last week of clinic

Last week was my last week at my clinic at SFGH, our county hospital, and while I feel ready to finish residency, I would stay in clinic here forever if I could. It can be frustrating, and can feel futile, and much less concrete than other parts of medicine. But saying goodbye to my patients and to the flow of clinic, despite there never really being a true flow to the hectic lumps and bumps of SFGH clinic, was and is hard. We often don't feel the role we can have over the course of intermittent 15-minute visits with people, but bonds form in all sorts of odd ways. And in particular for the patients who have few other support systems in place, I feel lucky to have been able to offer a base, as flimsy as it often was.

I feel so lucky to have borne witness to the paths of my patients. Over three years I've gained about a hundred primary care patients, maybe half of whom who come regularly enough for me to say that I know them; the other half I know of and for that I also feel lucky. I've seen a woman through the diagnosis and treatment of gastric cancer, and seen the strengths and vulnerabilities of her family through it, and seen the anxiety and worry that lingers afterwards. I've seen a man with physically debilitating inflammation of his skin and heart become emotionally debilitated by living with his illness, and see him slowly recover inside and out as he received treatment. I've seen young people my age whose characters have been shaped by a lifetime of battles fought by their bodies struggling through illness and bad environments. I've seen people with about a dozen life-threatening issues to their name continue to plug along, giving hope that we have time and space to tackle each in turn. I've felt so lucky to accept the stuffed animal, orchid, half dollar, scarf, and tears that patients give so, so generously in their farewell visits. Feeling that it is misguided to dismiss these physical gifts as material, because I know how it feels to want to be able to encase so much in something you can hold.

It's true that coming into residency you have little sense of what it is that you're actually going to do, and it's true that a lot of your visions are refuted by reality. But coming into primary care feeling that this is what I want to do because it's the most holistic perspective has proved itself right many times over. This doesn't mean that it always possesses the most holistic solutions, or even individual solutions to all of a person's needs, but it does mean that you see a whole lot of people. I will really miss the people who let me see them.

may

It's interesting that after several years away from the East Coast, my memories of May are what it's like over there--the beginnings of warmth returning. I was a little shocked by our cold San Francisco May, but it was a good month nonetheless.

1. Blogging: I had a lot to record with regular updates on weekly visits to the San Quentin prison. After those very full days that left us sapped of energy, emotional and physical, I was glad that I had a pre-formed space to dump some thoughts. This is something I'd like to return to with more nuance and filling later, so I'm very grateful to be able to put down a few of the details.

2. Recipes: My favorite recipe of May was an Indian fish dish that I was introduced to while I was in Uganda, and remains one of my top ten all time favorite dishes/meals. I tried at various times to replicate it, but there aren't many recipes for it and it calls for mint which I rarely have on hand and is a little pricey at stores to purchase for experimentation. But now that I go to the farmer's market most weeks, there is plenty of fresh, cheap mint, and cilantro, and I was inspired to try it again after finding this recipe: http://www.chillimix.com/indian-recipe/fish-and-sea-food/baked-fish-with-fresh-mint-and-coriander.html. It was very good, though I still haven't attained the divineness of what I tried in Uganda. It's hard to tell whether it's actual taste, or novelty, that I'm missing. Either way, I still loved the fresh mint and cilantro in this. I'm sure I tried other actual recipes to make my two new recipes a month resolution, but am forgetting at the moment, so will note that we also added the mint to our smoothies, making them newly refreshed (redundant? but seems appropriate).

3. Albums: In the vein of getting back into what used to be a major passion for me, I got recommendations from a music-trusthworthy friend and remembered why music is so awesome after listening to Future Islands (Singles) and fka twigs (lp 1), which had entirely different feels and equally unique. Also listened to Sufjan Steven's latest, Carie & Lowell, which felt like the return of an old friend.

4. News: I made significant headway on this, and then halfway through the month I discovered audiobooks, and I became really obsessed (they deserve a separate post). I think I will always prioritize fiction, and I think I will always feel a little guilty about that, and so will continue to incorporate real life into my knowledge base, but also with the acceptance that this is how I'm built.

5. Exercise: After incorporating swimming into my birthday party, I managed to swim twice and remembered how good it feels. Biking is something I still haven't incorporated back into my routine yet, but have decided that instead of making biking and running (which has been hard on my knees lately) long ventures, that I'll make my initial resolution (of biking, swimming, running, climbing and yoga each once a week) possible by biking or running very briefly before climbing. I'm hoping to make strides with this as summer approaches and work recedes...

insights

One of the things I love most about medicine is how much you learn from others, both patients and fellow providers. In these ways they remind me of what I love about books and writers--the ability to express something you've felt but have never quite expressed in the way that most embodies the feeling.

From a patient, on adapting to life in prison: "It's like when your body doesn't get what it needs for so long, it forgets how to ask for it."

From a physician, on advice to our graduating residency class: "Remember that you are not there to save them, but to witness them."

april

May flew by and forgot to post about April update on resolutions--

1. Blogging: This has been my favorite resolution because while I haven't written anything substantial, getting back into the mode of recording and reflecting has been good for me, and renewed the desire suppressed in residency to use words.

2. Recipes: The first week of April was blissful cooking, because I'd been working crazy hours for two months. I got buttermilk for some reason and made three new recipes with it: coconut buttermilk pancakes, buttermilk syrup, and homemade ranch dressing. We loved all of them, and I was impressed by how versatile cheap buttermilk is. M said it was the best syrup he'd ever had, and the pancakes were up there with our usual favorite lemon ricotta pancakes. These were a little more simple and less immediately out-of-this-world, but I loved the subtle coconut and the slightly tangy buttermilk that gave the pancakes a ton of depth.

3. Albums: On the flights to and from Amsterdam, I listened to albums that I'd listened to only passingly that I thought I would like with more time, and found that I did: City and Colour's Bring Me Your Love, St Vincent's Strange Mercy, and Cut Copy's Zonoscope. Favorite songs from each include The Girl, Cruel, and Blink and You'll Miss a Revolution. Outside of this category, I loved Passion Pit's new album. I remember first finding Passion Pit and that feeling of deep wonder that comes from unique beauty, and this album is more and more of it.

4. News: I had made a conscious resolution to get up to speed in April. Then my mom in the hospital, traveling, and recovering happened, and I got lazy. May's update will sound the same, but now I just purchased a diverse selection of subscriptions to feel like I'll actually be getting different perspectives and motivate me to be more well-informed.

5. Exercise: This resolution keeps fluctuating in terms of what I feel like doing. I don't think it's so much a resolution to keep me active since I'm pretty active, but to structure it in a way that benefits me most, because I've found that when I've had structure in the past I've been more fit with the same amount of time I spend on exercise now. But, I might've had less fun, so it's a give and take. Currently I've been focused on climbing the most, and getting better at lead climbing, so I'm happy with this goal of taking any opportunity to climb. At the same time I'd like to remember to diversify and keep myself limber.

And just like that, onto another...

therapeutic modules

One of the most powerful days at San Quentin yet. I spent the morning with a psychiatrist who provides care to the inmates in East Block. East Block houses Death Row inmates, otherwise known as the condemned. These patients live in small single cells, and are handcuffed at all times when they are not otherwise locked up. During a visit with a psychiatrist, they are placed in a clear cage so that the security guard can leave and offer a semblance of confidentiality. These cages are called "therapeutic modules" by the department of corrections, and are called cages by everyone else who actually uses them. These limitations made East Block distinct for me. I also had my own limitations--this is the only place in San Quentin others felt compelled to have me wear a security vest, which I have never worn before. In the same way that I feel lighter after leaving the prison and turning in my alarm system, I felt relieved to take off this weight after leaving East Block, despite its design for protection.

Many of these inmates have been here for twenty, thirty years. California hasn't executed an inmate in years, and is unlikely to ever do so. So these people are serving life sentences on what is called Death Row, and they have learned to adjust to a unique kind of life that I honestly never gave any thought to until I saw it in front of me.

There doesn't seem to be a set time for each appointment, and the loose wandering time that is locked up in our tiny interview room made me feel, in a small remote way, parallel to the inmate. He spoke incredibly insightfully and thoughtfully about his experience. "There are so many parts of yourself that aren't fulfilled while you're here, and you sit with your thoughts all day long trying to fill yourself." He spoke about experiencing by imagining experiences. "I thought, if I had money I'd go out and buy an expensive kite--the kind that costs a hundred dollars. I'd go out to the park and roll out the string until it flew high, so high you could barely see it...and then I'd pass it off to a kid. See the magical look in his face. Knowing that when I was seven or eight, that would just be magic." And for two minutes, he could feel the joy of this experience. Instead of being angry about not being able to experience it, he could really feel it. Then let it pass.

We talked about mindfulness, stories, and relapses. It's not always so easy to fulfill yourself without light to define shapes and senses. I thought about how I've never a thought quite like that one about the kite, an urge that captured quite that sentiment. I know it is too obvious, but it is too true that imprisonment opens parts of people that maybe everyone has but no one else truly experiences.

Unlike other times I've shadowed providers, these patients spoke to me directly. Asked me questions, explained things to me, looked at me instead of their actual doctor. They seemed to appreciate having another person to share with, to drink in the fact their words were being heard by a new person, newness being a rarity in this environment. One man sat quietly in the cage, and another pressed himself against the glass and stood on tiptoe, getting as close as possible to the small opening of air at the top. I've never spoken to a patient through a glass cage before, and never thought I'd feel such weight and closeness in that environment.

I spent some time in interdisciplinary team treatment meetings, where an inmate in the EOP (enhanced outpatient program for mental health) would sit at the head of the table and discuss his care with a team of psychiatrists, psych techs, and counselors. One felt he no longer needed these services. One wanted more services. Each meeting felt a little tense to me, partly because we were crowded in a room designed to house half the amount of people in it, and partly because each person in the room seemed to be either holding back or removed from the space. It reminded me of working at the Connecticut Mental Health Center in New Haven, where morning rounds which consisted of these strange meetings that I knew were meant to be patient centered but felt kind of like a court trial.

It's hard to write truly about these experiences, partly because I just want to record them before I forget more so than write about them well. But mostly because I don't really understand them enough to write about them, and I don't write well enough to write about things I don't understand. But it's this distance that compels me to stay, move closer, try.

ban the box

Another super interesting day at San Quentin Prison. When we arrived at the gate, the security guard took one look at my co-resident and said, "No blue." He was wearing blue pants, and since the inmates wear blue, this is a no-no color for any visitors into the facilities, the idea being that if we were being monitored from above we may be mistaken for an inmate and this could put us in danger. There was no leeway in this. We looked at each other and saw the other person rack the possibilities: gift shop? an employee with extra pants? sweet talk the guard? pull out the guidelines given to us that read "no blue jeans" and "no blue" but did not explicitly say "no blue pants"? Then someone suggested going to a nearby Target, which we did, where we acquired a new pair of pants, that we later returned after the day was over. Entering the prison that day I paid attention to their clothes, and found that their blue pants really did resemble what my co-resident was wearing, and it was interesting to consider how much that mattered, to distinguish ourselves.

We saw patients in the morning, which I generally enjoy for the exposure to the characteristics of this patient population (a lot of hepatitis C and liver disease, chronic pain, mental health in addition to the bread and butter diabetes and asthma) and for getting to know the individuals better. But the most interesting part was the afternoon.

We were able to attend a session in a class called Community Justice, that was started by a nonprofit called Alliance for Change. It is a 16-week curriculum where a group of inmates attend class four days a week to learn about civic engagement. It is organized by previous members of the course, and run and taught by the inmates to other inmates. Today's course was a debate regarding a real bill hoping to become a law, commonly known as Ban the Box. Simply, it bans employers from making an applicant check a box on their application regarding whether they had been convicted of a felony, until the applicant's full qualifications had been reviewed. If the applicant was then offered an interview, this information could then be attained, but not prior.

There were 22 inmates, and they were split into four groups representing 1) special interest groups against the ban; 2) special interest groups for the ban; 3) citizens against the ban; and 4) citizens for the ban. Each inmate had to go up in front of the large group and speak for two minutes about their position. It's amazing how much personality you can ascertain from two minutes, and I found it endearing when some of them were clearly very nervous about speaking in front of such a big group. Afterwards, the leader asked the group how many had never spoken in front of a group, and half a dozen raised their hands, which blew me away. I wasn't surprised rationally, but it was a concrete reminder of how different our environments have been, and it made me very proud of them for continuing this group and giving each other this opportunity. And some who had been very quiet during the small group discussions became clear and adamant during their moment, which was also touching.

I was also very impressed by how well the inmates argued against the ban. It was clear that the group was strongly for the ban, given their situations and experiences. But they carefully considered others' thoughts into this, and raised many strong points about economics, safety, and rights. They were also funny. One memorable speaker charged with speaking against the ban ended his argument with: "I ask those of you supporting this ban to ask yourself, would you want to work next to a creepy convict?"

Of course the obvious juxtaposition was that the group felt the very opposite of this stereotype. They were warm, engaged, very supportive and respectful of each other. And it seems that this is in large part due to programs and classes like these. I think the issues of what should happen in prisons and how and why are still very complicated, but there doesn't seem to be any question to this being good.

prisons

It took me forever to write this because this topic has become so extremely interesting to me, and there is so much to say about it.

In college I took two classes where I ended up writing an essay about prisons and/or prisoners--one in a moral reasoning (because they have to call everything by a different name; this is basically philosophy) and another in a literature class on misfits where I wrote about Kafka's The Trial. These were some of my favorite things I wrote about, mainly because I was pushed to think more deeply and in more nuanced ways about things I hadn't considered much, or had only considered in concrete ways. In the philosophy class, I wrote an essay about whether risoners had the moral right to revolt violently when certain rights were being withheld from them. This seems like it could be a straightforward argument, but being forced to use definitions and structured logic makes things both more complex and more streamlined. It made me think of a number of things more carefully. How is the prisoner different than the average citizen? How are civil rights different from human rights? The prisoner retains some baseline rights, but by definition is deprived of others, and also has more obligations to the state than the average citizen. But likewise, the state acquires different obligations to people when they become prisoners.

In literature, which in some ways is on the other end of the spectrum from philosophy, we also thought about prisoners, some more literal than others but the obvious one being in Kafka's The Trial, where a man is arrested for a crime that is never shared to the reader or known to the man himself. I didn't see it then but looking back, clearly there is a connection between the two disciplines in this topic--I opened my essay about the book with a line from the quintessential philosopher, Foucault: “He who is subjected to a field of visibility...inscribes in himself the power relation in which he simultaneously plays both roles; he becomes the principle of his own subjection.” This was written about the Panopticon, which is a building designed to allow prisoners to be observed without them knowing when they are being observed. A guard can stand in the center and have view of all the prisoners around them, but they can't see him. So even if the guard isn't looking at you, you feel like it is and it's your own sense of this that limits you. I became really interested in how this sense of individuality--that things are centered on you, that you have this singular relationship with the guard, that you forget about the many other prisoners around you (because you also can't see them)--is a source of imprisonment. In our society, individuality is the means of establishing identity, but in this case it can be detrimental to your sense of self. It also poses an interesting contrast to the other essay, where prisoners are asserting their individual rights.

Anyway, that's all to say that I thought a lot about these theoretical and written arguments when I started my rotation at San Quentin prison a few weeks ago and then a few days after that when we visited DeLancey Street which is a residential program for ex-convicts and would-be prisoners. Obviously these are two very different structures for a similar population of people, so it made think again of the nuances and complexity of this slice of life (which is the totality of life for some).

Our day at San Quentin started with a brief tour and an orientation on the language, rules, and etiquette of the place. But before that, the day really started with getting into the prison, which wasn't the easiest thing to do as a "regular" person. You aren't allowed to wear a million different things (blue jeans, green in any form, yellow raincoats...), and I wasn't allowed to bring in my gray hoodie which I had only meant to help me ward off rain until inside. So I had to walk around in the rain and it was freezing. Then we needed to attain what looked like something I'd call tokens but they called chits, which are round gold coins that look like they were used from the time of Game of Thrones. There are various definitions and uses of the word chit, but I think the one that might apply here is "a signed voucher of a small debt (as for food)." We turn in our chits for our key cards, which let us into the bathroom and not much else. Then we needed our alarm systems--a device we were to clip somewhere on us and strictly instructed to keep it vertical at all times--because if it leaned at all from 180 degrees it would set off a prison-wide alarm that wouldn't go off until a guard found you and was sure it was a false alarm. This is meant to alert the system if you were to fall down as the result of an attack. This seemed a little scary, but then another new medical provider set it off three times that day, twice while leaning over and once while going to the bathroom, so it became a bit less intimidating and more annoying in how self-aware it made us. At another point during the tour, a guard yelled at my co-resident for not having his driver's license on him at all times and proceeded to remind him about a half dozen times that he needed to have his ID at all times. These sorts of things gave a small, strange sense of what it might be like to live there.

Then we sat down for an orientation to the prison. I'm not sure what I expected to be oriented to, but what happened was that we were oriented to a microcosm. We learned about the different units, who was housed there and why, and the lingo for what they were called. We learned about the leader inmates of the prison, called "shot callers" who will direct the behaviors of their fellow inmates, from what type of exercises they will do in the yard to organizing hunger strikes to drug dealing. We learned about which medications aren't prescribed in prison that we routinely use in the community because they have black market value in prison.

And we learned about the bane of the primary care doctor in prison: chronos. A chrono is a request from an inmate for some type of accommodation: a cane, a back pillow, and the most common and most coveted: the lower bunk bed. At first, doctors felt happy about their ability to give, and gave anyone who asked whatever reasonable equipment they wanted--and the lower bunk. So much so that they ran out of lower bunks, since everyone wanted one and the prison is already housing 400% more than its intended capacity. And so this has become a political issue in the prison, with people vying in any way they can to attain a chrono for a lower bed, and the majority of the visit between a doctor and patient can become about attaining this form. They liken this to pain medications in the community (which are very much limited in prison), where the relationship can become very strained over different agendas. So much so that they have devised a "Chrono Clinic," which sounds a lot like "Chronic Pain Clinic." No matter how we try to structure and shape an environment, common inherent tendencies arise from anyone and everyone.

When I left for the day, I found myself relieved to turn in my alarm system. I'd felt consciously limited by it all day, trying to make sure I didn't move in ways that would set it off and have an army of guards running to me. I actually ended up loving my experience much more than I'd anticipated, but I also felt more "other" than I anticipated and it was also nice to shed that when leaving. I had that freedom.