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August 2, 2018

Health : Identity Through Injury & Illness



The last few months have been a succession of physical changes and abnormalities, each one progressively a little more difficult.  For me and for a number of people very close to me, injury and illness have shown up with sudden briskness (we are all relatively and fortunately fine).  Each one has challenged me to embrace the value of having the full spectrum of experience, which includes the stuff that sucks.  I started out pretty positive, have tried hard to sustain a reserve of patience and insight, and recently realized that getting worn out is a real, honest part of what people are. In that fatigue is the opportunity to confront things as they are, to unravel how to remain who we are in our daily routines when these routines are disrupted.  And how to be better.

Up until now, my life challenges have been primarily emotional and abstract.  This year, faced with changes in physical health, I'm learning a lot.  Despite spending the last decade in hospitals and clinics seeing people with acute and chronic illness, it's been shocking to me to confront more personally the fact that our bodies often operate independently of what we want, what we imagine.  I'm grateful for this very humbling reminder that for all our good intentions and wide exposure we never really understand what it is like: what it's like to be given bad news, what it's like to sustain and heal, what it's like to have a surgery, what it's like to live with risk and uncertainty. 

Physicality is something I've relied on as a constant source of strength through emotional difficulty--in my personal life and in work.  So when I stopped being able to push myself in that way, to maintain the movement that's been so crucial to getting unstuck, I didn't want to admit this loss.  I did everything (physical therapy, yoga, acupuncture, sauna, sports massages) so I could will healing into being.  I'm sure all of this is helping to some degree, but the majority of it is really up to my body, not me.  I think that part of why doctors make the worst patients is that we're trained to consider ourselves forces of change.  We acquire these tools and knowledge to make people better, and even though practice has proven to me the smallness of our scale of agency, underneath it all we hope that we have power.

During this whole tug of war with my body, I've thought a lot about what is defining for myself.  While climbing in a cast and then with a stiff foot, I developed a stronger appreciation of what I love about climbing that's independent of the level I'm climbing.  But I realized that even those things could disappear if someday I can't climb at all.  And until recently I couldn't run at all, which is something I've never been great at but has been an integral part of my identity and life.  I do it for pure pleasure and for coping with difficulties.  Without the things that you concretely do, you start to re-consider your conceptual self , and you question if there is anything about you that can remain constant.

This became even more prominent when faced with more permanent, life-altering physical changes in people close to me and in myself. Knowing that the broken ankle was temporary obviously made it much easier.  It was also the outcome (a fall) to an activity I chose to do (climbing). In contrast, when things happen to your body as a result of its own course and not from your direct action, this is another level of our lack of control.

What I've held most close through all this is that there's only so much I can do for myself.  We can want and will, and sometimes our bodies and our environments just say no.  So what is it that can stay true through all the things we might lose, all the aspects of ourselves and our surroundings that might change?

What I've found is that although there are limits on what we can acquire for ourselves, there is always something we can give others.  The degree and depth of gift fluctuate, but the presence is constant.  I love the malleability of this, our ability to adapt what we can offer depending on what we acquire and lose. The most important thing to me before injury and illness remains the most important thing to me now, which is the capacity to share. This isn't to say that I don't frequently forget and fail at that, only to say that it's the primary goal. 

I think that so far in life it's been easy to declare that a goal because I've been so extremely lucky in so many ways.  When things are good, it's easy to see the huge discrepancy between what I have and what others don't, and to strive toward more balance.  But on one particularly rough day, I found myself unable to provide and I was shocked at how quickly I could stop caring.  It's much harder to be giving when you're struggling too, when in moments of shock you feel not just like you're losing something but also that something has been taken from you.  I generally avoid framing things like the latter, because externalizing makes happiness hard.  But I recognize our natural tendency to do this, to feel why is this happening to me.  It's important to me to recognize without judgment our inherent inclinations, to better connect with each other and encourage each other to resist unproductive thought processes even as we know it's human to have them.

It was also hard that a certain number of events happened one after another, making me ask the contrived and real question of why this was happening.  We often talk about whether our lives really have an inherent narrative, or whether we piece the parts together to make sense.  As with many things I think the truth lies somewhere in between. If the former isn't naturally clear, I feel a certain responsibility to do the latter.  Given a set of circumstances, we're bound to move through them with some purpose.

And while at first this all seemed to be bad timing, some re-framing of perspective made me consider how things have aligned for the best.  That these things happen not to cause suffering, but to learn better how to ease it.  In the midst of all this, I received parallel gifts from an old friend and a new friend.  Neither of them knew about all these thoughts I'm just now putting down, couldn't have known that their sentiments came to me at a time I'm most able to absorb them, in most need of thoughts that take me outside my own needs.

I had just written most of the above when an old friend sent me this quote from Lincoln in the Bardo by George Saunders: "His mind was freshly inclined toward sorrow; toward the fact that the world was full of sorrow, that everyone labored under some burden of sorrow; that all were suffering; that whatever way one took in this world, one must try to remember that all were suffering (none content; all wronged, neglected, overlooked, misunderstood), and therefore one must do what one could to lighten the load of those with whom one came into contact; that his current state of sorrow was not uniquely his, not at all, but, rather, its like had been felt, would yet be felt, by scores of others, in all times, in every time, and must not be prolonged or exaggerated, because, in this state, he could be of no help to anyone, and given that his position in the world situated him to be either of great help or great harm, it would not do to stay low, if he could help it."

A new friend took me to the East Bay Meditation Center, where they spoke about the concept of a gift economy, where we give based on the fact that we all have something to share, not for trade or for acquisition. I read a little about it afterwards, and it turns out to be a complex topic of debate in economics and anthropology, but practicing the idea of giving without expectation of return resonated with me.

These fresh gifts recall the ever-giving value of the incredibly supportive and loving people in my life, and remind me that it's this sense of giving that I want at the core of my life, through changes in my emotional and physical identity.  So at these times, maybe the best way to maintain my sense of self when experiencing loss is to: bring to the surface what I've been given in the past; stay mindful of how much I have now; search for what even these challenges give me--for the purpose of giving all the above back and around always.


June 19, 2018

Reading : Underground by Haruki Murakami



If you know me just a little you know that Haruki Murakami is my favorite (not just favorite writer, but a favorite thing in life) and if you're one of the several people to whom I've recommended him and didn't love him as much as I do, I first apologize that I disappointed you.  Then I ask that you suspend those feelings and consider this book in a new, different way.  This book being Underground: The Tokyo Gas Attack and the Japanese Psyche.  Because while it capitalizes on so much of what I love about Murakami (his sensitivity, curiosity, and insight into individual people), it's a very different kind of narrative.  First because it's non-fiction and second because it contains primarily the words of others.

Like most Murakami fans, I know and love the motifs he loves: cats, delicate physical features like moles and ears, loner protagonists, loner characters hanging out at bars, mysterious women, disappearing women, Radiohead and the Red Hot Chili Peppers, islands, wells and underground worlds.  (I left out jazz because I don't know anything about jazz other than Murakami is obsessed with it, so can't claim to love it).  I also love that he writes lines like "The pillow smelled like the sunlight," which might be my favorite sentence in the world.  

The other thing I value so much about Murakami is his interest in trauma and its obvious and subtle after-effects.  In his short story collection After the Quake, he explores the lives of different individuals after the 7.2 magnitude earthquake in Kobe that killed over 6,000 people.  His characters didn't experience the earthquake themselves, but Murakami is sensitive to the idea that such impactful events can send out tremors, touch anyone, disrupt the flow of our psychological processes and concrete behaviors and daily routines.  All without any tangible connection to the event itself.  He really appreciates how subtle and sensitive humans are, how much we absorb and retain.   

I think that memories and how someone experiences the past are some of the most important and interesting elements to a person's self-identity and how that person moves in the world. (At least, I think that about myself so it must be true about everyone else, right?).  I've found that so much of our interactions with patients have less to do with who they seem in the present moment, and much more with who they have been in all the scenes preceding the one in front of us.  And equally, how they will continue to process their past in the future.  

In our current culture of scrolling facebook feeds and streaming podcasts (both of which I indulge), it's easy to experience a million presents without considering how what's happening now will continue to affect us and others, tomorrow and years down the line.  There's so much new shit that makes it easy to forget that the old doesn't disappear, that old tragedy re-presents itself over and over in new forms to those who experience it.  Not only that, narratives on trauma are inherently less accessible to people who haven't experienced the same.

This is why I really respect writers who commit to giving voice and remembrance and attempted permanence to these narratives (Missoula being another incredible example and a book that taught me an enormous amount).  In Underground, Murakami interviews sixty-two people connected to the 1995 Tokyo gas attack in which members of a religious cult released sarin on three subway trains, killing thirteen people and injuring over six thousand.  The terrorists placed plastic bags of liquid sarin on the trains and poked them open with the tip of an umbrella, injuring passengers through direct contact as well as by inhaling evaporated gas.  Sarin is a organophosphate pesticide that causes continuous muscle contraction that ultimately paralyzes you, that kills by paralyzing the muscles that move your lungs in and out to breathe.  Before that it will make you cough and vomit uncontrollably, will make your eyes get smaller so that things close in on you.  The subway passengers had no idea that sarin was the source of their symptoms, and subway workers trying to restore order handled the sarin directly without knowing what it was, resulting in their deaths and severe injury.

The book is divided into two parts, the first focused on the victims of the gas attack, and the second (published later) focused on members of Aum Shinrikyo, the cult that perpetrated the attack.  It's the first that Murakami was more driven to write, and the more compelling. 

Murakami divides the stories by the three subway lines that were gassed.  First we learn a little about the men who planted the gas on the subways, then about the people who inhaled the gas. Each section is titled with the name of the person who experienced the attack, preceded by a quote from his or her narrative.  Murakami introduces the section with some details about the person, and then the subsequent story is narrated directly by the person largely without interruption or authorial voice from Murakami.  The interviews focus on memories of the attack and what happened on that day, and how it has affected the person since that time.  Most are just a handful of pages long, so that the story before stays fresh as you move to the next one, and it's easy to get through a dozen in one sitting.  

The repetition of the same event experienced by different people creates this organic effect where each story is layered on top of one another.  The commonalities become deeper in color from being told over and over, while the variations are bright in color in contrast to the established patterns.  In this way, we gain a sense of how widely this gas permeated the community, and also how heavily it weighed on individual people.  It makes for a really unique reading experience, and I found myself wishing I could learn about more current events in this way.    

A picture of Tokyo emerges that isn't surprising, but is more palpable when described by its residents.  The trains are so incredibly packed that the force of crowds separate a man from his briefcase, trample the glasses of another.  The commutes are long.  People have a routine for the exact train they take and the exact car of the train they board and the exact door of the car they use to board.  

A picture also emerges of what is lost after the gas attack, small and large punctures in people's lives even as some routines resume. Or what is displaced, as emotions like confusion and anger consume space not meant to house that kind of intensity for that long. Some people continue to have problems with their eyesight, headaches, memory.  And some people died, leaving behind families shocked by this sudden senselessness.  There is the woman who lives in a vegetative state, whose story is told by her brother (who travels an hour every day since the attack to be with her for an hour) and by Murakami who visits her in her nursing home.  As moving as these stories are, the most heartbreaking is the narrative that's not there, the one she should have been able to tell herself.  

Murakami relates to the victims in the same way I feel we relate to our patients every day: "I came to them from the 'safety zone," someone who could always walk away when I wanted. Had they told me, 'There's no way you can truly know what we feel,' I'd have had to agree.  End of story."

But even if it's true that we can't fully know their experience, these people did choose to share, and most don't focus on hatred or revenge as their motive.  They ask us to reflect and remember, so that this doesn't happen again, and so that we respect the psychological aftermath as much as the physical event.  I'm grateful to Murakami for asking for their memories, for a slice of what they carry so that it doesn't remain underground.     



May 15, 2018

People : Family


Lately, as I've adjusted to a life in a cast and on crutches, I've been alternately angry, annoyed and resigned at the fact of losing my independence.  Every so often (every ten minutes) I want to throw the crutches out the window, and then I internally rage at the thought of how hard it would be to go down the stairs to retrieve them.   

All my life I've considered independence as something to constantly cultivate, something I was always at risk of losing.  Growing up as the youngest sibling and only girl with four brothers, then living most of my adulthood in long-term relationships, I was worried that being positioned against men meant that I had to actively fight for my own space.  Luckily, my thoughtful, generous brothers raised me with the sense that my gender was a gift and that I could be the same and different; that the limitations can be overcome and that there are advantages to be found.  Still, it can be easy to lose the volume of your voice when so many have spoken before you.  And in relationships, when you are continually weighing someone else's needs, your own can become hazy. So I've made it a conscious point to do as much as I can for myself, and while I have my own reasons for it I know that the desire itself isn't unique to me.  It's what we all clamor for in our adolescence, what we struggle to sustain in adulthood, and what we mourn in old age.  

Recently, as I've had no choice but to rely on others for both basic needs and overall purpose, I see how dependent I've actually always been.  And more crucially, that this is actually something to celebrate.  If I envision connection as a foremost goal in life, why would I not want to be connected to other people deeply enough to need them?  As I've let my mom stack the pillows under my leg (thanks for that third one), my boyfriend arrange everything by my bedside (thanks for thinking of items I didn't realize I'd need), and my friends feed me one dessert after another (thanks for the best gelato in the city which I can't believe I didn't know about)--I realize: this need for others is really what lets me be everything else outside of them.  Including, hopefully, needed by others.  

Coincidentally, I read this today: "The self without sympathetic attachments is either a fiction or a lunatic.  Yet dependence is scorned even in intimate relationships, as though dependence were incompatible with self-reliance rather than the only thing that makes it possible." (From On Kindness by Adam Philips and Barbara Taylor, as quoted in Maggie Nelson's The Argonauts, which I loved a lot).

As we often do when we're considering how best to evaluate something for ourselves, we think about patients.  Almost more than I like getting to know our patients as individuals, I like seeing their relationships to the people in their lives.  Coming from a large family where each of us interacts with every other of us differently, I can relate to the strong bonds created from dysfunction.  It's interesting, and important, to see what this is like for others.  It's tempting to perceive a person just as she sits in front of you, and forget that she exists within a web of relationships that can support or loosen her.  

We see so many incredible sources of care from family members, that remind me that for all our man-made medicine, it's often best to capitalize on what's naturally there.  There are the elderly brothers, one taking care of the other ever since a traumatic brain injury in his senior year of college.  The homeless grandmother who fights daily to secure nourishment and shelter for her grandson.  The couple in their eighties who still hold hands.  The 19 year old, newly transitioned teenager-to-adult, who answers every question with hesitant flatness, except when asked about the baby on his phone, then come a drawn out smile and three fast happy words: "That's my niece."  Their natures are quiet, their love full of force.

Then there are a lot of people who don't have anyone, whose primary sources of stability (case managers, social workers, health care providers) try hard but can never be as present as family.  The woman whose time is marked by the hours between drinks, who stops by our clinic every few days to ask for a medicine or a place to stay.  We don't have anything to relieve her pain, and the waiting room eventually closes.  The man who needs an important procedure, but can't get it done because he has no one to drive him home.  It took several visits to realize this, because he was embarrassed to admit he didn't have any friends.  We have so little to offer these people who don't have a foundation of dependence.

And for others, who we might be able to offer something small, they're often (reasonably) skeptical and mistrustful.  They're not used to having people to (reliably) rely on, and sometimes would rather withdraw than to displace hopes.

Seeing people who have been neglected and disappointed, who are now wired to expect little from others, I can understand the appeal of caring for children.  There's more malleability and room to restructure, more chance to instill each action with a sense of trust in the world.  To create family, that which will be your crutch, of the physical and of the emotional kind.  

But after my injury temporarily reverted me to a childlike state (thanks again to everyone for feeding me, transporting me, consoling me), I think it's possible and important to re-enter this mindstate in adulthood.  Especially for people who grew up without the support every child should be able to depend on.  Adults generally don't want to re-enter this state of dependence (I didn't); it's scary to be vulnerable and it sucks to be let down.  Maybe it's part of our job to break down this resistance.  It's really difficult but I think possible over time, and at the very least worth trying (over and over).  We talk a lot about empowering our patients to care for themselves, to see their own strength and capacity.  But maybe first they need to know that there's still space for them to be someone's child: to voice their needs, to be on the receiving end of a relationship.  To know that dependence makes self-reliance possible.

So on this Mother's Day I'm grateful to my family for giving me so much to depend on, for making my needs so easy that I can make the choice to care about other things, other people. And on this Mother's Day, I'm mindful of the many people who don't have the gift of this family, this dependence.  It's for you that we show up, hoping maybe once or twice that we are there in the right moment and space.

So thanks to my crutches for revealing all the places I stumble and how much support I'm lucky to have; for reminding me what we all want to be for other people.  I guess you have a purpose in my life.  (But I will still happily throw you out the window when this cast is off).


* This is one of the few photographs of my mom with all her kids.  She's 7 months pregnant with me so I count my presence, and that is also probably why my youngest brother looks so unhappy.

April 23, 2018

Health: Breaking Bones



So I broke my right ankle (the fibula portion) in a couple places after I took a fall rock climbing in Yosemite.  I am totally fine, safe, and lucky.  After some more distance from that event I'd like to write more about it and what it means about climbing.  The short story is that despite a sucky outcome, it really was a positive experience in which I gained a lot of perspective about myself, the environment, and how we interact (as in, it's a relationship and there are moments to engage and there are moments to let things be).  Also my most prominent feeling is immense gratitude for having so many people in my life who are so supportive.  Thank you, I really love you and appreciate you!

Which is really what I was thinking about as I hopped my way through the well-oiled machine of the Kaiser system this morning.  That I'm really lucky to have the resources to navigate a sudden change in my life, and how much these things affect every level of daily life, which can then spiral.  And how different it is for our patients.

In medical school, I once attended a lecture on palliative care that started with: "Sudden illness and death are inconvenient."  We talked about how all the ways in which these things mess up our lives, the simple and basic daily things.  In medicine, we focus on how to treat the acute sickness and injury, but who is there to help cope not just with the physical illness but with the logistical nightmare of being a patient?

Sometimes we forget just how bad we are at this.  A big part of what sustains me at work are our clinic's shared goals to provide the best possible care to our patients who are at the highest risk for being sick and have the fewest resources to get better.  I always thought we're pretty aware of how our system fails them at every level, because we deal with the daily BS of not being able to streamline so much that seems basic: we can't get medical records, we can't get a medication covered by insurance, we can't find a specialist, and so on.  And we try to be cognizant of all the chaos and instability that makes it difficult for people to organize all the things it takes to be well.  We know that transport is expensive and physically difficult, that homes (if patients are housed at all) are not structured well for mobility, that food access and insecurity can matter more than diabetic medications.

But now being a patient myself (with plenty of resources) who is blown away by how much a small fracture can change your day to day, I'm even more struck by just how difficult it must be to be a patient at the clinic where I work.

Access: Last night, when I realized how swollen my ankle was getting and how little I could bear weight, I went online and was able to book an appointment with my primary provider the next morning.  This is almost never available at our clinic.  Patients can go to urgent care or to the emergency department, neither of which can give appointments, so you'll never know when you'll be seen.  And for a non-urgent injury like mine, this can mean hours of waiting.

Mobility: I saw my primary care doctor and she ordered an x-ray which I was able to get in the same building as her office.  At our clinic, we have to send patients to get x-rays at a totally different site.  It's not far, but if you've broken your ankle and it takes about ten minutes to walk a block, it feels freaking far.  I also got crutches immediately, with someone to show me exactly how to use them.  We don't have crutches at our clinic, and when we have to order any equipment like splints for patients, it can take them weeks and often months to get them.

Diagnosis: My x-ray was read immediately, and I was scheduled with a podiatrist (again in the same building) to discuss the results (which I knew was a bad sign for my ankle but at the time I was more preoccupied by how seamless this whole process was).  At our clinic, we wait for results of tests to be faxed over (yes, faxed), generally several days or weeks later, and often they're not faxed at all.  With thousands of patients, we might not remember that it was even ordered, and if they're not faxed to us, we might not remember to ever look up the results.  And certainly we won't be looking for them on the same day, unless a patient is savvy enough to pester us about it.

Specialty Care: I was pretty amazed that I got in to see the podiatrist just like that, on the same day. We have to refer patients out for most things, and even urgent referrals can take up to a week.  Normal referrals (which are sent out by mail to patients) take a couple weeks to process, which means it takes patients a couple weeks to just get a number to call, to then make an appointment to see a specialist, which can take who knows how long depending on the specialist.  We can expedite things, especially orthopedic issues like this one, but that requires extra effort and a different process (for which we don't get any extra time)--it's not standard of care.

And at our clinic, because public insurance won't pay for two visits in one day, patients can't see more than one provider.  Even though it makes sense, both for convenience and for coordinated care.  So even if a patient could see their primary care doctor, counselor, and gynecologist in one day, they're not allowed to.  (Though, I asked my primary care doctor today if I could also get my PAP done since I was already there, and she said only gynecology does that, and I was pretty proud that all of our primary care providers can do PAPs).

Procedures: Kaiser has in-house people to do everything, so once the podiatrist diagnosed me with the fracture he handed me off to someone else to do my splint.  The procedure was quick, efficient and mostly painless.

It was at that point, though, that I realized how drastically the procedures of my actual life were going to change.  How will I carry anything while using crutches?  How will I get to work?  How will I shower? How will I drive home with my right leg in a splint? (um, I did it against medical advice).

Luckily, I have a lot of resources. I'm easily able to take time off work, which is not the case for many of our patients who try to grab episodic work like manual labor as it comes, or whose employers are not sympathetic to people who need recurring time off because they find low-income workers expendable and replaceable.  I have friends and family who have cars; I have expendable income so it's not the end of the world to take a lyft or leave my car parked in a garage overnight.  I can't tell you how many times a patient declines to go to the emergency room for a legitimate medical concern because they don't want to leave their car parked at the clinic and pay that expense.  I have a loving community of people (thank you again!) who have the kindness and bandwidth to go out of their way for me.

I also have the entitlement of being able to advocate for myself.  While Kaiser was great at efficient medical care, they weren't the best at actually caring about what my life looks like outside of their utopia.  The podiatrist didn't give me much information at all other than I'd have to be in a cast, and I had to ask him for how long I wouldn't be able to do anything.  When he said 8 weeks (and neglected to ask me what it is that I'd want to be doing), I almost cried which was already embarrassing and since he tried not to notice it, I got even more embarrassed so I spent most of my energy sucking it up.  By the time I actually thought of questions to ask, he was gone and I was on my way to getting a splint.  But afterwards I realized I had a billion questions and I emailed him to clarify exactly what was going on and what I should expect.  Though I still didn't ask him about how I would shower (for that I went to google and the answer is cast covers).

I know from experience with many caring health providers that people rarely intend to be cold or unsympathetic, but that there's often a lot of other things to consider as a doctor and it can be hard to remember how to just be a person (ideally they aren't separate, but here we are).  For healthcare providers working in a system much less functional than Kaiser, there's even more to navigate, and we often forget to ask about how patients are going to actually live their day to day after they leave our clinic.  And they, unlike me, are often used to systems that don't cater to them.  They rarely ask: What should I expect?  And I too infrequently ask the questions that would help me advise them what to expect.

One of the first things my friend Diana (one of the best doctors I know) asked me was: "Are you going to be okay at home?"  Her thoughtfulness in realizing that a broken bone really means many little fissures in my life, and my confidence that yes I would be okay, reminded me again how much I have, how relatively easy it is for me to piece things back together after a break.

It's not this easy for everyone (please remind me I said this when I cry and complain over the next couple of months), and I think that's the main immediate takeaway for me in the day after breaking my ankle.  While I don't necessarily believe in pre-ordained reasons for things happening, I do believe pretty strongly in drawing purpose from things that happen.  I've been spending a lot of time doing the things I love lately, and at the same time becoming a little more stressed at work, which seemed a little off as the former usually helps with the latter. So maybe this is a timely way of forcing me to stop and re-evaluate what I'm doing at work so that we're better able to recognize where things are broken and how to help heal in the places that matter most.

April 3, 2018

World : Going Away & Staying

 

In a (possibly manic) mind-frame of wanting to do everything I love with all the people I love, I spent four out of the five weekends in March out of town, immediately after taking a week off in February to climb in Mexico. I don't regret the movement, but I do now relish the ability to process in one place.  The act of constantly going away made me consider what it is that we seek, what we want to return to, the balance between the two.  What I miss when away, what I gain from the perspective, how to integrate the two in my life in a way that's meaningful, useful, sustainable.

Two weekends were spent in real winter (which my California spoiled self defines mainly by the existence of snow): Yosemite with my work family, and Colorado with my actual family.  We cross-country skied during both trips, and this same activity was extremely different with each group. My co-workers are active people who love the outdoors, and it was a near-miracle to get my family to venture into the mountains for the first time in a place they've lived for a dozen years.  But in both, I appreciated the sense of being somewhere different, together.  For my co-workers, it was the first time we've spent significant time together outside the confines of our clinic.  I love them for their natural inclination to take care, but trying to constantly fulfill that inclination can be stressful in the space of work, and I loved seeing them enjoying the space of nature just for themselves.  For my family, it was the first time we have really done anything active outside together, and seeing my 6 year old niece and 9 year old nephew experience this newness was the best gift.

Two weekends were spent climbing, one in Red Rock (outside Las Vegas) and the other in Bishop (in the Eastern Sierras).  These are among my very favorite places in the world, first for their incredible beauty, and second because they are places I've returned to most frequently.  This combination of familiarity of place and changes in myself is like the love for old friends. At Red Rock I was really lucky to be there with the kind of friend who both supports who I already am and makes me consider how to be better.  There I was able to make progress on climbs I'd tried before, and attempt new ones that I'd like to return to in the future.  It's a comforting, challenging feeling to know that this is rock--mostly stable at least in our lifetime--and we can come back to it as we change and have different experiences with it.

I think we are especially drawn to this feeling in Bishop, where I've gone annually since starting to climb outside.  In 2016, it was me and one girlfriend. In 2017, we brought another girlfriend.  Between that time and this year's trip, we've formed a group of four women, who have become dear friends and climbing partners.  The roots, and what we've grown into, are something I know I want to nourish indefinitely, and I'm grateful for that kind of certainty.

Bishop is a small town, and after the nine hour drive to get there, you can get everywhere in town within minutes.  By this third trip, we have established our place to stay (Hostel California), our place to get pre-climb coffee (Looney Bean), our place for post-climb burgers and beer (Mountain Rambler).  But there are concrete changes: we now know a local, who points us to new options and introduces us to the community.  And so we have coffee at Pupfish and dinner at Yamatani (substituting sushi and sake for the usual burgers and beer).  After failed attempts to get there the two years before, we finally make it to the hot springs.  We meet people for whom the magic of Bishop is their everyday.  And there are subtle changes in ourselves.  The four of us met and became close during a certain time of transition, and we've remained close as we navigate the unraveling and restitching of different parts of our lives.



In these remote, natural places less burdened by people and by the work people create, we become less burdened too.  We dream about a life dominated by climbing in these landscapes that don't ask anything of us.  We see stretches of space, and we know that we can traverse them if that's what we are feeling in the moment, or in the future.  The main problems to solve are presented by lines and ridges in rock, which are challenging but in many ways so much less so than the textures we find in other people and ourselves.  There's an ease of connection with others with similar dreams who do live this dream.  Every minute I spend in Bishop, I think to myself, how is it that I have so much right now? We're free to move quietly amidst beauty and power of the kind that assures of us of our own. The gifts of these places are so easy to see and to absorb and to wish would last forever.



And maybe it's the never-ending giving that makes me eventually want to leave and come back to where I am.  Where my movement is a little more restricted, and reminds me that not all places are so free, that not everyone has so much room.  Because I want things to be asked of me, to take on some burden and sacrifice some ease for a little purpose, if I've been given the privilege to choose that.  I don't necessarily believe in difficulty for difficulty's sake, but I do feel that the accumulation of so much good arms us for the hard, rewarding work of sharing it. 

The one weekend when I didn't go away, I spent in Oakland.  After two and a half years at my job in the East Bay (in Berkeley, on the border of Oakland), I still feel like I don't know our patients' communities very well.  This was the main motivation for running races in Berkeley last fall and Oakland last weekend.  While running through cities is heavy on the visual senses and most of the backstory is beyond simple sight, it does make me feel more connected to these places, and to the people who live in them.

After coming back from the magical weekend in Bishop, I wanted even more to cultivate this connection--to be with people different from me, who don't have the same choices to unburden themselves.  It seems to me that the best part of the vastness of mountains is that they're so far-reaching, they don't have to be enjoyed just in the physical place in which we experience them. We can take the feelings to other spaces that have less obvious beauty, and therefore more need.  We can use them to sustain us when we're presented with the lines and ridges in people and in the systems of people.  When we come across beauty and power of the kind that makes us question our own.  When we occupy space occupied by people with needs that are the same and different, making for a crowded and confusing life.  There's a lot there that can make me feel weak and sad.  More so than when I'm actually away, it's sometimes here that I most feel the impact of leaving.  We can remember how much strength and stamina these places give, and try hard to use it in the environments that challenge us most.



While all these experiences made for feelings that seem complicated, because there were so many feelings and to extreme degrees, processing them reveals a pretty simple formula.  I want to go away with beautiful people to beautiful places where I can physically move in the ways that suit me best.  These remind me that everything I want has been freely offered to me: from people, how much I can learn from others; from places, how much there is beyond me; from movement, how much I can and can't change with my own agency.

And then I want to return, to try hard to share what all this gives.  As much as I love places like Red Rock and Bishop (and I really love them so much), I think they will always give me a fullness I won't want to keep forever.  Each person has a different way of receiving and giving, and so I'm only speaking for my introverted self when I say that if I were to stay, I'd likely be more of a receptacle than a connection.  I know I'm incredibly lucky to be able to go away, and even more so to be able to come back.  It's this movement more than anything else that I want to stay with.

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