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December 10, 2017

People : Nuance

Red River Gorge Kentucky, October 2017

Once, several years ago, a friend and I are driving in a car and see a jogger go by.  My friend says, "That person is running really slowly."  I respond: "Maybe he's been running for ten miles and this is the end of a long run."  My friend responds: "That doesn't change the fact that he's going really slowly."

I remember this because it brings up questions that years later I still consider every day in work and life.  We have a conversation about the difference between making an objective observation, and forming a subjective narrative.  He argues that he was just making a comment, and it's true that objectively the person is running more slowly than your average jogger.  But I responded the way I did, because I think it's pretty rare to withhold all judgment from any observation.  This doesn't mean that the judgment is bad or wrong, just that we form thoughts about the things we see so immediately and instinctively that we don't recognize the jump from observation to judgment.  So what we think is an "observation" almost always carries some connotation in its statement, or opens itself up to connotation.

I also responded the way I did because context matters even when making what seems to be an objective statement, since something like speed is relative.  How long the runner has been running does change the fact of his speed, if you're talking about an adjective and not just a number.  You might see, and say, something entirely differently if you knew that slow runner is an ultra runner who is on mile thirty.

I've been told by a number of people that I make too many excuses for people (most often, our patients).  Most often it's a loving joke.  But in other contexts, this comment assumes a lot: that I'm naive, that I dismiss personal responsibility, that I let people get away with things, that this is harmful to not just me but to the people for whom I "make excuses."

It's true that I've had people take advantage of me, as we all have, but I'm glad to have pushed the boundaries of giving people the benefit of the doubt to see how far that can go. I'm also not blindly imagining a world outside of the confines of our clinic; I'm making a conscious decision to remember that that world is more real than this artificial space we've created.  So I'm not naive and I understand the dangers of trying to analyze why someone is an hour late to an appointment, or yells at me for no apparent reason, rather than being straightforwardly strict about those behaviors.  My co-workers who see me go through it and go through the same things themselves know that we strive for a certain balance of boundaries, of support and tough love. They also know that I very often tell patients in the moment that these actions are not okay and that I try very hard to not give into unreasonable demands.

But I think that this type of response to the effort to contextualize--the "you're making excuses for them"--is just another example of why it's so important to contextualize in the first place.   Don't assume that just because we can imagine a lot of stories, that we believe all of them.  Or that just because we can imagine a lot of reasons, that we ignore the implications.

We just believe in the importance of imagining, and in appreciating how much nuance every action possesses.  When we imagine all the possible reasons for an action, we're not necessarily saying that the action is justified, or that it can't/shouldn't be changed, or that people shouldn't be held accountable.  We just want to acknowledge how much we don't know.

When I find myself frustrated--with something in clinic, in the world, in my personal life--and try to figure out what exactly is frustrating me, the source is most often a lack of nuance.  People are hardwired to make so many assumptions, and we all trust in our own judgment above all else, and sometimes this makes me really angry.  I know that this happens for evolutionary and human reasons, that immediate judgment is part of a survival skill set.  But when we are comfortable and have the resources and space to consider the world beyond our personal survival, instead of accusing someone else of making excuses, I'd ask what is our excuse for not imagining the depth and complexity below our observations?

If I had to choose one thing I am most grateful for in my education, and the one thing I'd wish most for in our education system, it'd be the value that books give in imagining this depth and complexity.

I recently read Beartown by Frederik Backman, which is a fictional novel about a very real, frequent occurrence: the rape of a teenage girl by a prized athlete in a small town whose livelihood relies on the sport.  After having so many patients suffer from this kind of trauma, I've read a lot about it this year (Missoula is a must-read for anyone interested in this topic).  This has taught me so much about how to re-evaluate how we judge, how reluctant we are to admit our gaps in understanding and knowledge.  While I had a lot of issue with the ending, I thought the beginning of Beartown does an excellent job letting us slowly get to know its characters and how many factors converge to create tragedy, such that there are many ways to answer the inevitable question of "How could this happen?"  It also shows the ramifications of not imagining, of simplifying people and situations.

There's little that drives me crazier and makes me angrier than this closed thinking.  It doesn't come from a cruel place, but can lead to such cruel consequences.  I know that when I'm busy and tired and overwhelmed (often), I do it too.  So it takes active energy and reminding to stay open, renewing the intention over and over when we fail.  With so many unimaginable things happening in the world right now, the least and best we can do is to hold ourselves accountable to imagining why and how.

October 15, 2017

Health : Plasticity


In August, I saw some of my old med school friends and I realized that I met them all a decade ago,
in 2007 when I first started school.  It made me think a lot about what's happened since then and whether I feel older.  In their thirties people start talking about how old they feel--can't stay out as late, can't drink as much, can't subsist on a few hours of sleep.  Maybe it's because I never had much capacity for those things to begin with, but I don't really feel like this makes me feel much older.  (Maybe in that way I feel the age I've always been).  I do feel more time, mainly because I've had more experiences.  But those experiences make me feel whatever it is that people refer to as young--the joy we often equate with youth.  As I've gotten physically older, I've found that for me happiness is less about being able to do the same things and more about finding newness, creating changes, and being aware of my growth.

A friend referred to this video recently, of a man versus his child, the challenge being to learn to ride a bike with the handlebars backwards: http://viewpure.com/MFzDaBzBlL0?ref=bkmk.  It took the man eight months to learn, and the three year old a few weeks.  It's an example of how the brain's plasticity and ability to learn new things decreases over time.  And really, it's a marker of age that we reference all the time--being set in our ways, slow to learn new things.

But I think that even if we're not as good at doing new things (and maybe for that reason), pushing to do new things gives a unique kind of satisfaction as we get older.  I didn't learn how to swim or ride a bike until I was in my mid-twenties.  While that kind of sucked and was definitely much harder to do when I was older, I was also much more aware.  Of myself--I didn't take it for granted that my body could just do these things.  And of my surroundings--water felt like a really different environment, as did being above the ground on two wheels.

What I (we?) miss about being young is this openness to our potential, and as we get older maybe it depresses us that our potential narrows.  Even though that is in some ways true, it doesn't mean we should stop being open to the potential we still have.  And when we do new things, the fact that they're harder now than they might have been in the past give them a different kind of appeal.  I've never wanted to stick with things that come easily, and sticking to that sentiment keeps me tied to how I was ten or twenty years ago.  

I find this especially easy to see in physical activity.  We're always talking about the aches and pains that we develop as we get older, how it's harder to recover.  And I know this is true, but I also try a lot more than I did when I was younger and in that way I still viscerally feel all the things our bodies can do.  While our ability to progress linearly in one thing might be less, we still have the ability to try as much as possible across the spectrum of things, if we want and if we commit.


This past summer, the ladies I regularly climb outside with (who, happily, are also great people and friends) and I started learning a type of climbing called traditional (trad) rock climbing.  This means that you climb rock walls that don't have any sort of gear or equipment already on them.  You carry your own gear, and as you climb, you place gear that you then attach yourself to.  This means that if you fall, it's the gear that you've personally placed that will catch your fall.  In addition to the actual climbing, you want to be confident that you've placed gear correctly for your safety in case of a fall.  So it's mentally pretty scary, and it takes a lot of technical skill.


You don't need to know me for that long to know that I'm bad at technical things.  When we did our first trad climb, I forgot everything anything ever taught me and felt overwhelmed by everything to remember.  Part of what I love about climbing is that it's cerebral in a physical, intuitive way, so that I can think things through with my body.  With trad climbing, there's a lot of actual mindful thinking about how to place your gear to ensure safety.  And there's no definitive check other than your own processing.

But over time, I've grown to love the newness it has given me.  The mental challenges it presents, and the physical places it takes me.  With this type of climbing, you can climb thousands of feet up mountains not at all accessible by hiking, purely by means of your own movements and placement.


Recently, my very patient and experienced friend let me be her trad climbing partner for a weekend in Yosemite.  Everyone knows that Yosemite is a special place, and sometimes that common knowledge makes me forget it.  Returning to it in any form always makes me remember: driving into the valley, hiking to the falls, snoeshowing its cliffs.  But trad climbing feels like a secret, a way of being in Yosemite that makes me breathe differently the rock formations, the height of them and depth of the air between them.  It's not something that comes easily, and I love that aspect of discovery about it.  It's something I have to push my brain and body with their declining plasticity to learn.  And that makes me hold the experience both more gently and tightly.

It's true that if I learned this type of climbing as a teenager, I'd be much better at it now.  It'll definitely take me more practice to grow comfortable with the skills.  But I'm also really grateful for the struggle that may not have been there when I was younger, for the awareness that this is new and scary and hard and worth it.

October 8, 2017

People : All Are Welcome



This weekend I went to a symposium called All Are Welcome, on supporting the health of immigrant children and families. From the panels of speakers and workshops, I learned several concrete ways to advocate for this community.  Equally valuable were the more abstract, less tangible sentiments and perspectives.  These made me remember the importance of creative thinking and openness to reframing how we view the things closest to us: our work, our language, our values.

To be honest, I thought the conference would emphasize the need to be sensitive to these vulnerable communities facing so much fear and hate, and I wasn't sure if this would be useful since I'm already sold on this being important.  But we're continually hardened by the day to day, making it more difficult to be malleable and absorb new things.  We get stuck in our framework, even if that framework is about being open.  So it's still very possible for smart, kind, passionate people to challenge us to widen ourselves.

There were several sentiments that pushed me and I found important, and wanted to share:

"Don't underestimate how hard it is to elicit the story." 
From Nick Nelson, a physician who cares for patients seeking asylum from countries where they have been abused and persecuted. He reminded me how much trauma is not visible, and how even after an intentional search and direct questioning, people don't always answer and inform in ways that we expect.  Someone responded that after twenty years of being her patient's primary care provider, she didn't feel like she would have missed this.  But I think it's very possible, and more likely than not, that we miss a lot.  That the onus is on us to keep asking questions and leaving space for untold stories for as long as you know someone.

"People don't yet perceive and understand the effect of trauma on people's ability to tell their stories."
From Jason Thompson, a clinical psychologist who studies resilience in youth from marginalized communities.  We often refer to patients who are unable to provide a clear narrative as "poor historians," a term more functional than descriptive or inclusive.  This reminds me again of our responsibility to hear more carefully, to look for pieces.  To re-scramble our own linear processes so that we can see experiences that are beyond us, that are often too unwieldy for those who actually experienced them.

"The original dreamers are not the young people; they were the parents and grandparents." 
From Bill Ong Hing, a lawyer and professor of immigration policy and race relations.  He refers to the recipients of DACA (deferred action for childhood arrivals), undocumented immigrants who came to America as minors.  He finds issue with the argument that these people entered the U.S. "under no fault of their own," which implies that by contrast their families bear fault.  He argues instead that their families face phenomena beyond their control and aren't to blame for their movement. "These parents came here not for adventure. If given a real choice, they would have stayed home. They want to stay home.  They came because of violence, because of economic imbalance not created by them."  This really resonates with me.  I've believed for a long time that choice is qualified by the circumstances imposed on us, which necessitates a more careful way of considering volition and fault.

"What is our responsibility to the world?" 
From a student, on a sign in a classroom of the high school where the conference was held.  I loved that the conference took place in a high school, a time when our belief systems are starting to form.  It reminded me of the need to continue to ask these questions, and not to lose sight of the answers we developed when we were sixteen, even (especially) if the world is so much more complicated sixteen years later.

September 27, 2017

Reading : Autumn by Ali Smith



Sometimes, things and people happen in life at the right time and that falling into place has a satsifying click, a warmth that's both surprising and soothing. Autumn by Ali Smith is that kind of book at this time in my life--perfect on its own but also more moving because it's September, because it takes place during Brexit and a time of hate, anger, and confusion.  Timeless and timely.

A lot of my favorite books are driven less by plot and more by character, so I would give the disclaimer that this book isn't a conventional storyline.  Not a whole lot happens.  It feels like the book version of the movie Lost in Translation (my favorite movie), so if you're not into things that are more about mood than action, it might not appeal to you as much.  But if you like lush language and short scenes full of atmosphere, Autumn does this so well. It's the first of four books in a series of seasons, which made me skeptical at first since that's been done so much, but now I'm so glad there will be more.

The foundation for the book is the platonic friendship between Elisabeth, an eight year old girl, and her elderly neighbor Daniel Gluck (also reminiscent of Lost in Translation).  The book moves back and forth in time, from Elisabeth's girlhood to Daniel's dying days (when he's one hundred and one).  They relate to one another by telling stories and describing paintings, getting at the truth and feeling of things by.  Sometimes this is a way to cope with the brutality of real life images, like the xenophobic spray-paint of "GO HOME" plastered on an immigrant home.  Sometimes it's just the pure pleasure of making things up.  It's a means of living for each person on their own, and a way of connecting to one another.  When everything else is divided (England, races, family), this remains solid, even when Elisabeth reads aloud to Daniel while he's in a coma.

Smith somehow makes the book really simple and incredibly layered at the same time.  It's short, reads fast in big print, and the words themselves aren't obscure or pretentious.  She strings them together in so many different ways, sometimes more like abstract poetry than prose, which seems like it would be jolting.  A passage I savored: "His heart is beating and his blood's going round his body, he's breathing in then out, he is asleep and awake and he's nothing but a torn leaf scrap on the surface of a running brook, green veins and leaf-stuff, water and current, David Gluck taking leaf of his senses at last, his tongue a broad green leaf, leaves growing through the sockets of his eyes, leaves thrustling (a very good word for it) out of his ears, leaves tendrilling down through the caves of his nostrils and out and round till he's swathed in foliage, leafskin, relief."

But even as the style changes it all feels like part of the same universe.  From the mind of an eight year old comes lines like "He said it as if a time could be a place."  And I love this depth that Smith gives a young person: "Crying came out of her like weather."  She blurs the line between external conversation and internal thought, and everything feels very naturally connected, whether she's talking about Elisabeth's personal life, or about nature, or about politics.  I'm not descriptive and imaginative enough to articulate exactly how this book reads, which is part of what's so great about it.  It's incredibly creative, but in a way that makes it more visceral and accessible, not less.

One thing I treasure so much in Autumn is the love for what reading does for us: "Always be reading something, he said. Even when we're not physically reading. How else will we read the world? Think of it as a constant."  Most of all, the book is kind to people, and knows that sometimes the best way to stay kind in real life is through fiction: "If you're telling a story, always give your characters the same benefit of the doubt you'd welcome when it comes to yourself...And always give them a choice--characters who seem to have no choice at all. Always give them a home."

It's also really funny, which is something I've always appreciated because I'm not funny.  I also value this more and more as I've gotten older and experienced more difficulty and have found a consistent solace in humor.

I get most of my books from the library, but after I read this library copy, I bought an actual copy.  Mostly, I want to have it near me because its existence--that someone wrote these words, formed these sentiments--makes me really happy. It's also something I will want to read again, in the same way that I've watched Lost in Translation dozens of times when I just want to be in that kind of wide-open mood--a space attentive to senses and the story of character, the kind of fiction that makes life better and makes you in life better.  

September 19, 2017

People : Voices



I haven't written about work for over a month because August was so busy, and it's hard to find words again. Honestly, it's been hard ever since I started my medical residency and got out of the routine, and now two years post-residency I've yet to feel that things flow when I want to write.  I can't really get at that voice, and I miss it.

In this work, other voices usually crowd out my own.  We have so many conversations with people living in realities different from our own that it takes awhile for me to settle back into where I am.  While it would be healing and healthy to disentangle myself from that web by writing it out, it's often hard to 1) reside in the worlds of others enough to understand them and 2) exit them enough to do them justice in writing.

But I think it's important to try regularly, for my own care and theirs.  Lately, I feel especially immersed in the voices of other people--patients who hear things that other people can't hear, feel things that are at odds with the reality the rest of us feel; patients whose depression crushes their capacity to speak altogether; patients whose anxiety render them unable to hear any soothing response to their run-on panic.

This past year I've been participating in a program designed to teach primary care providers some basic mental health care for patients with psychiatric disorders.  It's amazing, and stupid, how little training we get in medical school about how to communicate with people whose minds function differently from our own.  And the more time we spend in school, the more we get trapped in our own heads and the less actual life we experience.  Then we're thrown into practice, and find that often patients care less about hearing what we know, and more about sharing what they hear.

A woman in her late twenties comes in to clinic with chest pain.  The symptoms aren't consistent with a heart attack, which would be unusual in such a young person. When I ask her whether she is experiencing any specific stressors, she says, "Yes. I'm stressed because I'm worried that I have an aneurysm, because a voice told me that I will have an aneurysm on 9/11."

It can be challenging to compete with these voices, when they are so much closer, louder, and more familiar than mine. There are moments where I'm frustrated by this alternate view that eclipses mine--why can't I share what I've learned to reassure people; why don't they believe me?  And there are other times where I'm saddened by the immense fear that these phantom perspectives instill in people--how alone and scary is it to live in a place so misaligned with those around you?

Then there are the days when I think that these are glimpses into dimensions that we just can't experience.  One man asks me to test him for radioactive material, because he walked on the moon and wanted to be sure that he wasn't contaminated.  Sweetly, his main concern is that he might pass the radioactivity to others.  The same man tells me that our clinic has bad vibes, and that we should watch out for earthquakes.  The next day, we have an earthquake. It's subtle, I don't even feel it, but I believe that it happened because everyone says it did.  And I wonder what else exists outside my senses.

Sometimes these views for patients are so prominent, they close out the things that I can see, which includes myself. There's a muted response to my presence, and a shutting down of conventional senses.  One woman is so consumed by her mood that I can't find any way to connect.  She doesn't speak to me, she keeps her gaze down and doesn't look at me.  I ask her to look at me, and she doesn't move her eyes or face, and I try not to react as though she's refusing. I fall into the trap of telling her what to do in the guise of helping: "I want to help you, but I need you to talk to me," as if she has the same choice to speak as I do.  I then feel bad for making this assumption, and my guilt doesn't offer any new solutions.

At other times, people communicate things that are less directed towards me and more towards whatever else exists only for them.  In the middle of a fairly normal and routine conversation with a patient, I notice that she is becoming more and more irritable--fidgeting, sighing, shaking her head and rolling her eyes.  I ask whether something is bothering her.  She stands up and yells, "I hate this clinic, and you have such a bad attitude!"  She leaves the room before I respond, really before I absorb.  This doesn't hurt my personal feelings because I know it has nothing to do with me, but it hurts that general thing in us that wants to connect.  We occupy such disparate places, hear such different sounds.

Then I laugh, because the out of ordinary is almost always funny, a little ridiculous in its suspension of belief.  It makes me think of a line from a book I read recently: "It wasn't that happiness led to humor, but that humor could lead, perhaps to happiness--that an eye for the absurd could keep one active in one's despair, the opposite of depressed: static and passive." (Lillian Boxfish Takes a Walk by Kathleen Rooney).

The two things I aspire to in these moments are humor, and humility.

In all these situations I feel my presence shrinking, small in the face of what people experience in themselves and in their lives. There's so much potential for burnout in that, because we don't want our efforts to make us feel lesser. Because as people whose agency and work have been rewarded all our lives, we don't want to admit that we have much less control than we think and want.

But most often, I see this humbling questioning of ourselves as a huge reward of this job.  The goal and gift of this work is to feel small against the expanse of what people are and can be. There are few things that make me feel the weight of human-ness more than seeing how different people are, pushing the edges of the wide spectrum what we can experience, how little each individual can perceive but how much we collectively contain.  I feel lucky to witness such a range of feelings and voices.  For me the key to continuing, and to helping, is to treat these voices not as oppressive, but as expansive.  And if I feel pity for myself, to make sure that it's not pity for not being able to convince others of my perspective, but regret that my view is too narrow to see what they see.
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