I've been spending the last few days reading a book on motivational interviewing. One of the main problems I see in medicine is communication, and one of the things in which we aren't trained enough. In medicine and in my own life I've seen the weight of words. I have personal biases too, because having spent years writing essays about the choice of particular words and their context, I'm inclined to feel the nuances of everything that's said. This book is founded on the idea that while change must happen from a source internal to a person, the facilitation of the change very much depends on external factors, like how you talk to them about the change. I think this is all very true, that people are consciously and subconsciously affected by tone, syntax, vocabulary.
For that reason I try to take care with words; it's one reason I find it easiest to write rather than converse, when I have more time to consider. I've been told that this is a mode of filtering, that I'm being less honest because I don't just say what comes to mind. But for me I don't feel that my immediate words reflect my immediate feelings, mostly because I've barely figured out how I feel, not nearly enough to explain why I feel that way, and to explain it to convey it.
But it is hard, because language, even the same one, doesn't overlap from person to person. There are subtle differences in connotation and meaning for each person, and not only do you have to process what it means to you, but also what did the person mean, and which is more meaningful? Since I give it so much thought, I often forget that most people don't. And so, I shouldn't take things this way or that; that's not what was intended, and then following that things are said with clear meaning but that aren't meant. Too much care can be ultimately detrimental, and so balance is a goal in even something like that.
Friday, December 17, 2010
Wednesday, December 8, 2010
talking to each other
A very rough retrospective summary of happenings at the end of October, beginning of November--
*
When we first learn how to interview patients, we are taught to center our conversation around the patient’s chief complaint, with subsequent questions designed to elucidate its source and nature. Because people aren’t naturally inclined to speak following such structure, we’re taught to set an agenda early on in the conversation, to prevent unnecessary ramble and distracting tangents. Emphasize the main points and shed the rest to the sidelines. When a person comes in with a long list of concerns, we’re advised to ask the patient what is most personally important, while we silently also consider what may be most medically important. In this way we cut down and narrow for efficiency, but in doing so sometimes we also dilute, and make murky the source that we develop such intricate formulas to discern.
I’d seen several patients with chronic pain with Dr. McGarvey, and they often have multiple issues both within and outside the realm of physical pain. It can be overwhelming, and unrealistic, to address all of them. One woman, followed by Dr. McGarvey for pain and depression, comes to the clinic with concerns about head pain radiating down her arm, bilateral feet cramping, an episode where she felt sweaty and “drunk,” and sinus tenderness. These are what she names as most important to her, when asked to narrow her initial multitude of issues. She brings all her medications, and narrates a lengthy story about having stopped certain drugs after attributing her drunken sensation to her medications, and recent additions to her medications, and then having stopped all of them after visiting a native medicine healer, and not knowing where along this line lay the cause of her symptoms.
Armed with her bottles and stories, she is someone who may be quickly considered difficult and unreasonable by a healthcare provider meeting her for the first time, or one who has seen her often. But Dr. McGarvey uses his several year history with her to delicately untangle the threads of her state of health, taking each one in turn and stopping to examine the intersections where one crossed another. He translated the sweating and drunkenness that she described in association with her medications to diaphoresis and altered mental status, symptoms of a process called serotonin syndrome that may have been precipitated by a recent addition of trazodone to her usual sertraline, both drugs acting to increase serotonin in her system. This may also account for the cramping in her feet.
When she says that occurrences like these make her feel like she is taking too many medications, because she can never be sure what is acting on what, he doesn’t present the removal of trazodone as the only solution. Instead, he works with her to rework her medication regime. He groups them into drugs for pain, depression, and prevention and maintenance. He points out the few medications he felt were very necessary, and points out others that are more for long-term that may not be as crucial to take at this current moment. He knows her well enough to know to not overwhelm her now, and to know that she will be open to restarting these medications later. With the drugs for pain, he listens to which ones she feels help and which don’t, and rearranges things accordingly. The doctor having often talked through her medications before, the patient understands the details of her medications, and asks intelligent, thoughtful questions.
This is a routine that may be recurring, and that will never eradicate the continual pains and problems, but his care helps her take care of herself the best she can. For her there is no chief complaint, but a general sense of non-well-being, and a person in such a place often benefits from us broadening our view.
She pushes us to do so when she asks for a referral to the native medicine healer in the hospital. After checking in with the pharmacy to begin filling her prescriptions, I take her to the hogan where Larry, the native medicine healer, is working. A hogan is a traditional Navajo building, where families live and host ceremonies. It’s built in the shape of an octagon, and you enter the hogan in one direction and leave in the other, clockwise, to mimic the rotation of the earth around the sun. This one has a fireplace in the middle, rendering all the dimensions of the chimney completely visible until it reaches the roof.
Larry sits in one chair without a back, she sits on another chair with a back and so do I. While the light is still on in the hogan, he asks her what is plaguing her, and she tells him about her head pain radiating to her arm and her feet cramping. Then he takes out a small zippered pouch containing three crystals, a feather, an arrowhead, and a longer item I can’t identify. He’d received the set of three crystals from his grandfather, who had been a medicine man. He can’t say where they are originally from or how they came to be in his possession other than that they’d been passed on in the family for years and years. As a child, Larry followed his grandfather as he healed others, and when Larry was thirteen he perceived the light of the crystal while crystal gazing, the process which he is commencing now.
He lays out two square white cloths. One behind him, one in front of him. The one cloth behind him holds the items he will later place in his hand, and in her hand. On the one cloth in front of him, he places a small round glass bowl. He pours water from a water bottle into the bowl, and places one crystal and the arrowhead in the bowl after the water.
The feather he places in front of this cloth. He holds one crystal in his hand, gives one crystal for her to hold, as well as the item I couldn’t discern. He turns off the lights, turning to me and saying, “This is like an X-ray. It must be dark so that I may see through the body.”
They begin conversing in Navajo for a few minutes, and then he stares for a long time into the crystal. He speaks to her again for another few minutes. In the crystal he sees that in several years ago she had cut and burned the cactus around her home. This disruption of natural surroundings seeped into her body, and I wonder in what spaces—blood, bone, mind?
“You must communicate with all the elements: the sun you feel, the animals you eat, the trees you cut down to make a hogan. You tell them what you are doing with them, you ask permission. They talk to you too, if you listen.”
When there is a rearrangement of the state of things without conversation, the disorder is carried inside and manifests itself as illness. Other happenings like lightning and tornadoes can bring upon a person the aches of arthritis or a silent rise in blood pressure. I’m not sure if these natural occurrences are sources, or reflections, of disturbance.
Like others, this patient will need prayers, one which Larry chants now, and a ceremony in the future to fully recover. In her case, it will entail an offering to cacti and stages of placing sand paint, white for the new dawn and yellow for the closing evening, on her face and chest.
Ceremonies are performed for intervention in times of sickness, as well as for shaping in times of health. When girls experience their first menstrual period, they undertake the process of a kpuberty ceremony. Because a girl’s body is in a phase of change, everything about it is considered sacred; her spit is saved and used as medicine. Everything about it is also malleable. The ceremony lasts four days, and the girl runs at dawn and noon every day, each time going a bit further, to imbibe stamina for the rest of her life. She bakes a large cake for everyone from corn, which she is to grind herself from kernels to powder, using grindstones (one long stone and a bigger slab of stone), and she hand weaves the carpets and baskets used in the ceremony. These movements provide form, and she is also shaped by others in a process called molding, where she lays atop blankets as her skin is massaged by older women.
At the end of this ceremony, the patient drinks the water from the round glass.
“Where water comes together is birth; everything comes from water,” Larry explains.
I am a witness, as someone other than the giver and recipient of prayer must be present. If I had not been there, Larry would have used a long wooden stick he calls a ladder, as a witness. He would communicate with the ladder before beginning the crystal gazing, and then throughout the process, explaining what he sees and feels, just as he did with me.
Everything requires communication. When Larry offers to give me a travel prayer when I leave Arizona next week, I ask whether that it’s all right for someone from another culture to receive a prayer. With a short, light laugh he says, “Yes!”
“Before we start the prayer, I will tell the elements who you are, how you grew up, what your culture is. For those who believe in a Christian God, I will include this in the prayers too; for those who don’t, I don’t. I myself go to three different churches. I was raised Catholic by my mother, I go to Protestant church for the songs, and to Mormon church because my wife is Mormon. I feel the belief is all the same thing.”
“How important is belief to whether the prayer will work?”
“It works sometimes even for those who don’t believe. Belief is the thing, though.”
And so, on my last day on the Navajo reservation I’m blessed by Larry for safe travels. He uses a feather that was a gift given to him in Canada, where he took his wife once when she was feeling badly about her father’s death. At that time, seeing her grive, he had said to her, “Let’s drive North,” and that’s what they did. He brought back this feather that he uses often for prayers. He sings a travel song, and then prays, all in Navajo. The only thing he says in English is: “going to drive to Connecticut.”
He burns wheatgrass atop a burning coal. He gathers the smoke in the air with the feather, using the feather to wave the wafts around my body, then touching the feather lightly to my body: my feet, shins, knees, thighs, arms, chest, shoulders, cheeks, back.
When he says goodbye, he gives me a gentle hug sideways, stooping very slightly to meet me.
*
When we first learn how to interview patients, we are taught to center our conversation around the patient’s chief complaint, with subsequent questions designed to elucidate its source and nature. Because people aren’t naturally inclined to speak following such structure, we’re taught to set an agenda early on in the conversation, to prevent unnecessary ramble and distracting tangents. Emphasize the main points and shed the rest to the sidelines. When a person comes in with a long list of concerns, we’re advised to ask the patient what is most personally important, while we silently also consider what may be most medically important. In this way we cut down and narrow for efficiency, but in doing so sometimes we also dilute, and make murky the source that we develop such intricate formulas to discern.
I’d seen several patients with chronic pain with Dr. McGarvey, and they often have multiple issues both within and outside the realm of physical pain. It can be overwhelming, and unrealistic, to address all of them. One woman, followed by Dr. McGarvey for pain and depression, comes to the clinic with concerns about head pain radiating down her arm, bilateral feet cramping, an episode where she felt sweaty and “drunk,” and sinus tenderness. These are what she names as most important to her, when asked to narrow her initial multitude of issues. She brings all her medications, and narrates a lengthy story about having stopped certain drugs after attributing her drunken sensation to her medications, and recent additions to her medications, and then having stopped all of them after visiting a native medicine healer, and not knowing where along this line lay the cause of her symptoms.
Armed with her bottles and stories, she is someone who may be quickly considered difficult and unreasonable by a healthcare provider meeting her for the first time, or one who has seen her often. But Dr. McGarvey uses his several year history with her to delicately untangle the threads of her state of health, taking each one in turn and stopping to examine the intersections where one crossed another. He translated the sweating and drunkenness that she described in association with her medications to diaphoresis and altered mental status, symptoms of a process called serotonin syndrome that may have been precipitated by a recent addition of trazodone to her usual sertraline, both drugs acting to increase serotonin in her system. This may also account for the cramping in her feet.
When she says that occurrences like these make her feel like she is taking too many medications, because she can never be sure what is acting on what, he doesn’t present the removal of trazodone as the only solution. Instead, he works with her to rework her medication regime. He groups them into drugs for pain, depression, and prevention and maintenance. He points out the few medications he felt were very necessary, and points out others that are more for long-term that may not be as crucial to take at this current moment. He knows her well enough to know to not overwhelm her now, and to know that she will be open to restarting these medications later. With the drugs for pain, he listens to which ones she feels help and which don’t, and rearranges things accordingly. The doctor having often talked through her medications before, the patient understands the details of her medications, and asks intelligent, thoughtful questions.
This is a routine that may be recurring, and that will never eradicate the continual pains and problems, but his care helps her take care of herself the best she can. For her there is no chief complaint, but a general sense of non-well-being, and a person in such a place often benefits from us broadening our view.
She pushes us to do so when she asks for a referral to the native medicine healer in the hospital. After checking in with the pharmacy to begin filling her prescriptions, I take her to the hogan where Larry, the native medicine healer, is working. A hogan is a traditional Navajo building, where families live and host ceremonies. It’s built in the shape of an octagon, and you enter the hogan in one direction and leave in the other, clockwise, to mimic the rotation of the earth around the sun. This one has a fireplace in the middle, rendering all the dimensions of the chimney completely visible until it reaches the roof.
Larry sits in one chair without a back, she sits on another chair with a back and so do I. While the light is still on in the hogan, he asks her what is plaguing her, and she tells him about her head pain radiating to her arm and her feet cramping. Then he takes out a small zippered pouch containing three crystals, a feather, an arrowhead, and a longer item I can’t identify. He’d received the set of three crystals from his grandfather, who had been a medicine man. He can’t say where they are originally from or how they came to be in his possession other than that they’d been passed on in the family for years and years. As a child, Larry followed his grandfather as he healed others, and when Larry was thirteen he perceived the light of the crystal while crystal gazing, the process which he is commencing now.
He lays out two square white cloths. One behind him, one in front of him. The one cloth behind him holds the items he will later place in his hand, and in her hand. On the one cloth in front of him, he places a small round glass bowl. He pours water from a water bottle into the bowl, and places one crystal and the arrowhead in the bowl after the water.
The feather he places in front of this cloth. He holds one crystal in his hand, gives one crystal for her to hold, as well as the item I couldn’t discern. He turns off the lights, turning to me and saying, “This is like an X-ray. It must be dark so that I may see through the body.”
They begin conversing in Navajo for a few minutes, and then he stares for a long time into the crystal. He speaks to her again for another few minutes. In the crystal he sees that in several years ago she had cut and burned the cactus around her home. This disruption of natural surroundings seeped into her body, and I wonder in what spaces—blood, bone, mind?
“You must communicate with all the elements: the sun you feel, the animals you eat, the trees you cut down to make a hogan. You tell them what you are doing with them, you ask permission. They talk to you too, if you listen.”
When there is a rearrangement of the state of things without conversation, the disorder is carried inside and manifests itself as illness. Other happenings like lightning and tornadoes can bring upon a person the aches of arthritis or a silent rise in blood pressure. I’m not sure if these natural occurrences are sources, or reflections, of disturbance.
Like others, this patient will need prayers, one which Larry chants now, and a ceremony in the future to fully recover. In her case, it will entail an offering to cacti and stages of placing sand paint, white for the new dawn and yellow for the closing evening, on her face and chest.
Ceremonies are performed for intervention in times of sickness, as well as for shaping in times of health. When girls experience their first menstrual period, they undertake the process of a kpuberty ceremony. Because a girl’s body is in a phase of change, everything about it is considered sacred; her spit is saved and used as medicine. Everything about it is also malleable. The ceremony lasts four days, and the girl runs at dawn and noon every day, each time going a bit further, to imbibe stamina for the rest of her life. She bakes a large cake for everyone from corn, which she is to grind herself from kernels to powder, using grindstones (one long stone and a bigger slab of stone), and she hand weaves the carpets and baskets used in the ceremony. These movements provide form, and she is also shaped by others in a process called molding, where she lays atop blankets as her skin is massaged by older women.
At the end of this ceremony, the patient drinks the water from the round glass.
“Where water comes together is birth; everything comes from water,” Larry explains.
I am a witness, as someone other than the giver and recipient of prayer must be present. If I had not been there, Larry would have used a long wooden stick he calls a ladder, as a witness. He would communicate with the ladder before beginning the crystal gazing, and then throughout the process, explaining what he sees and feels, just as he did with me.
Everything requires communication. When Larry offers to give me a travel prayer when I leave Arizona next week, I ask whether that it’s all right for someone from another culture to receive a prayer. With a short, light laugh he says, “Yes!”
“Before we start the prayer, I will tell the elements who you are, how you grew up, what your culture is. For those who believe in a Christian God, I will include this in the prayers too; for those who don’t, I don’t. I myself go to three different churches. I was raised Catholic by my mother, I go to Protestant church for the songs, and to Mormon church because my wife is Mormon. I feel the belief is all the same thing.”
“How important is belief to whether the prayer will work?”
“It works sometimes even for those who don’t believe. Belief is the thing, though.”
And so, on my last day on the Navajo reservation I’m blessed by Larry for safe travels. He uses a feather that was a gift given to him in Canada, where he took his wife once when she was feeling badly about her father’s death. At that time, seeing her grive, he had said to her, “Let’s drive North,” and that’s what they did. He brought back this feather that he uses often for prayers. He sings a travel song, and then prays, all in Navajo. The only thing he says in English is: “going to drive to Connecticut.”
He burns wheatgrass atop a burning coal. He gathers the smoke in the air with the feather, using the feather to wave the wafts around my body, then touching the feather lightly to my body: my feet, shins, knees, thighs, arms, chest, shoulders, cheeks, back.
When he says goodbye, he gives me a gentle hug sideways, stooping very slightly to meet me.
Tuesday, November 30, 2010
back & forth
This fifth year, this in-between year of personal goals and time for self, has been a year of coming and going. Took a post-boards vacation in California, came back to living at the VA for my medicine subinternship, trekking cross country and living on a Navajo reservation for a month. Even having been back in New Haven for a couple weeks, the weekends have been spent elsewhere, in Boston then in Long Island/NYC. It was nice to dwell in bigger cities than New Haven, cities that are big parts of my past, and to share them with someone open to new sights and feelings. At the same time, because of the trips and because of the upcoming trip home for Christmas and because many friends are also coming and going and I see them in spurts of their being in New Haven, time in New Haven feels transitory, and the slight instability makes it hard to get down to the business of slowness. Instead of taking the time for what it is, it feels like filler until the next movement, when what I really do want is just to stay.
It's both helpful and frustrating to think of goals that stretch past these bumps in place. On the one hand, I find it really hard to work on things I know will have to be paused. On other hand, it's nice to have things to come back to, after an endeavor or a return home. Everything I want to do is a long-term pursuit, the pile of books to read and topics to read about, the work to run better after a setback from which I haven't recovered, maintaining friendships in the midst of a lot of transitions for all of us, being with him and exploring the newness of me and of my surroundings that he makes me feel, the list of stories I feel compelled to narrate. I want to give each of these things room, and it's hard when I keep moving around, but I'm trying not to so strongly associate internal and external spaces, to remember that what's best about these things and why I value them is their mobility.
It's both helpful and frustrating to think of goals that stretch past these bumps in place. On the one hand, I find it really hard to work on things I know will have to be paused. On other hand, it's nice to have things to come back to, after an endeavor or a return home. Everything I want to do is a long-term pursuit, the pile of books to read and topics to read about, the work to run better after a setback from which I haven't recovered, maintaining friendships in the midst of a lot of transitions for all of us, being with him and exploring the newness of me and of my surroundings that he makes me feel, the list of stories I feel compelled to narrate. I want to give each of these things room, and it's hard when I keep moving around, but I'm trying not to so strongly associate internal and external spaces, to remember that what's best about these things and why I value them is their mobility.
Tuesday, November 23, 2010
rearrangement
[October 20 & 26]
In the same way they teach us how to derive a differential diagnosis from a history and physical, they teach us how to interact with patients, in patterns and algorithms. I have a lot of respect for the critical thought that the development of these structures entail, and a lot of admiration for the beauty of the forms they produce. But they would feel a little suffocating, get a little boring, if not for the fact that they’re applied to people who aren’t static, who move, who each move with different fluidity even if in the same space as everyone else, and so who make you move too. In a place in the country that feels like another country, you instinctively let go of some of your ground, and become more open to continual rearrangement.
And even without the backdrop of an entirely different culture, there are characteristics that inherently place distance between people. There is a lot of stretching to be done, to talk to people at different poles of age and experience and expressiveness.
I spent one morning at the teen clinic at Chinle High School, where teenagers can make their own appointments and see primary care doctors during the school day. There is a security guard both at the parking lot and within the entrance of the school. Not unusually, they mistook me for a high school student. Despite looking so much like a sixteen year old, the clinic made clear how far from those years I am, how much intangible can happen in ten years’ time. I spent most of my time talking to the patients about sex, depression, and sports—many of them came for physical exams required to play sports; these were often the same patients with whom I ended up talking about sex and depression.
For me, it’s hard to assess what teenagers absorb from their surroundings, because I think their capacity to feel progresses more quickly than their capacity to express, or maybe their desire to express. They’re so different from people just a few years younger or older, making this period of time feel rare and fragile. The subtle changes we all experience from moment to moment are more pronounced in them, but with perhaps less self-awareness. All of this can be frustrating if you try to tackle things too quickly, and so they almost therapeutically push you to take time and care to read them. And if they open just a fraction, they can be in different phases of so many processes at once, many that lack obvious linearity. If you want to do anything with that, you have to be okay working in rough pieces without knowing their sources or trajectories, not immediately and often not in the near or distant future either.
It’s a challenge for me to speak to the quiet girl with skinny jeans, converse sneakers, black glasses and thick black eyeliner, and a short boycut with all the hairs angled to the left of her face, making her face look strikingly straight in comparison. She is one of the students who’s here for a sports physical; she’s playing softball in the spring. She pauses before answering any question, then answers with as few words and movement of her face as possible. The stillness isn’t effortful; it’s without thought, as though the moment her eyes and lips move out of place they naturally fall back to their original state of clear and mute.
All adolescents are asked to fill out a screening form before their visit, which asks them about school, diet, exercise, sexuality, mood, home life, and so on. On her screening form, the girl indicates that she has felt down for more than two weeks and has once thought about killing herself. Talking to her more, she has almost all the symptoms of major depression: decreased appetite, poor concentration, interest in activities she’d enjoyed before, bad sleep, and of course depressed mood. Her mother moved to New Mexico five months earlier, and she misses her a lot. She isn’t at all interested in talking to anyone about these things.
The screening form also asks if the patient has any questions about any of the following: diet, exercise, sexuality, school, relationships. She had circled exercise, and when I asked her what her questions were, she said that I’d already answered all of her questions during the visit. I asked her what kind of questions she had that I’d answered. She responded, “Oh about being bisexual.”
It took me a moment to go with that. I’m already too far removed from high school to understand how teenagers process their environment and relay what’s internal. And I think sometimes we try too hard to really understand; I respect the effort, but I think the subsequent discouragement that comes with failure can be harmful. We get tired and closed. Maybe we can just accept that we don’t know how a person gets from one place to another; maybe we’re closed off from that hallway, but once they’ve gotten to a place we can try to enter that.
So even though I wasn’t sure how we got to this point in the conversation, I took this comment as a gift from the guarded 14 year old. She then looked at me straight in the face, with eyes finally visible behind her glasses and hair even though neither had shifted position, and asked with such earnestness that the numbness of all her past sentences struck me: Is it okay to be bisexual?
I’m not at all equipped to answer this with the sensitivity and exactness that a fragile person deserves; I’ve never been asked that before. All I can do is hope to reciprocate her earnestness. She talks about having told a friend, who then told everyone, who then treated her badly. They tell her to go back from where she came from, and as she describes this, she looks genuinely confused; strange how her strongest expression of emotion is one of not knowing how to feel.
The doctor knocks on our door to retrieve us so that we can complete the visit together. I welcome this reminder that I’m a student, that learning is an explicit part of my role, but I wonder what to do with what I’ve learned. At first the girl doesn’t want me to tell the doctor about anything we talked about. When I talk to her privately about the reasons for speaking to her primary doctor about our conversation, she nods. When we are all in the room together, I tell her that I’m going to tell the doctor a little about what we talked about, that I know it’s personal, and that if she wants to tell the doctor herself that would be all right too; again she nods.
The girl refuses any sort of resource offered, and it’s hard to see her go without much more than she came with, and knowing I won’t see her again. It’s really hard. The doctor feels it too, but she makes the point that now it’s known somewhere whereas before it was only in the girl, and she knows she can come back. It’s one step; it’s a different place, even if a lot of doors are still closed to us.
The transition between places can be jarring even when elicited and anticipated. It can feel sudden when traveled gradually by this quiet teenage girl, or when it pours forth from the outgoing middle-aged woman whose slight change in the folds of her face make me lean forward and ask, precipitating a complete reworking of her face. This woman with strong features and build, a carpenter who can’t imagine not working with her hands, who has gone through rehab for alcohol use, who had her first cigarette in a long time yesterday because that was “just how I was feeling,” who comes to us with questions about a colonscopy that a woman at forty years old does not need, begins to cry. This time again I’m unsure how we arrived here; this time not because the concrete steps were unlinked, but because she moves so steadily on a new path that I lose track of the steps that initially brought her there, and again it seems more important to just continue.
She talks about how she has just moved here last night from her hometown of Ganado, how she doesn’t know if she can go back; she wants to go back but things won’t be the same; she needs work but she can’t go back to pick up her tools; it is hard to find work in a new place; her partner is a woman who abuses her verbally and physically; her family tells her to leave her; she thought she’d been strong; she hasn’t talked to anyone. We spoke for some time. When the doctor saw her a little while later, he provides her with some resources that she seems interested in pursuing and schedules her for a follow-up appointment, a streamlined process that seems a blur compared to what came before.
Watching her leave with an effortful smile and half of the demeanor she’d carried into the room, I’m reminded of something a resident told me on my psychiatry rotation. He’d said that after you’ve helped a person break down part of their exterior to expose other coves, and have dwelled there for awhile, you need to help build them back up before you leave them. With this woman I felt she left more exposed, without much protection for open patches, and so I feel that it’s not just closed spaces that are tenuous. These interactions can be difficult, and so when there’s movement there’s fulfillment, but no guarantee of safety. But to be so lucky as to be given a choice, it seems to me worth the risk.
In the same way they teach us how to derive a differential diagnosis from a history and physical, they teach us how to interact with patients, in patterns and algorithms. I have a lot of respect for the critical thought that the development of these structures entail, and a lot of admiration for the beauty of the forms they produce. But they would feel a little suffocating, get a little boring, if not for the fact that they’re applied to people who aren’t static, who move, who each move with different fluidity even if in the same space as everyone else, and so who make you move too. In a place in the country that feels like another country, you instinctively let go of some of your ground, and become more open to continual rearrangement.
And even without the backdrop of an entirely different culture, there are characteristics that inherently place distance between people. There is a lot of stretching to be done, to talk to people at different poles of age and experience and expressiveness.
I spent one morning at the teen clinic at Chinle High School, where teenagers can make their own appointments and see primary care doctors during the school day. There is a security guard both at the parking lot and within the entrance of the school. Not unusually, they mistook me for a high school student. Despite looking so much like a sixteen year old, the clinic made clear how far from those years I am, how much intangible can happen in ten years’ time. I spent most of my time talking to the patients about sex, depression, and sports—many of them came for physical exams required to play sports; these were often the same patients with whom I ended up talking about sex and depression.
For me, it’s hard to assess what teenagers absorb from their surroundings, because I think their capacity to feel progresses more quickly than their capacity to express, or maybe their desire to express. They’re so different from people just a few years younger or older, making this period of time feel rare and fragile. The subtle changes we all experience from moment to moment are more pronounced in them, but with perhaps less self-awareness. All of this can be frustrating if you try to tackle things too quickly, and so they almost therapeutically push you to take time and care to read them. And if they open just a fraction, they can be in different phases of so many processes at once, many that lack obvious linearity. If you want to do anything with that, you have to be okay working in rough pieces without knowing their sources or trajectories, not immediately and often not in the near or distant future either.
It’s a challenge for me to speak to the quiet girl with skinny jeans, converse sneakers, black glasses and thick black eyeliner, and a short boycut with all the hairs angled to the left of her face, making her face look strikingly straight in comparison. She is one of the students who’s here for a sports physical; she’s playing softball in the spring. She pauses before answering any question, then answers with as few words and movement of her face as possible. The stillness isn’t effortful; it’s without thought, as though the moment her eyes and lips move out of place they naturally fall back to their original state of clear and mute.
All adolescents are asked to fill out a screening form before their visit, which asks them about school, diet, exercise, sexuality, mood, home life, and so on. On her screening form, the girl indicates that she has felt down for more than two weeks and has once thought about killing herself. Talking to her more, she has almost all the symptoms of major depression: decreased appetite, poor concentration, interest in activities she’d enjoyed before, bad sleep, and of course depressed mood. Her mother moved to New Mexico five months earlier, and she misses her a lot. She isn’t at all interested in talking to anyone about these things.
The screening form also asks if the patient has any questions about any of the following: diet, exercise, sexuality, school, relationships. She had circled exercise, and when I asked her what her questions were, she said that I’d already answered all of her questions during the visit. I asked her what kind of questions she had that I’d answered. She responded, “Oh about being bisexual.”
It took me a moment to go with that. I’m already too far removed from high school to understand how teenagers process their environment and relay what’s internal. And I think sometimes we try too hard to really understand; I respect the effort, but I think the subsequent discouragement that comes with failure can be harmful. We get tired and closed. Maybe we can just accept that we don’t know how a person gets from one place to another; maybe we’re closed off from that hallway, but once they’ve gotten to a place we can try to enter that.
So even though I wasn’t sure how we got to this point in the conversation, I took this comment as a gift from the guarded 14 year old. She then looked at me straight in the face, with eyes finally visible behind her glasses and hair even though neither had shifted position, and asked with such earnestness that the numbness of all her past sentences struck me: Is it okay to be bisexual?
I’m not at all equipped to answer this with the sensitivity and exactness that a fragile person deserves; I’ve never been asked that before. All I can do is hope to reciprocate her earnestness. She talks about having told a friend, who then told everyone, who then treated her badly. They tell her to go back from where she came from, and as she describes this, she looks genuinely confused; strange how her strongest expression of emotion is one of not knowing how to feel.
The doctor knocks on our door to retrieve us so that we can complete the visit together. I welcome this reminder that I’m a student, that learning is an explicit part of my role, but I wonder what to do with what I’ve learned. At first the girl doesn’t want me to tell the doctor about anything we talked about. When I talk to her privately about the reasons for speaking to her primary doctor about our conversation, she nods. When we are all in the room together, I tell her that I’m going to tell the doctor a little about what we talked about, that I know it’s personal, and that if she wants to tell the doctor herself that would be all right too; again she nods.
The girl refuses any sort of resource offered, and it’s hard to see her go without much more than she came with, and knowing I won’t see her again. It’s really hard. The doctor feels it too, but she makes the point that now it’s known somewhere whereas before it was only in the girl, and she knows she can come back. It’s one step; it’s a different place, even if a lot of doors are still closed to us.
The transition between places can be jarring even when elicited and anticipated. It can feel sudden when traveled gradually by this quiet teenage girl, or when it pours forth from the outgoing middle-aged woman whose slight change in the folds of her face make me lean forward and ask, precipitating a complete reworking of her face. This woman with strong features and build, a carpenter who can’t imagine not working with her hands, who has gone through rehab for alcohol use, who had her first cigarette in a long time yesterday because that was “just how I was feeling,” who comes to us with questions about a colonscopy that a woman at forty years old does not need, begins to cry. This time again I’m unsure how we arrived here; this time not because the concrete steps were unlinked, but because she moves so steadily on a new path that I lose track of the steps that initially brought her there, and again it seems more important to just continue.
She talks about how she has just moved here last night from her hometown of Ganado, how she doesn’t know if she can go back; she wants to go back but things won’t be the same; she needs work but she can’t go back to pick up her tools; it is hard to find work in a new place; her partner is a woman who abuses her verbally and physically; her family tells her to leave her; she thought she’d been strong; she hasn’t talked to anyone. We spoke for some time. When the doctor saw her a little while later, he provides her with some resources that she seems interested in pursuing and schedules her for a follow-up appointment, a streamlined process that seems a blur compared to what came before.
Watching her leave with an effortful smile and half of the demeanor she’d carried into the room, I’m reminded of something a resident told me on my psychiatry rotation. He’d said that after you’ve helped a person break down part of their exterior to expose other coves, and have dwelled there for awhile, you need to help build them back up before you leave them. With this woman I felt she left more exposed, without much protection for open patches, and so I feel that it’s not just closed spaces that are tenuous. These interactions can be difficult, and so when there’s movement there’s fulfillment, but no guarantee of safety. But to be so lucky as to be given a choice, it seems to me worth the risk.
Monday, November 22, 2010
first day meeting open space
Have finished my primary care rotation in Chinle Arizona on the Navajo Indian reservation, and am slowly backtracking in writing about the experiences. It will probably take awhile, but here are some thoughts of the first day.
*
[October 19]
I approached Chinle Hospital in the dark, turning left onto the first paved road after a long stretch of lightless highway. The past hour and half encompassed nothing behind or ahead, focusing on the few feet of sight afforded by my headlights and hoping hard that my car wouldn’t break down or run into livestock. I’m relieved to see a sign, and a building in the distance; my fingernails released slightly their hold on my steering wheel. The directions written by one of the physicians noted that we would pass over three cattle grates on the road to the hospital. I didn’t know what these were, but I soon learn that when the sounds of the ground and feel of my seat beneath the car’s wheels changed, that meant I’m going over said cattle grates. This is how I came to know Chinle, in pieces of sensations. In the dark, the expanse is immeasurable; the next morning, the immeasurement is visible.
When parking my car facing the hospital, the sky stretches behind. Every morning the clouds are a different kind of spectacular, still and nonchalant. When I ask employees who had grown up there where they were from, they point to specks in the landscape: that peak next to the dipping crests, this bend in the road. On runs and drives along the two roads that take me from my housing to the hospital and back, looking at what’s straight ahead is like looking down from above; this and the sharp cold reminds me of the 5000 feet elevation. On one day, a cluster of green trees on the side of the road are burning in transitional sunlight, between the day’s rawness and the modesty of dusk. The space above the grove is encased in thick creamy gray cloud, such that you have to face the other side of the road to find the source of the yellow cloaking the trees.
Against the open space, I slip into the interior of the hospital a little off balance. There I am surprised to find that at first the inside here is not so different from the inside back elsewhere. There are aisles of patient rooms equipped with computers, otoscopes and ophthalmolscopes, and hand sanitizer. I recognize these sights, but I’m newly aware of the air surrounding them. The first day of clinic is muffled, faintly familiar with a lot I couldn’t quite understand. The medical problems are not dissimilar from what I have seen: diabetes, hypertension, hypothyroidism, back pain, joint aches; nor were the services rendered: routine physicals, medication changes, laboratory tests. Despite the intimacy of our relation to our blood and hormones, it is normal to disengage them from ourselves to form concepts of illness. Reading the medical chart before entering the patient room, I feel no hitch in turning the wheels of listing these problems and considering treatment of them. But once inside, I’m struck in that compact space, as I was in the emptiness of Arizona desert, by a depth made foreign not only by its thickness but also by the texture of it layers.
Meeting a homogeneous patient population connected by their residence on the 26,000 square mile Navajo reservation, where the distances between homes are far in miles and close in experience, I’m worried that it is at first too easy to perceive things in broad strokes. I’m surprised to find that the backdrop doesn’t blur individual outlines; instead it places details in relief, some of which do converge into a large perception.
The town of Chinle holds a little under 5000 people; this had seemed small when I read it on paper, but encountering a dozen patients in a day feels the same here as it does in a city of 500,000. The patients I see on the first day of clinic make me wonder at how many people exist, how much experience lies in what’s considered a gap in life when driving across country.
On the first day there are several people who individually move me, and as a group make me question our separation of illness and person. Not separation in the sense that we forget there is a person experiencing the illness; we know this happens often and the danger of this kind of thinking is familiar to us. Separation in the sense that illness happens to a person by outside forces, and thus can then be taken away by outside forces. The people I meet today attribute so much of what they feel physically and emotionally to themselves, and this philosophy and practice of internalization is new to me, as someone who learned about disease first as subjects in school, then as objects people have the way they might own a winter coat, something not readily shed but is in principle detachable.
There is a 13 year old girl with very long, straight hair obscuring her pretty features, with glasses and crooked teeth still too large for a mouth still adjusting to the shape of her face. The oldest of six children, she is unsure of how she should stand. She’s tall, but skinny too such that she easily folds herself over at the waist and looks small. She’s here for her annual physical exam, and tells us that she often contemplates suicide. She admits to cutting her wrists, a process I hear a relative lot about over the rest of my time here. It’s hard for her to express why, her feelings spanning a spectrum broader than her vocabulary. On the teenage questionnaire that asks if you could change one thing about your life and yourself, she responds that she would choose to “be brave and emotionless.”
There is a middle-aged man who is here for management of his chronic lower back pain. He wears glasses too, but they don’t overwhelm his face the way the teenager’s did. He yells at himself when the pain is too much to take, because he knows he’s to blame for the source of it. Years ago, he fell off a ladder while intoxicated, and the impact to his back has continually flared since then. He yells at himself outside, away from his children, and defers from repeating his words here in the office. He doesn’t want counseling; he has had it in the past and does not think he is in a place where counseling is necessary. He is reluctant to pursue surgery for his back, because he won’t be able to take care of his children, and his wife who left him a year ago will then take them from him.
There is another middle-aged man with a cowboy hat, checkered blue shirt, and heavy brown boots, compliant with his medications and without any complaint other than fatigue after a bout of cryptogenic organizing pneumonia on top of severe heart failure. He says that a native medicine healer told him that this was due to his practice of killing and burning snakes during his childhood. The defiled spirit of the snakes has encroached upon his own, causing him physical illness. When asked why he killed and burned snakes, he replies that he was scared of them. He says that the healer believes this is also the reason why his face has been more swollen recently. It’s hard to be Navajo, he says to me. He says it not for his sake but for mine.
Each person responds differently to their respective self-blame: the girl tells herself cutting is stupid, the first man resorts to alcohol to soothe the injury first induced by alcohol, the second man participates in a ceremony to remove from himself the spirits of snakes killed. Successfully or not, they carry and shift and distribute the weight of whatever is disturbing them, in a way that I haven’t recognized before. I’m not sure how this new awareness, still a vague theory without real understanding, will help in handling the weight. But learning to be open to its presence and to the process of building a sense of its character made for a fitting first day.
*
[October 19]
I approached Chinle Hospital in the dark, turning left onto the first paved road after a long stretch of lightless highway. The past hour and half encompassed nothing behind or ahead, focusing on the few feet of sight afforded by my headlights and hoping hard that my car wouldn’t break down or run into livestock. I’m relieved to see a sign, and a building in the distance; my fingernails released slightly their hold on my steering wheel. The directions written by one of the physicians noted that we would pass over three cattle grates on the road to the hospital. I didn’t know what these were, but I soon learn that when the sounds of the ground and feel of my seat beneath the car’s wheels changed, that meant I’m going over said cattle grates. This is how I came to know Chinle, in pieces of sensations. In the dark, the expanse is immeasurable; the next morning, the immeasurement is visible.
When parking my car facing the hospital, the sky stretches behind. Every morning the clouds are a different kind of spectacular, still and nonchalant. When I ask employees who had grown up there where they were from, they point to specks in the landscape: that peak next to the dipping crests, this bend in the road. On runs and drives along the two roads that take me from my housing to the hospital and back, looking at what’s straight ahead is like looking down from above; this and the sharp cold reminds me of the 5000 feet elevation. On one day, a cluster of green trees on the side of the road are burning in transitional sunlight, between the day’s rawness and the modesty of dusk. The space above the grove is encased in thick creamy gray cloud, such that you have to face the other side of the road to find the source of the yellow cloaking the trees.
Against the open space, I slip into the interior of the hospital a little off balance. There I am surprised to find that at first the inside here is not so different from the inside back elsewhere. There are aisles of patient rooms equipped with computers, otoscopes and ophthalmolscopes, and hand sanitizer. I recognize these sights, but I’m newly aware of the air surrounding them. The first day of clinic is muffled, faintly familiar with a lot I couldn’t quite understand. The medical problems are not dissimilar from what I have seen: diabetes, hypertension, hypothyroidism, back pain, joint aches; nor were the services rendered: routine physicals, medication changes, laboratory tests. Despite the intimacy of our relation to our blood and hormones, it is normal to disengage them from ourselves to form concepts of illness. Reading the medical chart before entering the patient room, I feel no hitch in turning the wheels of listing these problems and considering treatment of them. But once inside, I’m struck in that compact space, as I was in the emptiness of Arizona desert, by a depth made foreign not only by its thickness but also by the texture of it layers.
Meeting a homogeneous patient population connected by their residence on the 26,000 square mile Navajo reservation, where the distances between homes are far in miles and close in experience, I’m worried that it is at first too easy to perceive things in broad strokes. I’m surprised to find that the backdrop doesn’t blur individual outlines; instead it places details in relief, some of which do converge into a large perception.
The town of Chinle holds a little under 5000 people; this had seemed small when I read it on paper, but encountering a dozen patients in a day feels the same here as it does in a city of 500,000. The patients I see on the first day of clinic make me wonder at how many people exist, how much experience lies in what’s considered a gap in life when driving across country.
On the first day there are several people who individually move me, and as a group make me question our separation of illness and person. Not separation in the sense that we forget there is a person experiencing the illness; we know this happens often and the danger of this kind of thinking is familiar to us. Separation in the sense that illness happens to a person by outside forces, and thus can then be taken away by outside forces. The people I meet today attribute so much of what they feel physically and emotionally to themselves, and this philosophy and practice of internalization is new to me, as someone who learned about disease first as subjects in school, then as objects people have the way they might own a winter coat, something not readily shed but is in principle detachable.
There is a 13 year old girl with very long, straight hair obscuring her pretty features, with glasses and crooked teeth still too large for a mouth still adjusting to the shape of her face. The oldest of six children, she is unsure of how she should stand. She’s tall, but skinny too such that she easily folds herself over at the waist and looks small. She’s here for her annual physical exam, and tells us that she often contemplates suicide. She admits to cutting her wrists, a process I hear a relative lot about over the rest of my time here. It’s hard for her to express why, her feelings spanning a spectrum broader than her vocabulary. On the teenage questionnaire that asks if you could change one thing about your life and yourself, she responds that she would choose to “be brave and emotionless.”
There is a middle-aged man who is here for management of his chronic lower back pain. He wears glasses too, but they don’t overwhelm his face the way the teenager’s did. He yells at himself when the pain is too much to take, because he knows he’s to blame for the source of it. Years ago, he fell off a ladder while intoxicated, and the impact to his back has continually flared since then. He yells at himself outside, away from his children, and defers from repeating his words here in the office. He doesn’t want counseling; he has had it in the past and does not think he is in a place where counseling is necessary. He is reluctant to pursue surgery for his back, because he won’t be able to take care of his children, and his wife who left him a year ago will then take them from him.
There is another middle-aged man with a cowboy hat, checkered blue shirt, and heavy brown boots, compliant with his medications and without any complaint other than fatigue after a bout of cryptogenic organizing pneumonia on top of severe heart failure. He says that a native medicine healer told him that this was due to his practice of killing and burning snakes during his childhood. The defiled spirit of the snakes has encroached upon his own, causing him physical illness. When asked why he killed and burned snakes, he replies that he was scared of them. He says that the healer believes this is also the reason why his face has been more swollen recently. It’s hard to be Navajo, he says to me. He says it not for his sake but for mine.
Each person responds differently to their respective self-blame: the girl tells herself cutting is stupid, the first man resorts to alcohol to soothe the injury first induced by alcohol, the second man participates in a ceremony to remove from himself the spirits of snakes killed. Successfully or not, they carry and shift and distribute the weight of whatever is disturbing them, in a way that I haven’t recognized before. I’m not sure how this new awareness, still a vague theory without real understanding, will help in handling the weight. But learning to be open to its presence and to the process of building a sense of its character made for a fitting first day.
Wednesday, October 13, 2010
northeast to southwest
On a cross country drive there's a lot of time to think about why you're doing what you're doing. In the larger scheme of things, but also in the moment--like, why are we driving all day long? I think that that thought is one of the reasons to love long drives. Caitlin, my partner on the road, mentioned a meditative exercise where you sit and concentrate on sensation starting from your toes moving up, so that you become acutely aware of yourself piece by piece. Watching long stretches of road feels similar. You notice sudden and subtle changes in the landscape, and in the position of your arms and legs, and in how much sun is coming through the window to warm your skin. There are moments too when you lose attention altogether, which is nice too.
Caitlin and I both have clinical rotations on Indian health reservations in the Southwest for the month of October. She's doing ob-gyn in Gallup New Mexico, and I'm doing primary care in Chinle Arizona. Both places are in the middle of nowhere, hours from the nearest airport in Albuquerque. The cities are two hours from each other, and we planned on driving from Connecticut to the Southwest together since the end of summer, though most of our few concrete plans were made in the week before leaving. Another thing to love about drives, the freedom and flexibility and living out of the car and not having to carry stuff and worry too much about packaging.
The drive took us way down south on 95 (I had no idea 95 went so far), into regions of the country I'd never seen before. I've wanted to see the South for awhile, not because I had any appealing images of it but because I had no images of it at all. After a night in Maryland we drove through North Carolina, stayed along the coast in Charleston South Carolina and Savannah Georgia, saw Alabama and Mississippi through the car windows, spent a full day in New Orleans, drove along an L-shaped route through Louisiana to reach Dallas for a night, drove across a lot of nothing to get to the next Texan city of Amarillo, and completed a drive across the whole of Texas and the beginnings of New Mexico to arrive at Albuquerque.
To describe the South is hard, after such sensory overload in a new place; and unfair, after such a brief glimpse. But with those caveats, I think it's worth sharing. Driving from Maryland and Virginia into the Carolinas, the weather changed palpably from cold rain to warm yellow. I saw cotton fields for the first time; in Georgia we stopped to pick some, probably illegally; in Texas we were surprised to see miles of cotton and picked those as well. Caitlin had said they smelled like earth, and she was right, and Georgia earth smelled different from Texas earth. Against all overexposure and desensitization, I always feel pleasant surprise at seeing pure white lying so low to the ground (snow, salt, cotton).
We met Charleston SC at nighttime, where the homes have long wide columns, side porches, gates guarding gardens and fountains, and painted family portraits visible through windows. The street and house lamps burn real fire, and the trees and gates stand close to the homes, creating quietly gorgeous shadows. After the night sun takes over for the fire, though they keep the fire during through daylight too. Savannah was more developed and less striking than Charleston, but we did find plenty of magnolia trees, oak trees, and Spanish moss hanging off the oak trees. The drive through Georgia was populated by peach tree orchards, baby pine farms, and lots and lots of cotton.
I fell asleep for a good chunk of the drive through Alabama, due to the sun and to the Faulkner audio book playing in the car (Light in August: worthy to read and very Southern, but listening to books read aloud by strangers hasn't grown on me yet). I went to my first Waffle House in Alabama, and I remember Mississippi being very pretty with its water and expansive fields, and I also remember this day being a daze of a drive. Once in New Orleans, Caitlin snapped me out of it with rapid fire commentary on every street, home and billboard in her hometown. She took me round to all the good eats (crepes, beignets which I called French doughnuts which offended someone, ice cream, burgers & milkshakes), and drove me down St. Charles and her favorite street and Bourbon St in the French Quarter, stopping every few moments so I could take pictures of the incredible houses and balconies. She also introduced me to her tall kind lovely parents, showed me turtles in her favorite park, had our hair cut at her go-to hair salon, and had our pictures taken in a photobooth at a local bar; these parts were best for being specific to her and her home.
From there we had a long drive to Dallas; we didn't have much time to see the city, but we had our own kind of experience through Texas as we drove from there to New Mexico. Between Dallas and Amarillo there is a whole lot of nothing, and it was the first time on the trip that we felt like we were in the middle of nowhere, with mostly trucks on the road and no rest stops for a hundred miles at a time and speed limits of 80 and skies absolutely clear (we saw exactly one cloud). There is something really calming about driving across entire states, sensing both the immensity of things and the fluidity of lines. This made for the best day of the trip, with a soothingly empty landscape of concentrated red dust on either side of us, sometimes suddenly broken by unusual beauty--small sunflowers growing like weeds, a cluster of leaveless trees with gnarled branches, a dilapidated farm house, a field of what we'd call ranch country, stretches of what we called prairie grass--lightly tinged at the top with maroon and purple in a way that seemed unreal, in the way that its faint color could make you feel so much. There was also an adult video store every so often, standing on its own with nothing for miles before and after, because as Caitlin said, even the middle of nowhere needs that.
Once we arrived in Amarillo, we had our Texan experience over the course of five miles and an hour, none of which had been planned (we'd only known that Amarillo was the only city besides Dallas that showed up on our Google map route). This included a huge tacky road-side shop with a sign claiming "everything really is bigger in Texas" and a huge cowboy boot for evidence; breezing through a big warehouse of cowboy boots; a glance inside Hooters (neither of us had been to one and thought TX was a fitting place for our first venture); and a stop at Cadillac Ranch, a public art installation of ten Cadillacs vertically half-buried into the ground that people are free to spray-paint with whatever they fancy as they road-trip across Texas.
Then we were off for more flat landscape (this was our longest day, roughly 12 hours from start of driving to end) until we entered New Mexico, where the land changed dramatically to flat-topped canyons and crumbly ground sprinkled with little bushes. We arrived little before sunset, and drove until dark when the sky became dense with stars, and the outlines of mountains blended into black so that you had to squint to see if they were there. I've been to New Mexico before, but entering it this way felt new. We drove fast in the dark blasting pop songs, and when we got into a neighborhood we stopped at a stop sign and got out of the car to dance outside barefoot (until a car came up behind us and we raced back).
I looked back at something I wrote on the cross country trip I took a few years ago: "When in your life you feel both brave and unsure and open to emptiness, drive across your country with your Thelma." Still believing this to be true, I know I'm lucky to be able to 1) feel this way, and 2) act on it; to not be stuck or closed in feeling or movement. We ended our trip with the hot air balloon fiesta in Albuquerque, getting up at 3 AM to catch the balloons inflating and rising from the heat of fire. It was funny to watch things float and fly after so many days on ground, funnier that I was content to stay in place. Until we left again.
Caitlin and I both have clinical rotations on Indian health reservations in the Southwest for the month of October. She's doing ob-gyn in Gallup New Mexico, and I'm doing primary care in Chinle Arizona. Both places are in the middle of nowhere, hours from the nearest airport in Albuquerque. The cities are two hours from each other, and we planned on driving from Connecticut to the Southwest together since the end of summer, though most of our few concrete plans were made in the week before leaving. Another thing to love about drives, the freedom and flexibility and living out of the car and not having to carry stuff and worry too much about packaging.
The drive took us way down south on 95 (I had no idea 95 went so far), into regions of the country I'd never seen before. I've wanted to see the South for awhile, not because I had any appealing images of it but because I had no images of it at all. After a night in Maryland we drove through North Carolina, stayed along the coast in Charleston South Carolina and Savannah Georgia, saw Alabama and Mississippi through the car windows, spent a full day in New Orleans, drove along an L-shaped route through Louisiana to reach Dallas for a night, drove across a lot of nothing to get to the next Texan city of Amarillo, and completed a drive across the whole of Texas and the beginnings of New Mexico to arrive at Albuquerque.
To describe the South is hard, after such sensory overload in a new place; and unfair, after such a brief glimpse. But with those caveats, I think it's worth sharing. Driving from Maryland and Virginia into the Carolinas, the weather changed palpably from cold rain to warm yellow. I saw cotton fields for the first time; in Georgia we stopped to pick some, probably illegally; in Texas we were surprised to see miles of cotton and picked those as well. Caitlin had said they smelled like earth, and she was right, and Georgia earth smelled different from Texas earth. Against all overexposure and desensitization, I always feel pleasant surprise at seeing pure white lying so low to the ground (snow, salt, cotton).
We met Charleston SC at nighttime, where the homes have long wide columns, side porches, gates guarding gardens and fountains, and painted family portraits visible through windows. The street and house lamps burn real fire, and the trees and gates stand close to the homes, creating quietly gorgeous shadows. After the night sun takes over for the fire, though they keep the fire during through daylight too. Savannah was more developed and less striking than Charleston, but we did find plenty of magnolia trees, oak trees, and Spanish moss hanging off the oak trees. The drive through Georgia was populated by peach tree orchards, baby pine farms, and lots and lots of cotton.
I fell asleep for a good chunk of the drive through Alabama, due to the sun and to the Faulkner audio book playing in the car (Light in August: worthy to read and very Southern, but listening to books read aloud by strangers hasn't grown on me yet). I went to my first Waffle House in Alabama, and I remember Mississippi being very pretty with its water and expansive fields, and I also remember this day being a daze of a drive. Once in New Orleans, Caitlin snapped me out of it with rapid fire commentary on every street, home and billboard in her hometown. She took me round to all the good eats (crepes, beignets which I called French doughnuts which offended someone, ice cream, burgers & milkshakes), and drove me down St. Charles and her favorite street and Bourbon St in the French Quarter, stopping every few moments so I could take pictures of the incredible houses and balconies. She also introduced me to her tall kind lovely parents, showed me turtles in her favorite park, had our hair cut at her go-to hair salon, and had our pictures taken in a photobooth at a local bar; these parts were best for being specific to her and her home.
From there we had a long drive to Dallas; we didn't have much time to see the city, but we had our own kind of experience through Texas as we drove from there to New Mexico. Between Dallas and Amarillo there is a whole lot of nothing, and it was the first time on the trip that we felt like we were in the middle of nowhere, with mostly trucks on the road and no rest stops for a hundred miles at a time and speed limits of 80 and skies absolutely clear (we saw exactly one cloud). There is something really calming about driving across entire states, sensing both the immensity of things and the fluidity of lines. This made for the best day of the trip, with a soothingly empty landscape of concentrated red dust on either side of us, sometimes suddenly broken by unusual beauty--small sunflowers growing like weeds, a cluster of leaveless trees with gnarled branches, a dilapidated farm house, a field of what we'd call ranch country, stretches of what we called prairie grass--lightly tinged at the top with maroon and purple in a way that seemed unreal, in the way that its faint color could make you feel so much. There was also an adult video store every so often, standing on its own with nothing for miles before and after, because as Caitlin said, even the middle of nowhere needs that.
Once we arrived in Amarillo, we had our Texan experience over the course of five miles and an hour, none of which had been planned (we'd only known that Amarillo was the only city besides Dallas that showed up on our Google map route). This included a huge tacky road-side shop with a sign claiming "everything really is bigger in Texas" and a huge cowboy boot for evidence; breezing through a big warehouse of cowboy boots; a glance inside Hooters (neither of us had been to one and thought TX was a fitting place for our first venture); and a stop at Cadillac Ranch, a public art installation of ten Cadillacs vertically half-buried into the ground that people are free to spray-paint with whatever they fancy as they road-trip across Texas.
Then we were off for more flat landscape (this was our longest day, roughly 12 hours from start of driving to end) until we entered New Mexico, where the land changed dramatically to flat-topped canyons and crumbly ground sprinkled with little bushes. We arrived little before sunset, and drove until dark when the sky became dense with stars, and the outlines of mountains blended into black so that you had to squint to see if they were there. I've been to New Mexico before, but entering it this way felt new. We drove fast in the dark blasting pop songs, and when we got into a neighborhood we stopped at a stop sign and got out of the car to dance outside barefoot (until a car came up behind us and we raced back).
I looked back at something I wrote on the cross country trip I took a few years ago: "When in your life you feel both brave and unsure and open to emptiness, drive across your country with your Thelma." Still believing this to be true, I know I'm lucky to be able to 1) feel this way, and 2) act on it; to not be stuck or closed in feeling or movement. We ended our trip with the hot air balloon fiesta in Albuquerque, getting up at 3 AM to catch the balloons inflating and rising from the heat of fire. It was funny to watch things float and fly after so many days on ground, funnier that I was content to stay in place. Until we left again.
Tuesday, September 28, 2010
editing
My few weeks of nothing is coming to a close, as I ready for a cross country drive to Arizona, where I'll be doing a primary care rotation for a month. Probably because my mind is preparing and no longer in cruise control, I've come to the realization that these past weeks were more editing and maintenance than writing and moving forward.
In one respect, I enjoyed that a lot. Often I relish editing someone else's words more than forming my own. It's less taxing in a lot of ways that writing can be frustrating, and it can also be its own sort of challenge, as I found anew while working with the patient for my project on her personal story. On first read, you might think that it required a lot of reworking, both structurally and textually. In terms of structure, it wasn't something I could shape just by removing repetitions and grouping similar details. That's the first step, but just a concrete one, and if anything solid is to come from that, I had to understand what the author wanted to say. The same goes for nuances of text, choosing words etc. But in terms of that, I found it a really interesting and satisfying endeavor to keep her words while trying to manipulate the presentation of the words to better convey what she wanted. Again, on first read the story would be taken as undeveloped in terms of style, but I found myself falling in love with her simple narration, very much a mental print of memories as they came to her. I liked the sense that this was her, and didn't feel compelled use or add different words, which would change this sense.
Figuring out what she wanted of course was the most important, and this isn't straightforward. I can most definitely relate to writing without consciously knowing my purpose. So this grew out of a lot of conversation, questions, and reading versions of the story as things were concretely refined. And in those, I found that her words supplied both structure and text, and overall purpose. Everything added was added in the raw form that she gave it, and then it was a matter of placement and detail.
She had begun the story all because of the fact that she had known this person, and she ended it feeling that she hadn't really known the person at all. To go through that process with her and be able to document and express that process, it made me feel again how natural it is to want to shape narratives, how complex and fulfilling the effort can be.
It was also a pleasure to speak to someone who has experienced worlds and lands so vastly different from the ones she occupies now; to see in one person how much can be had in a life. It makes me feel less caught up in doing the things I wanted to do during these weeks, makes me feel all right with letting experiences happen and unfold as they come, to feel less lame for expending energy on simply maintaining the things in my life that take me places without actually going any place (car, camera, body). Just continuing can bring newness and fullness, and even though I've done almost no writing at all in this period, maybe sometime in the near future my words will come as simply and clearly as hers.
In one respect, I enjoyed that a lot. Often I relish editing someone else's words more than forming my own. It's less taxing in a lot of ways that writing can be frustrating, and it can also be its own sort of challenge, as I found anew while working with the patient for my project on her personal story. On first read, you might think that it required a lot of reworking, both structurally and textually. In terms of structure, it wasn't something I could shape just by removing repetitions and grouping similar details. That's the first step, but just a concrete one, and if anything solid is to come from that, I had to understand what the author wanted to say. The same goes for nuances of text, choosing words etc. But in terms of that, I found it a really interesting and satisfying endeavor to keep her words while trying to manipulate the presentation of the words to better convey what she wanted. Again, on first read the story would be taken as undeveloped in terms of style, but I found myself falling in love with her simple narration, very much a mental print of memories as they came to her. I liked the sense that this was her, and didn't feel compelled use or add different words, which would change this sense.
Figuring out what she wanted of course was the most important, and this isn't straightforward. I can most definitely relate to writing without consciously knowing my purpose. So this grew out of a lot of conversation, questions, and reading versions of the story as things were concretely refined. And in those, I found that her words supplied both structure and text, and overall purpose. Everything added was added in the raw form that she gave it, and then it was a matter of placement and detail.
She had begun the story all because of the fact that she had known this person, and she ended it feeling that she hadn't really known the person at all. To go through that process with her and be able to document and express that process, it made me feel again how natural it is to want to shape narratives, how complex and fulfilling the effort can be.
It was also a pleasure to speak to someone who has experienced worlds and lands so vastly different from the ones she occupies now; to see in one person how much can be had in a life. It makes me feel less caught up in doing the things I wanted to do during these weeks, makes me feel all right with letting experiences happen and unfold as they come, to feel less lame for expending energy on simply maintaining the things in my life that take me places without actually going any place (car, camera, body). Just continuing can bring newness and fullness, and even though I've done almost no writing at all in this period, maybe sometime in the near future my words will come as simply and clearly as hers.
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