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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.

September 13, 2017

Reading : Books People Like That I Didn't Like



I need some better book recommendations, because I've been reading a string of mediocre books, or books that I'm too mediocre to appreciate.  

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The Sympathizer by Viet Thanh Nguyen
I wrote a little about my struggle with this here (along with books I liked better), and I was determined to give it another try. Written by a Vietnamese-American about the Vietnam War, it won the Pulitzer.  The nameless narrator is a Communist spy who escapes to America with a South Vietnamese contingent after the South is taken over by the Communists.  His role is to keep tabs on the contingent, for fear that they will continue to plot against the Communists, which they do.  

So I felt obligated, and interested.  I made it to almost 200 pages the second time around, and still couldn't finish.  Maybe I'm not qualified to write about it without finishing it, but I'm trying to make two attempts count for something.  I just couldn't get into the narration.  Maybe it's because I had a really hard time connecting the narrator with the Vietnamese men in my life, a case of cultural context intefering with my openness to a character.  Or because the writing is dense in a way that was unweildy for me and I felt like I was trudging through to get at what happens more than to actually read. 

But it doesn't escape me that there's a scarcity of Vietnamese perspective in literature about the war, that accounts have focused on what Americans experienced.  That while there is more and more written about the refugee experience, not much is written about the actual experience of the war from the point of view of its native participants--its politics, divided loyalities, moral conflicts.  So I do really appreciate that this brings more attention to the people at the war's center.  And if you've read it please let me know what you got from it so I can benefit without having to actually finish it.


Marlena by Julie Buntin 
When I looked up this book, it was advertised for fans of Emma Cline's The Girls (didn't like it) and Elena Ferrante's My Brilliant Friend (couldn't get into it), so maybe I should have known that I wouldn't love it.  It's about the teenage friendship between Cat and Marlena.  The story is told from the retrospective voice of Cat, as we know early on that Marlena dies a year after the girls meet.  Theirs is the classic friendship of opposites, Cat the bookworm with little sense of real life's dangers, and Marlena the pretty cool girl from a troubled home.  I feel like I can't write about it without these familiar words and concepts--bookworm, troubled, opposites--because that's how it felt to me, a little too familiar.  Generally I really appreciate stories sensitive to hidden trauma and the complex difficulty of being female.  But the book seemed more attached to its tragedy than to its people, with Cat becoming an alcoholic after Marlena teaches her simultaneously how hard reality is and how to escape it with substances, with no mention of how Cat processes her adolescence in the years after Marlena dies.  As if it's enough to say that what happens to us when we're young will keep us darkened as adults. It feels a little too easy, this story of hardness in a girl's life.


Small Great Things by Jodi Picoult
Even though I flew through this book, I hated it. Even though I respected its intention to highlight the role of race and racism in our society, I hated its inevitable desire to easily color things black and white.  Ruth, an African-American nurse, is forbidden to care for the newborn baby of a white supremacist couple.  When the baby suddenly stops breathing, Ruth initially hesitates, then tries to save it.  When the baby dies, Ruth is blamed for both her inaction and her attempt, and prosecuted for manslaughter. She's represented in court by Kennedy, a well-meaning white lawyer who has yet to recognize her unconscious biases, a stand-in for the author and the people she's trying to reach with this book.  The book is told from the first-person perspectives of Ruth, Kennedy and Turk, the white supremacist father of the baby.  I'm conflicted about books like these, because I understand that simplifying things makes them more accessible and palatable.  But ultimately, artificially shaping a happy ending (I'm not giving it away because it's obvious from page one that this will be a people-pleaser) makes our burden seem much lighter than it is.  Like just by reading the book you're now so much more aware and not much more needs to be done, and this seems as dangerous as remaining unaware.


Talking as Fast as I Can by Lauren Graham
My lukewarm reaction to this book (Lorelai of Gilmore Girls) should be taken for a grain of salt, because I've generally not loved audiobooks by comedians even when I love the comedians (Aziz Ansari's Modern Romance, Tina Fey's Bossy Pants, Jason Gay's Little Victories).  If you like these books, you might like this one because it hits the checklist for books like these: snarky, good-hearted, self-deprecating in quality; lessons on how to be humble and grateful in content.  I don't think comedians are inherently more equipped than others to impart these lessons, so I don't necessarily expect that these books will be uniquely insightful about life.  But I think we expect that they will be funnier in their delivery, and I just haven't found that to be true in these memoirs (except for David Sedaris, Naked in particular).  So this wasn't an exception.  But it probably won't stop me from listening.  I like to listen to these rather than read them, since their voice and performance are so much part of the humor.  And also because I like these people, so listening to them is enjoyable even if I don't get into the content.  I love Lauren Graham because I love Lorelai as a character and the Gilmore Girls as a whole, and if you do too, I would still recommend listening to it, more for the voice than for the memoir.

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Since writing this post I've read some new books that I'm much more excited to share, but I would still love recommendations (be my goodreads friend please).

September 6, 2017

Health : Perfect Day



It's taken me thirty-three years, but I've come across the fool-proof formula for the kind of day that makes me feel happiest and healthiest.  A disclaimer that I call a lot of things my favorite in the following description, which kind of makes sense.

It starts with coffee.  I love coffee, but drink it pretty rarely because I'm sensitive to the caffeine, or because I want to stay sensitive to the caffeine.  I tend to get moodier on caffeine, happy at first from the stimulation, then a kind of coming down where I dwell a little too deeply in whatever I'm feeling.  So I save coffee for our climbing trips, when 1) we wake up pretty early, and 2) I know that I'll have natural endorphins that will counteract the aftereffects of the caffeine.  It's a special treat.

Then we drive, and even though I lament the distance we have to drive to get to rock climbing and would likely eliminate it if it were possible, I do also love long drives.  People who've known me awhile know that they're one of my favorite things ever (favorite number one, not in order and I won't continue to count).  I like the long stretches of scenery, being forced to do nothing except take it in.  I like the comfortable conversation, the podcasts and music as backdrops to the views; I also like the silences.


Drive to & from Bishop, CA. February 2017


When we arrive, there's usually some hiking involved to get to the area we want to climb. It's called an approach instead of a hike, since the goal is to get to climbing.  Similar to the drive, we'd all eliminate the approach if given the choice, but similar to the drive I generally enjoy it (depending on the distance, and on how long we get lost as getting lost is routine for me).  It's usually the first of many waves of feeling grateful to be outside and away from a city (a city whose compactness I love but can sometimes compress).

Then, there's the climbing itself, which I already glorify in more ways than anyone wants to hear. Suffice to say that it's the main ingredient for the perfect day, because there's a sense while doing it that I couldn't possibly feel exactly like this doing anything else.  Strong and scared, alone in my head and connected to outside.  I'm open to the possibility that something else compares but will gladly take this for now.




If it really is the perfect day, there's a body of water nearby to jump in after hot sweaty climbing.  This can be a creek, river, lake, or a hotel pool (followed by hot tub); any sort of water feels like a miracle after clinging to rocks. And there's beer, which is another thing I really enjoy but don't consume that often due to my sensitivity (I know, this isn't the sort of sensitivity that I like either), and another thing I indulge on these days.  They taste especially good for knowing that we carried their weight to savor them now.




On the perfect day, it's the first of more days of climbing, so 1) we camp and 2) as the light is winding down we know there's more.  Preparing and eating a simple hot meal outside makes me feel how much can be had by fulfilling a basic need.  Everything tastes more distinct and better outside, uncrowded by its neighbors on the spice rack or grocery store shelf.  With fire and wine and chocolate, I'm pretty sure every space I have is filled.

As a person drawn to complications in my work and personal life, I really appreciate how much camping pares things down.  The tent is a favorite thing, shelter from so much made from so little.  The perfect day ends with a warm night, where you can leave the fly off the tent and fall asleep with stars as your ceiling. And it stays warm even as it steeps into dark, so that I can sleep (mostly) naked in my sleeping bag which is one of my favorite sensory feelings.  And if I get up in the middle of the night to pee, I can stop to look up to the denseness of light that we've replaced in the city with the denseness of people.

Not that people aren't part of the equation for a perfect day--they're the outline for everything else, for making it possible and shared.

This summer has been full of variations on this day, and it's been a long time since I even felt summer as a different season (in medical residency the days were marked less by season and more by a sleep cycle that was always screwy).  Each one has felt perfect.





September 4, 2017

People : Colleagues



When I talk about work it's mostly about patients, but more and more I realize how much my work experience has to do with our clinic community.  Especially lately with all the hate happening in the world, I feel so lucky for the daily welcoming warmth of my colleagues.  Their beyond dedicated care for our patients inspires me to do better, their engagement with community issues keeps me accountable, and they are just funny, kind, interesting people who go out of their way to help each other and I love spending time with them outside of work.

My feelings about this are so deep, they're hard to express in a way that does them credit. I've always known it's important to be surrounded by people who have the qualities that I want to work towards, and that seems like an obvious fact.  But over these last two years, I've gotten to know this as an organic, dynamic thing.  And I now recognize how much of this has to do with keeping these values tangible and in motion.  That's what I admire most in my co-workers, how actively they work towards goodness.

It's impossible to do hard work if you don't have colleagues who understand the difficulty, value it, and are willing to wrestle with it. A huge part of keeping this work sustainable has been not giving into the frustrations.  Together we work through not just clinical questions but the tougher questions of how to empathize, how to communicate, how to help. I love that people ask each other: How would you share this test result? How would you frame these options?  What do you tell someone when you feel like there's no concrete answer to their symptoms?  And how do we cope with our heavy sense of limitation, both clinically when we don't know what's going on physically with a patient, and personally when we get impatient or angry with how a patient makes us feel?  Their questions prevent my own complacency, and motivate me to keep asking and pushing.





Recently, at a training about transgender care, one co-worker shared a story about an experience with a female-to-male transgender patient. When he asked her about breast reduction surgery, she told him she would look into it and he started to cry.  He told her that no provider had so easily said, "Yes, I'll try" in response to his needs.  That he'd never been to a clinic with such visible support for black lives and immigrant rights.  Our co-worker shared how this made her really proud of our clinic.  I'm so inspired by the way our colleagues actively reach out to people more vulnerable and less privileged, and use what they've been given to make more for other people.  And it makes me think that the one good thing about the election has been new awareness about how important small, active actions are.  As much as people say, what difference does it make and maybe we're just making ourselves feel better--it does matter to show solidarity with people who feel unsafe, unvalued, neglected.

Our co-workers also genuinely care about me as a person outside of my job, which has just been the sweetest.  We know about each other's families and hobbies and neuroticisms, and take care of each other.  During a week in which I had no time to get groceries, the nurse on my team brought me home-made leftovers for lunch two days in a row, and in general she often brings me dessert because we all know I love dessert.  At the time I also had no hot water at home, so another co-worker let me use her laundry and shower (she put my clothes in the dryer for me, and checked beforehand that I didn't have any delicates).  So basically, they feed, bathe and clothe me.

Because they're so great, being with them outside of clinic is a always a welcome break from work (even if sometimes we rant about work).  We go to concerts and plays and operas together, and climb together once a week.  I like happy hour-ing with them as much as I like backpacking with them.    Just like I appreciate their activeness in their work, I love our active togetherness and there's no group of people with whom I'd rather be active and together.

July 13, 2017

Health : Humble Warrior



A common icebreaker in yoga classes is asking about your favorite pose.  I think I have different favorite poses for different categories--a favorite comforting pose, a favorite challenging pose.  But my overall favorite is humble warrior.  I love the idea of blending strength and humility.  Your legs have to be strong to keep you stably rooted to the ground, and at the same time you bow towards the ground.  It's one of my favorite feelings, this balance between the embrace of individual power and the acceptance of a bigger force.

Most recently during our climbing trip to the Emeralds, I realized this feeling is the main reason rock climbing is so powerful for me.  People (myself included) often ask why I actively seek doing something that often terrifies me.  Usually I talk about how it's good to be challenged, that it's satisfying to climb against fears of falling, how this translates to real life, etc etc.  It all sounds kind of reasonable, but these explanations don't really capture what I feel.  And maybe that's because there's so much immediate to think about when climbing that I'm often not mindful of what underlies the movement.

Lately, as I've been focusing on the mental and fear-based aspects of climbing, I have found the most growth in fully believing in contrasting concepts--that I have the capacity to complete climbs that are scary for me, and that I'm ultimately subject to the nature of the rock and the physics of motion.  Agency over my movement on the one hand, and the immutability of my environment on the other.  I'm kind of love with this, because it combines the height of what I can do with the depth of the world I live in.  The power of person alongside the power of place, this feels more like a coalescing and less like the collision that characterizes most battles of force.  

In many ways, this is the physical manifestation of how I feel about my work in medicine and life in general.  That we should recognize our immense power to have impact on other people and our environment, while respecting the limits of our efforts against the course of history and human development.  For me, the closest I've come to real purpose is throwing myself into this dynamic, of continually, humbly creating strength and re-creating it when one force overcomes another.

I've written before about how valuable and healthy it is to feel strong. I'll never understimate how much of my love for rock climbing has to do with how much I love feeling strong.  But I know now it's more about how that strength fits into the pockets of what I'm climbing--sometimes these crimps and crevices give way to our hands, and sometimes we collapse into them.


Zion, Utah


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