take a lot of effort (at all stages of the game--initially, once you get going, when you near the end). It's nice to come home at the end of the day or escape to during the weekends, to something I'm used to.

I have an amazing wife (my roommate; I can't actually remember how and when we started calling each other wife). She once said if this is really what marriage is like, it might be nice, and I agree. I'm always happy to see her, even if after we retreat to our rooms like the lone ones we sometimes like to be. She makes comfort Chinese food, including the best hot pot I've ever had. She's never once been mean to me, even when I'm neurotic or annoying or irritable. The few times I've gotten upset, she's sensitive, not defensive. She always tells me I look nice, and after a year of living together she's still considerate about washing the dishes. She listens to me struggle through being complicated, and what I see in me as the best and worst, she values. When I break things (often), she fixes them. She glued together one of my tea cups that I shattered. When one of the drawers detached from my desk, leaving a gaping hole, and the center slowly sunk from the weight of my books, she brought home another desk that looked almost exactly the same. When I complained about morning light waking me up and I was too lazy to get a face mask, she got me one. When I tell her an embarrassing story, she tells me one back. I can't describe how it works with a list of what to do and what not to do, but I know that a whole lot flows in the space between us, and each day we're at home I'm thankful for that.

Last weekend my college friend with the same name as wife came to visit New Haven, then I visited her in Cambridge. We don't see or talk to each other very frequently, but we caught up quickly at first and then slowly. She showed me the new stores in Harvard Square that replaced those familiar to me, and I had that sensation of things stretching and rearranging my skin. It didn't hurt like I thought it might. Instead it felt the way it does to see old friends. There's new growth to recognize, and old to unearth. J. has been through a lot and through it, became and remains one of the kindest and most genuine people I know. In reacquainting ourselves with each other's presence, I so admired the capacity to see and emulate good after having experienced not so good, a value I've only been able to articulate over the past few years. She's mindful of what's been given to her; yet she gives not out of obligation to give back but out of her nature. This generosity makes it easy to share, and in traipsing around our respective corners, things were exchanged through the pores and cracks--the confusion of the sliding doors at the subways where there used to be turnstiles, the way sunlight infuses the solid marble of the windowless Beinecke rare books library, the fatigue after walks in summer heat, the browsing for cheap clothes and purchase of matching bright checkered patterns, the fear of dodgy characters in the South End, the drives.

I know these are rare and to be kept close, because every so often I get mad at the tendency of the masses to paint over the cracks, the way I cover the sunken middle of a cake with extra frosting. Of the things that really bother me, among the top is people boxing other people up. I think of character as the full range of what a person can and will do and feel, and I've found that for most, this stretches quite wide. On a bigger scale, I dislike speculation about people from afar, the way classmates and colleagues are branded as such and such, concrete images built from smoke. Brushing aside mass perception--frequently misperception--can be tough in practice; I hate being misunderstood, and I hate that people settle for lesser explanations because the true one is complicated. So it's part personal, and it's part indignation at the substitution of gray for black and white. So I'm still learning to ignore all this, and rely on what I know, and in the end I'm thankful to be pushed to self-reliance.

On a smaller scale, but often a more potentially harmful one, is the boxes we create from actually really knowing someone. I do it too. I appreciate the positive qualities people attribute to me, but those closest to me have learned that nothing is defining, or I still remind them because I know it's hard to let go of what we've built up. Some who saw me as rational and together recognized a bit late how emotional and lost I can get with relationships. I don't blame them; I was stunned by it too at first, but once you step beyond borders, you need to make room. I do fight and I am mean, quite possibly meaner in those arguments than people you naturally assume are confrontational. This applies to more trivial things too, that don't directly bother me but indirectly do by nature of pigeonholing people. I do like some rap music, I've kissed boys recently met (for relativity's sake--two), I've stolen, I'm even more neurotic than you already know, I'm envious of others' talents, I actually do like some sports but have gotten myself stuck long ago in a self-conscious image of conventional girl and never developed the skills to now get over it, yes I do like to keep things but I throw certain things away. I like knowing these for myself because they've helped me give other people leeway, to know them more deeply, or to at least be more open to whatever they offer. This isn't to say that our understandings of each other are flimsy; they're obviously shaped from real things. I'd hope that some baseline qualities remain underneath it all, and I'm guilty of expecting people to know me well enough to predict or assume my actions or feelings, which might seem to go against this idea of malleability. It's more that things can be rearranged, and sometimes they can be torn down; you don't need to assume that they have, but you shouldn't assume they haven't.

I mentioned this to a high school friend, someone I've mentioned in my blog before as the one person in my life who is completely open to who I am, who is never surprised by anything I say or do because to her I'm capable of being anything. She wrote back something that I imagine she typed freely: "i can't even begin to tell you how much i feel i've been pigeonholed about issues and situations, over and over again, like ppl can't accept contradictions and opposites, and such a simple thing as change. their limitations end up limiting me, and i start being convinced of their perceptions, but i'm learning to be strong.. i understand ppl can be jaded. but i'm jaded too. i still think everyone is a mystery. fun mysteries."

The past few years have me seeing those fine rifts between nose and lip, that are attractive in the manner of the hollow that ends the neck, the slight indent that lends delicacy and nuance. I think of those babies whose moms consumed alcohol, whose philtrums are flattened as a result. Knowing what it is to be dulled, I trace these lines again from time to time.

no, really this time

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

path of least resistance

Told wife today that one reason I didn't pursue journalism was a fear of reality. I don't write anything about the world, mostly because I don't have much new or original to say. The only thing I know any more about than anyone else is my own life, sadly. But in addition to all the immediate coverage, reading the flurry of links sent about Israel & Palestine from friends the past day or so, well, I still don't have anything new to say...but it does make me think about choices and how things we do on a daily basis seep into the world as a whole.

It is unbelievable to me how natural it is for people to cling to status quo even, and even especially, in the face of overwhelming reason to change. And how hard it is to commit to a principle rather than a side. To realize that though context does affect what's right and what's wrong, there are absolute rights and wrongs we have agreed upon. Among some friends the phrase "path of least resistance" has come up some times this year, not in relation to current events, but I find it apt for the awful craziness of what's going on in the Middle East. And back here, we continue the way we've been because it's easy.

The phrase came up in relation to me as a person. In recently asking a wonderful friend for some reassurance, of a kind thankfully rarely needed, he told me I'm a crazy person, a mix of immediate relentlessness and everlasting patience. It's true that this doesn't make for an easy personality, that patience simply being a euphemism for the neurotic relentlessness. Aside from pure stubbornness, I hope that the difficulty stems from certain value, and I am thankful every day for the people and things in my life that make me feel that. I've never been and probably will never be the path of least resistance. And I don't want to be, even if were to make me the path that's taken.

But for the world, let's not make this an exception, let's please take the harder route this time and the next.

the second time around

Back in the fall, in biochemistry, we learned about Lesch-Nyhan disease. People with Lesch-Nyhan are deficient in an enzyme called HGPRT involved in purine salvage, which leads to uric acid buildup. I remember these details because the other thing about people with Lesch-Nyhan is that they for some reason also mutilate themselves. They bite their own lips and fingers. Completely helpless to stop themselves, people with this disease often bandage their hands to prevent inflicting hurt upon themselves. Our professor referred us to a New Yorker article about a man with Lesch-Nyhan, and how the lack of control in self-mutilation pervades his entire approach to life. Instead of telling someone he loves them, he swears at them. Seeing a sharp pencil induces an uncontrollable urge to take it and do harm. He uses his right hand to grab and restrain his left hand from grabbing a knife and hurting himself or someone else. His intentions and his actions are completely at odds, and they divide his body.

The author of the article framed the disease as the extreme end of a phenomenon of which we are all victim, what Edgar Allen Poe termed "the imp of the perverse." The idea that we all do things that we know are bad for ourselves, like eating too much junk food to the point it's not pleasurable anymore or contemplating swerving your car into oncoming traffic for no particular reason. I remember first learning about this strange, rare disease and thinking that I must have some emotional form of Lesch-Nyhan, where I perpetuate things that I know, in mind and in heart, are not good for me and will hurt me.

Doing it once made me none the wiser the second time around. In a recent lecture about the biological basis of pain, we learned that when you feel a certain kind of pain for the second time, you feel it more acutely because you know its character. I'm not sure about the implications about your recovery and resilience, because I would guess there is also a desensitization process, the idea that pain makes you stronger and more able the next time. But what was clear is that once you get to know pain through first encounter, you are more aware when it hits you again. You don't have to feel around in the dark to learn its edges and figure out how to hold it. You know its contours without exploration.

The professor who lectured on pain did make a mistake, though, when he alluded to Lesch-Nyhan and said that people with the disease don't feel pain when they self-mutilate. I distinctly remember that they do feel pain, but the awareness of it can't stop them from hurting themselves. For them there is no desensitization or increased strength, only a constant fight against recurring pain. But I admired the man in the article, because there was a deliberate fight, a will against what he did to himself even if he knew it would continue.

For all the mistakes that I make twice and three times, growth does lurk in the corners. Despite similar themes, and a similar trajectory of trying not to hurt anyone and in the process hurting everyone including myself--there are different circumstances, reasons, people, feelings, and most importantly, more things learned. It does make me wonder again if I'll ever feel the same as I did the first time around. That used to worry me, but now I know that each thing offers something else, and it's valuable. And if I experience that feeling again, it will still have newness and surprises and a sense of other. It makes me think that for the man with Lesch-Nyhan, each finger bitten is not quite the same, and that even though you know the shape of its pain, you still reach out to find something different.

When I told Guson I was going home before summer because I missed my parents, he said I was maturing. My immediate reaction was to reject that idea, because isn't growing up about not missing home, not needing your parents? But it turns out he was right. There's only been one other time when I made sudden plans to go home. That time was a result of wanting to be away from where I was, a push from there to home. This time, I don't feel a push away from anything--I absolutely love where I am, in all senses--instead, it's a pull from home. That time I felt a little weak and this time I feel stronger. This time around, it's different.

loss

To borrow a sentiment from Steph's blog...God, it fucking hurts again.

*

A couple of weeks ago a graduating medical student was killed by a car outside of our dorm building, at an intersection we've all crossed hundreds of times. She walked along a red light, following a truck that was doing the same, and the car going green didn't see her. I was struck ajar at how much it affected me, the people around me, and the Yale community as a whole. There are many factors, I think--her youth, an emanating sweetness that seemed to touch those to whom she was unknown, proximity and inclusiveness. I don't really have anything new or insightful to say about the tragedy, neither its obvious immensity nor its subtleties. I'm sorry for that, but I'm glad there are many people who will do her memory full justice.

A few days after it happened, I read a short story called Found Objects about a woman who compulsively stole personal items. She didn't steal from stores, just people. She didn't steal for monetary or other gain; she didn't use any of the items she took. She piled them onto a table in her home, separate from all else in her life. She took a screwdriver from the back pocket of a plumber, a wallet left by a woman in the bathroom, bath salts from her best friend. The climax of the story was when she rummaged through the wallet of a one-night-stand and found a scrap of paper, saved through time and place, on it scrawled: I believe in you. She took it and never returned it. You could tell she hated herself for it. And you could tell she didn't know how else to be. It wasn't about the addictive thrill of getting away with the crime. It was about collecting pieces of people, and hurting them and hurting because of it.

It caught my eye in the New Yorker while I was in the waiting room at the pharmacy, because the title made me think of a short column I read once in the magazine about a person who collected people's lost gloves, storing them away in the hopes that someday one would find its other half. Found Objects turned out to have a very different theme, and it wasn't so much about things being found as being lost.

On the same day that we mourned the world losing Mila, I lost something separate and large in my life. It felt selfish, yet fitting at the same time, to be consumed by this multifaceted pain. What I lost, I lost because I was a little stupid, a little careless and not brave enough. Natural things that afflict most, and things sewn into all of us, and things grown out of circumstances and other people's mistakes too. So I'm learning to not place too much blame on myself but that doesn't decrease responsibility or the quite awful realization of your own capacity to cause pain.

I felt a bit like the woman who steals, and it makes me think of the driver of the car in Mila's accident. Granted that no one will ever suffer like those close to her--but the driver must suffer too, knowing what his mistake (and it was no one's clear or full fault) did to a life and having to live with that always. I feel a sort of immense sorrow for him, and I worry this is a little unfair and not right, but it seems to me that pain can't be too relative. It hurts very much to be hurt, and it hurts very much to inflict the hurt upon someone else. The driver on Frontage Street, the woman in Found Objects, and me, different beads on the same string.

Nowadays when I see people crossing that intersection against traffic when the light's red, I get a little sad because they don't know any better. And nowadays, when I do the same, I get a little sad because I do.

backwards

Yesterday I met a baby two days old, and realized that's the closest I've ever come to the concrete very beginning of life. Then we saw another newborn born without a small intestine who, the nurse told us, wasn't going to make it. And that was the closest I've ever come to the concrete very end of life.

Last weekend, I left the rain in New Haven for rain in Fremont. The hills had turned green since I last saw them. There is nothing I love more in my hometown than the green hills on gray days. The greenery is so fresh against the rain. We drove through Niles, a part of Fremont I rarely see; the last time might've been the summer before high school, with the same friends. We drove for two and a half hours to get to Sutter Creek, and drove through numerous new-to-me and lush highways and narrow roads along the way. We passed hills sprinkled with churning windmills, hills strewn with cows, flattened hills that stretched to remote ranch houses. I saw a whole new part of California, with two of my oldest friends as passengers, going to the wedding of a friend whose closeness I still miss. The tears at the ceremony were for him growing together with his one, but selfishly, the feeling that lingered afterwards was our growing apart.

I missed home and family something awful while I was at home, most when they were right there for me. I sometimes get the impression people here don't think I'm attached to them or value these values as much as they do because I don't miss California and my family when I'm away. It's hard to explain that these things are so sewn in me that I rarely feel disconnected from them. Yet for whatever reason this past weekend, the physicality of my parents made me feel there are some things I can't carry as well as they can give me in their presence. When I was leaving, my mom exclaimed, I miss you so much! She often forgets to insert the right tense in her English phrases but her mistake made my nonsensical ache for home while I was there right. I miss missing home.

Last month, Henry visited me at Yale and I talked to him in person for the first time since June 2006 when we graduated, and we had similar conversations as we did then. Or at least similar topics of conversation. He mentioned the people we respectively let go. He called them the birds we let fly...willingly, purposefully. He talked about how hard it was, how he hasn't loved anyone that intensely since then, but focused on how much he's grown since then, and how he didn't think he could've grown in the same way if he hadn't. I agreed but will never make up my mind about a concrete rationale for any of that, no longer want to make sense of my senses. I miss the bird I let go, the one who nodded yes you are a difficult person but I don't find it difficult and want to be there as you figure it out because I love all of you. All of you. I grew with him and I've grown a lot without. I've been incredibly happy in both. Like Henry, I know that I've lived distinctly differently because of that willful, purposeful choice.

But that's a given for anything you choose or anything that happens to you, that it has shaped your life in a certain way that's never quite the same as if you had chosen something else or if something else had happened to you, but you can't judge which is more worthy, and in the end you can only be grateful for having had something and later, something else.

weaknesses and messes

Over the course of an overload of conversations, feelings and observations, I've seen that the judgments we make about what's fair and honest become complicated when applied to romantic relationships. "Complicated" is a copout for a concept that's really too complicated for me to explain. I don't mean that the guidelines have changed, only that I seem to be much more forgiving when they're not followed, now that I've broken them too. We hurt people we care about, unintentionally but also when we know what we're doing even if hurting someone else isn't the purpose of our action. At first this seemed to be an excuse for what I've done--saying that it's an inherent weakness, and in some ways it probably still is an excuse. Yet, I also do believe that this is a part of how people are, and this recognition doesn't mean I'm giving in and will stop trying to be stronger than this weakness.

Growing up I was my brother Stephen's confidante. By the time I was in high school, just 14 which seems so young now, he would tell me about his girlfriends, who he pined for, how he saw love. For years since then I would listen and offer my idealistic views of how things should be: that if this girl was the one, she would love him too; that if that girl cared about him, she wouldn't be so self-centered; that if someone was in a relationship you shouldn't interfere; that if feelings were unrequited it's not meant to be; that if you truly care for someone you can be selfless without losing independence because love is good that way. Easy, unqualified comfort. And if you didn't follow these concepts, you must either not really love a person or you were being too selfish for it to work--something was wrong, in any case.

Now, having gone through certain things and seeing people close to me go through the same and more, I'm less able to harshly judge people's vulnerablities and weaknesses. I have the same sense of what's right, but can understand why people go the other way and I no longer think of them as too weak to do the better thing. Even without feeling all of the same exact things or without having been in the same exact situations, I can understand why a person would stay with someone who's unsure about their love and commitment, why a person wants to let go of something and still half-hang-on, why a person stays because of uncertainty or fear, why we hurt people when we want to be selfless. Feelings like these make you strong and weak in different areas.

I've spent a long time coming to terms with the guilt I felt over being weak about these different things. Part of why it's taken so long is because despite everything, I still have those clean, ideal visions of how things should be; I never expected it to be so messy and fragile. Over time I've become more forgiving to myself and to others. People hurt each other, sometimes because they don't know any better, other times because they thought what the other person might lose wouldn't be as great as what one person or both people gain. All of this is more complex than I could ever fully grasp, it's all such a mess--but the fact is even if we don't completely understand or anticipate, it's still our responsibility to deal with it.

What I really want to say and declare for myself is that even though I'm accepting my weakness, I'm no longer willing to just keep being that way. I can see and imagine the ways in which people hurt one another, and it makes me incredibly grateful for how he has treated me and I absolutely know that he deserves better. It has never been about putting myself down, because though I've learned much about my flaws, what I take away most is knowing what I can give and knowing what I don't know yet. I think I'm more ready now to try and overcome this weakness that seems to plague all of us when we feel. I don't know yet how capable I'll be, but I really want to give it an honest effort. I get scared and guilt returns when I remember that I'm not any better than anyone else, and that selfish desires are not so easily suppressed. But I want to stop dwelling in the middle because of my own needs, because of a need to control things, a need to sustain a closeness, a need to remedy the problem I started. I have to let go of these things, because deep down I still believe in all those things I told Stephen when I was a teenager. It's like I've told people in conversations about these things...when you care about someone there comes a point where you care about them outside of yourself, outside of how they are connected to you.

I still believe that love, in all its forms, can be selfless, and I'm going to try and stop looking to the world to prove it to me, to instead take it into my own hands. I think it'll be okay, and probably less melodramatic than this is making it seem.