grateful

In the second and third years of residency, we're on a schedule where for two months we're working in the hospital with tough hours, then switch to two months of a clinic schedule where we get weekends off and work more 9-5 weekdays. Some of my co-residents get a little restless during these more regular, free months (which are like normal-people-schedules), and miss the hospital in some ways. I appreciate my hospital months, but I don't miss them at all. The months of normalcy never, ever get restless for me. I'll forever be grateful to Yale, and the personal growth and exploration that its flexible system allowed us. Because of it, it's hard for me to ever have enough free time or at least time in which I have the freedom to structure work and life how I want to. So I'm grateful for these clinic months, when not only do I get to the kind of patient care I love most but also indulge other parts of myself.

A list of things I've really enjoyed these past two months of being a normal person:

A new schedule

M and I have started having a regular schedule of sleeping early and waking up around seven, which before daylight savings was when it would start to get light. It's such a luxury to actually be able to have a regular schedule. I love not having to set an alarm, because this well before I need to get up for work, and the light naturally wakes me on most days. I love being up early, but not so early it's depressing like during the days of my tougher schedule. I love being able to go to morning yoga, and I love experiencing all hours of daylight. Lots to love.

Three Junes by Julia Glass

I read this on the plane ride to Kilimanjaro last month, and it was beautiful from page one. Since residency doesn't offer much time for pleasure reading, it can be a risk to start a book without knowing how much I'll enjoy it (this makes me sound practical to the point of being robotic, which can be true). So I was actually excited about the 30 hour plane ride, the long stretch of nothingness with time to experiment, and bought a bunch of books for the plane ride. This was the first one I read, and by far the best. The first section takes place near the water, and the book itself felt like water: fresh, filling and layered despite being incredibly easy to take in.

HIV Clinic

I've been able to spend a half day each week in urgent care of the HIV clinic. A big part of Three Junes is about AIDS in the 80s, and we also recently watched Dallas Buyers Club, and in contrast to those narratives HIV care now is more about longitudinal primary care, less dramatic catastrophes. Though we still see a lot of end stage AIDS and HIV complications in the hospital, the patients I see in clinic are able to live with their illness with all the medications out there. The publicly insured population is a diverse and at times eccentric one, but the HIV population in San Francisco is pretty unique and one that I don't get to see in my primary care clinic since there is a specialized HIV clinic. I appreciate learning things specific to a condition. I think this is something we all value as people, the ability to cater towards something, to feel that familiarity with the unique contours of something helps you to know some of the inside.

Runner's high

After hiking Kilimanjaro I took a break from running because the climb down felt really hard on my joints. But after lots of yoga to recover and with beautiful weather beckoning, I started in again with an hour through Golden Gate Park on a Sunday morning. We don't spend much time there since we live on the other end of the city, but I was craving greenery so drove there. Because it was Sunday morning, there was no traffic and I could take in all the hills and corners that make this city so gorgeous. Golden Gate Park was full of kids playing baseball, people walking dogs and riding bikes and power walking and running. The smells hung heavily in the air, making me forget that it smelled any different anywhere else in the city. The first miles of running were glorious, the middle got choppy and then turned the kind of amazing that makes people wonder why you're smiling so hard to yourself. I'm not fast and my endurance is in the middle depending on the comparison, but I love that that doesn't matter--you can still get the high as long as you go far enough.

Cooking

One of the things that makes me feel less human during my inpatient rotations is the amount of frozen dinners I eat. It's been really nice to cook almost every day, even simple meals. I hate grocery shopping, but with M's help I've grown to like it by getting a bit better at it. Developing certain routines has made me feel very normal and happy and natural. Little things like cleaning out the fridge when we just got new groceries, choosing a new cheese each time we go to the store, placing leftovers in a certain place to remember to eat them. Some recipes we've enjoyed are Alaskan salmon with dill, healthy cinnamon roll pancakes, sesame turkey meatballs (tofu for me) sometimes with an orange glaze, and different kinds of pesto, lentils, quinoa. I like being comfortable enough with certain recipes to vary them every so often.

High school friends

This month I was able to spend more time with Kristina, one of my best friends from high school, and also saw Richard who was visiting from Seattle and who I haven't seen in several years. We got to cook for Kristina and Wayland, and had a long cozy dinner at home. M often talks about how our younger selves can be a pure version of us, indicators of what we want when untethered by expectations and responsibilities. Spending time with people from high school reminds me of what we desired then, of what we naturally gravitated towards, and reminds me to seek those in my life. Kristina's regular blogging during a period of facebook abstinence inspired me to return to this, and her presence made me think of my own, of what I want to make from myself.

So, thank you to all this.

relations

Clinic days are the days I feel most at home in medicine and also most out of sorts. This morning, it was my turn to present a difficult patient case to the rest of our primary care program. These cases are meant to discuss challenging patient interactions and personal management rather than clinical questions. As I narrated the one year course of a relationship with a patient who has presented multiple complex challenges for me, and listened to others' questions, thoughts, and suggestions, I felt the weight of this one relationship. I don't mean weight as a burden, though it's clearly been hard for me to navigate, but more objectively as an observation. In learning about one person there's a lot there, and also a lot of gaps in perception and understanding. It overwhelmed me to think about it.

Later that afternoon I had actual clinic, where I saw four patients. One of them asked how many I see in an afternoon, and I told him somewhere between four and six, and we commented on how that wasn't that many. But I always feel like it's a lot; each person is a different place and there's always so much to process. What strikes me is how much of medicine is about developing these relationships. You know this is a cliche beforehand, but living it is so different (also a cliche). What strikes me even more is how ill-prepared we are for developing them, especially at a place like the county hospital where the patients are so very different from the doctors taking care of them. I think of how much different life they have experienced, and how much of my time has been spent in books in order to help them deal with these lives that exist in a totally separate realm. M and I talk about this all the time, but now that I'm actually responsible for people, it hits hard the flaws in our book learning and even our patient-centered learning. But even as I flounder with it, I'm incredibly grateful to encounter so many diverse people, and to have a relationship even when unable to relate.

coming back

I've been going to yoga a lot lately because I've consciously felt the need for physical and mental recovery. At the beginning of our class today the teacher spoke about the distractions that kept her from her daily morning practice that morning. Instead of being at her mat, she would find herself at her desk with her computer or on her bed with her phone. Each time she would come back to the mat. "Don't feel guilty," she suggested. "Just keeping coming back."

I spent the last year and half away from this blog, playing briefly and intermittently with another one centered on monthly updates of my rotations, since my residency schedule has me thinking of my life in terms of what I'm working at for four weeks at a time. It never became a flow or an escape in the way that this place was for me in medical school, for different reasons. Obviously, I've had less time, space, and energy. Less obviously, I've realized that this kind of compartmentalization isn't really me. When I started this blog, I painstakingly re-entered entries from my previous blog onto it, to maintain a continuity (one that no one else but me experienced). I thought that with the move and graduation I should start over and grow. But what I've wanted most is to come back.

In some ways this makes it easier to make space for something that I don't want to lose--my desire to record, process, and share by writing. During some rare but strongly felt times, I think I didn't commit enough to something that's felt most natural to me, and I get sad. I think about writing silly stories on the typewriter as a kid, about the long afternoons with the high school newspaper, the intense focus on essays as an English major, and most personally this blog. And I wonder, was it worth it to have sacrificed such a big part of me, a part I never had to force for any external reason? And I find it hard to admit that I never thought it would've had to be sacrificed to such a large degree. But it turns out that medicine is hard, and that many parts of it don't come to me as naturally as it may for others, so I'm left with less reserve that I anticipated. And with that reserve, I've found it easier to invest in being physically active, prioritizing climbing and running over sitting down to write.

This is partly because medicine has been so emotional for me, that it seemed both easier and healthier to use any free time letting movement seep that from me, than to steep it more deeply into words. And while I don't regret using those moments that way, I look back and feel a lost link. Now that I've looked, I won't feel guilty and I won't look anymore. I'd just like to continue.

we're in kansas now

So intern year has started, and I never got around to transitioning from this blog to another. Even though I'm on a very light month right now, there are still a lot of competing priorities for my free time to balance. I've been focused on doing a lot, rather than processing, which is too bad because this month has been great in its emphasis on giving things thought. I'm planning on backtracking short thoughts on each past day of this rotation, which I've never actually done because it seems so daunting to go back while continuing to move forward, but I don't want to forget these feelings.

Before that--this is a halfhearted effort to wind down this blog, which contains the first of my public journals from college and then a transition to this space sometime during med school. This makes me think of an ongoing effort to make my new home home by burning a candle I've sentimentally kept for several years. It's encased in a jar, and I'd like to fill the jar with other sentimental keepsakes, and to do so I have to burn the candle inside down. I've been taking showers by candlelight, falling asleep to candlelight, cooking dinner to candlelight. Candles burn for a long while.

At one point I wanted to write about graduation, which is now about two months past. Even as I get excited for them, I never like my graduations. They're always rushed, inadequate, and leave more emptiness than fulfillment. It's also rained on my last two of three. It's no one's fault really that graduations are this way. There's just too much to be contained in that amount of space. This year during graduation, I got laryngitis and lost my voice. This actually really depressed me. I'm grateful though that my kind advisor opened her home to my family and me, and that I was sick in a comfortable home. And for my awesome friend who drove out to this home to bring me lunch and chamomile tea. Dealing with the stresses of physically moving and emotionally graduating, on top of feeling drained of the energy and resource needed to deal with them, was pretty crappy. My family was very supportive, but I don't think families have a sense of what graduation is for the graduate, and I felt a little alone in the difficulty of those moments.

But, I'm reminded that while graduation is supposed to be representative of what comes before, what I take isn't that representation but the actual substance of what came before. After the laryngitis, I developed what I've grown to habitually develop after any sort of cold--a chronic cough that keeps me up at night. This particular one was the worst I'd ever had; it could have me dry heaving, and coughing for an hour straight, and in physical pain from the strain. It's mostly gone now, though it'll come back in lesser degrees when I'm tired or worn or anxious.

In some ways, I've adjusted to this being the way graduations are meant to be (now that I'll never have one again)--painful in visceral ways, your body aware of a real movement, and feelings that overwhelm to the point that you can't digest any one sense. It's a lot, and instead of forcing yourself to handle it, it can be easier to let yourself be vulnerable to being overtaken. And grow more comfortable with the very gradual falling into place of things.

I've had to adjust to giving a lot of things more time. Moving, and settling. I didn't find an apartment until I started internship, and it stressed me for a little while to not be set up before I started work. But M said, why not just let it happen slowly. And since I didn't have much practical choice in that, I let go of my personal need to have everything in place before starting this new stage. Sometimes things don't align at the edges, and so I'm grateful for every step in home-making even as it coincides with a step in doctoring. It was only a couple days ago that I recycled all my boxes. I still don't have a dresser, so my clothes are piled in the closet and across the shelf that lines my room. But I do have plants and a couch and chair and dining table and one picture hung. The day after I moved in, I realized that a shower curtain was a real necessity, and I set up my bathroom soon after that, with my favorite item in the apartment so far, a rug that's green soft in color and texture and feels so good under my feet after a shower.

Also, it took me a long time and much neurotic decision-making to get this apartment. The housing market was even more insane than usual this year. I thought hard about a couple apartments; one I finally decided against, another that I decided for but didn't get. In classic this-is-my-life, the one I finally got is amazingly better than either of those. So when I worry about living among a lot of half-unpacked things, I look at where those half-unpacked things are and feel extremely lucky for this space.

My apartment is on Kansas Street. When I first learned the address, I had a funny feeling that the fitting name would make it mine...in the way that I think both that things work out in a cosmic sense and that I make it seem to cosmically fit. But after all those thoughts about how coming home hasn't really felt like home, it feels right to say, well I actually AM in Kansas now. It's that feeling that this former home that feels foreign to me is now my home again. I named my wireless network NewHaven, and all these havens are congealing and I know this melding process takes time to seal. I think it's this stitching that keeps everything so close, but leaves me open to what's coming.

So--new blog.

san francisco

Almost everyone loves San Francisco; there are a lot of ideals, and there is an incredible unique energy. I'm not that unique; I love it too. But to be fully honest, I have to acknowledge the cons of actually living in the place. At times they can be substantial. The worst: commuting makes everyone mean. Drivers, pedestrians, bikers. They (we) are simultaneously impatient and slow, and everyone's out for themselves. This city is small, and packed. There's no easy way to drive through it. Five or six miles, which is all it takes to go from one end of the city to the other, will take you an hour to drive. Public transportation isn't good. Being a bike-friendly city doesn't mean it's safe to bike, and it's hard for beginners to compete with aggressive, entitled bikers who know that their gear intimidates you.

Close to worst is parking, and the inevitability of being ticketed, often and highly. You'll see as many meter maids as bikes, and this just doesn't seem as friendly as California is supposed to be (an inconsistency that makes the commuter mentality even more frustrating). There are some other bad things about the city (the insanely high cost of living, the cold in some pockets), but nothing compares to the problem of getting around.

But. When you do get around, it is incredible.

One of our intern orientation events was a scavenger hunt around the city. Over the course of a few hours, we sampled flavors with eats, sights, airs, and streets. It was a gorgeous sun-drenched evening; when we started out around 6 PM it felt like early afternoon, and as we finished near 9 it felt like dusk.

We drove along the Embarcadero for beautiful views of the Bay, and the Bay Bridge. We sped down to the Mission district, where we stopped at our leader's house to pick up a pinata (which was on our list, and which she happened to have for a birthday party). We walked through the Mission to Dolores Park, a grassy knoll smattered with families and couples with dogs and teenagers smoking weed. We walked to Bi-Rite Creamery, and had salted caramel ice cream, which felt rich and light and full all at once. I had mine on a cone and we sat in the park relishing the sweet. Then we strolled, looking for tacos among all the Mexican food in the Mission. We decided on a place called Tacolicious, a trendy place packed with happy hour goers. We ordered, and went in search of murals while the food was being made. A few blocks away, a corridor of colorful murals was tucked away, with different styles and sentiments poured on brick. Got so lost in the neighborhood that I forgot about the tacos, and when I found ourselves back there, it was like a surprise to gather fresh, hot tortilla and real-spiced salsa. We walked for awhile, and found a "public parklet," a random, cozy seating area "open to the public" with a booth and stools. There we devoured tacos with a million flavors packed into a handful of food--mine had the sweet and tangy of mango, spice of jalapeno and other peppers, citrus of lime, and natural ocean taste of yellowtail. Full, we drove our way to the other end of the city, to Golden Gate Park. Where we saw bison, waterfalls, and gardens, all along a five minute stretch of road. As we left from the opposite end of the garden, we made our way to Ocean Beach and along the ocean to Sutro Baths, the ruins of an indoor swimming pool complex, now swimming in the ocean. Surrounded by mountains,greenery turned black from silhouettes, pinks in the sky and glassy water from changing light. From there we ordered Chinese take-out by phone, and sped to the Richmond (SF's second Chinatown) to pick up home-made dumplings. We gathered our list of items seen, eaten, experienced and met with everyone at an Irish pub in Haight for drinks and sharing.

So much makes it hard to navigate, but it's not lost on me how much there is.

it's okay

This transition hasn't been too easy so far. It hasn't been crazy difficult, but in all honesty there are waves of anxiety that even when interrupted by calmness contribute to a general undercurrent of discomfort. So it's been important for me to actively breathe after each frustration, remember context, and appreciate. There's been a lot of opportunity to practice this...

I haven't found a place to live. Last week, my first day of physically looking at places threw me into a window of depression that lasted until I decided to block out reality and visit M in La Jolla, stat. That was a beautiful time. During it, I missed getting a place that was the most ideal of what I've seen so far. I was pretty disappointed when I first heard that I didn't get it, mainly due to not being in town (by a matter of one day; this market is even crazier in experience than in rumor). But before that, I'd been anxious deciding over another place. Finding the second one, even though I didn't get it, made it more clear that I was right to pass on the first one. And makes me more open to taking things in stride. It sucks to be starting work next week not having settled into a place yet, but I know it's just a matter of patience.

I don't know a whole lot of what's going on, knowledge-wise and logistics-wise. Our first two days of orientation were BLS and ACLS training, which required an online course to pass before taking the actual class. There was a pre-assessment test, simulations of a dozen patient scenarios that you have to repeat until you manage them correctly, and an exam at the end. I failed all of these horribly multiple times, which fed my general sense of being more unprepared than most, because I've spent the majority of the last two years outside of medical knowledge. But at the actual orientation there was a general consensus that the training had been pretty hard, and I reminded myself that in groups I'm not that different, in either good or bad ways. And also that even if it was harder for me, that's okay too.

Because the online stuff took longer than I anticipated, I was running late to the actual training, which also flustered me for being out of it for my very first day. But I learned how to maneuver the crowded streets of SF more easily, and managed to be only a little late. And when I got there, a nice man who'd retired and was now volunteering at the VA, transporting vets to and from the parking lot to other areas of the hospital, offered to drive me on his cart from the parking lot to where I needed to go. Even though this roundabout drive actually took longer than walking, it was nice to be taken somewhere when I'd just been worrying about figuring things out. And the next day, when I returned to the VA for the second day of training and again running late because I hadn't accounted for how long it would take to find parking, another nice man let me park in a non-parking spot because he knew I wouldn't be able to find an official one. I haven't been very on top of the logistics of these things--I didn't plan for parking, I didn't even know I had to do the ACLS training until a couple days before, and I'd forgotten to check my residency email where apparently a lot of information has been sent. I also lost all of my ACLS online training after I'd completed it. I've sent our administrator no less than a dozen emails, with questions that had often been already answered in previous emails, and with questions about other mistakes (one being losing my ACLS online training), so have concretely established this sense that I don't know what's going on. I noticed that I started becoming like this at the beginning of med school...having things work out in unexpected ways for me in med school made me unconsciously loosen a little of my desire to be in control of everything, and I think that's been a good thing overall. After all, if I didn't know, more than one of my classmates definitely did. In the beginning of a transition like this one, it can be uncomfortable to be out of the loop, but I still got my BLS/ACLS certifications, and I'll figure it out eventually. While I don't think I should drop all efforts to be in the know, I'm also learning to be more comfortable with not being on top of every single thing.

Which brings me to other things I can't control, with the top one currently being the traffic in this city. The drivers here are both extremely impatient and extremely slow, which I don't understand. I find that traffic is the best practice for calming techniques, and even interpersonal relations. I have to remember not to judge too harshly because I'm not the best driver either and I make lots of mistakes like having to switch lanes at inopportune times and interrupting others' lane spaces when trying to get around something. At the same time, I haven't been able to resist getting mad and honking when someone has done something clearly inconsiderate. Turning left to get onto the bridge, when I clearly have the right of way to go straight, just because you're impatient to get on a jammed road? That one really blew my mind. It also made me think that when we're behind, we're so eager to gain inches. Not to say that those inches don't add up; I think sometimes that they do, but maybe are not the worth the expense of principle. Frustration with traffic led me to public transportation, which led to another, unexpected level of frustration that also took some active effort to calm through.

So I haven't felt this underlying anxiety about a phase in my life for awhile. I think a big part of it is that I'm used to things generally working out. I've been incredibly lucky in that sense. But remembering in retrospect is tricky, and I think that a few other factors contribute to my memory of the past. One, I've forgotten the degree of logistical and emotional anxieties. Two, the positives overwhelm the negatives in my memory. Which lead me to now. These anxieties will smooth themselves and in the midst of them I'm still incredibly lucky. I have a luxurious apartment with gorgeous views to stay in while I'm looking for a place, a brother who lets me stay there and supports me through the difficulties. I have a few old friends in the area who look out for me in such thoughtful ways, from seeking out my company when I'm down to checking out apartments for me. I've already met some wonderful people in my program. I live in the Bay Area, and the San Francisco June has been unusually, unbelievably warm and sun-full. M sent me a birthday gift of a framed print of Andrew Wyeth's Master Bedroom: http://www.nytimes.com/2009/01/17/arts/design/17deba.html?pagewanted=all

Before I left La Jolla for graduation, I wanted to spend a little time objectively describing artwork to M, an activity we once did in med school and I found to be useful in sharpening observations. This is one I chose to describe to him; it was new to me at the time, and as we talked about it, we discovered an affection for it. For the simple lines and sentiment. It exudes a calm that's fitting at a time when I'm anticipating--when I don't have a bedroom yet but now have something to place in it when I do. I'm so lucky for this feeling, and for him.

And I get to start.

expectations

Being back in the Bay Area feels less like a familiar flow and more like a sudden dislodging. The feeling arises mostly from a disconnect between the immediacy of expectations and the slow buildup of adjustment. Being home should feel right; graduating should feel like an achievement; starting residency at the place I've been striving towards for a vaguely long period of time should feel exciting. These are the expectations, the kind that everyone reinforces with congratulations and questions of what's next, and the kind that I personally build with the need to affirm my decisions and values (because if I'm not happy, I probably did something wrong, right?). There are waves of rightness, like when I drive over the Bay Bridge or when the moon's so bright it lightens the black ocean at night. But honestly, over the last week as I've been looking for a place to live in the area I grew up, and preparing for the orientation to the career I've been educated for through my twenties--things don't fit.

  I'm pretty surprised and bummed by this, but I momentarily escaped some of it by visiting M in La Jolla, and in conversation with him and thought on my own, I've realized that these feelings feel bad due to some faulty expectations.

  *The expectation that because home remains in one place, my relationship to it would be similarly stable. Growing up in the Bay Area, I couldn't imagine another place I'd rather return to after sufficient exploration of the world. While living on the East Coast, I loved it. I haven't met many people from California who love the East Coast as much as I do. But I always assumed I could leave it for California, seamlessly. In fact, it was the move from West to East that was seamless--the ties to MA and CT and the state I drove in & through, were woven quietly and gradually, and as they were stitched I didn't notice that this tightness was drawn from loosening ties to my childhood home. The bulk of my development, at least as I feel it now, came from the places and relationships of the East Coast. Coming back to California, I expected only the renewal of my old connections to the place but instead there was an abrupt pull of my attachments to the other coast, without anything to immediately replace it.

  *The expectation that the end goal of a process should feel better than the process. The excitement of being a doctor and not a med student hasn't hit me. I was excited on the day of graduation, but somehow I think has that more to do with it being a part of medical school than with it signifying my transition to doctorhood.

  *The expectation that the right decisions should feel right, right away. My decisions to pursue this residency at this place seemed to form naturally over the course of who I am and who I'd like to become. It seemed to me that the result should follow a naturally free-flowing course that just fits. Instead, I find myself having a lot of doubts about whether I'm right for this, whether it's right for me. I feel clumsy.

  Looking over these, some things come to mind. All of these unfulfilled expectations have the potential to seize me with self-doubt and fear...and they have. But recognizing a couple mistakes on my part lessen this power to frazzle me--mainly, that I shouldn't expect so much, and so quickly. Just because these things haven't happened doesn't mean they won't happen at all, and when they have happened in the past they've always taken time. I've just never been as frazzled by waiting, because in the past I wasn't waiting for them to happen. They just did. I've been so spoiled by things falling into place that this time around, I actively expected them to.

  I suppose that's a part of accumulating experiences and having bases of comparison. I know that this step up to MD is seen as a culmination of what's come before, but I think that maybe the best bet is to step into it with a certain blankness, and openness to what might happen instead of what's supposed to happen.