Thursday, August 10, 2017

there's no need to say goodbye

This is not a post anyone wants to read, but I am writing it nevertheless because I foolishly reread Elizabeth Bishop's One Art with impeccably bad timing.

I signed two death certificates this week.

Ms. H was an anxious ball of nerves who initially thought she could live for several years with metastatic renal cell carcinoma. But after a surgery to remove a significant deposit in her spine, when it came time to medically treat her cancer, she had a change of heart. She was a strong-willed woman who had been diagnosed only because she could no longer carry bricks into her backyard as she had been doing for most of her life. She lived alone and though she had children, she felt strongly that she did not wish to be a burden on them. She passed peacefully at home. I knew her for less than a year.

I inherited Mrs. G from a physician who had left. She was supposed to just be monitored to make sure her cancer stayed away, supposedly in remission. The first time I met her, she had new neck pain, and the next day, she was in the hospital getting an aggressive sarcoma excised from her cervical spine. She should have lived for six months after that, but for a while radiation held the sarcoma at bay. She saw me every month, with her two daughters, one with healthcare experience who kept trying to prepare her mother for the end, the other with no healthcare experience who wanted her mother to fight until the bitter end. The two sisters would squabble, and sometimes the medical assistants would tell me they were about to brawl in the examining room. But when you grow up in a South Asian family, loud sisters don't frighten you. The sisters would always apologize afterwards and Mrs. G would always make some joke.

One of Mrs. G's daughter's had a son in college, all the way out in EBF, where I grew up. It was one of those details that patients and their families believe bind you to them. Because it does.

She beat the odds, and when I say she beat the odds, I mean that it took a year before the cancer came back. As if to give us all the middle finger, the cancer came back vengefully, in her nerves, starting by making her face droop on one side. Then her legs started to go numb. The cancer was laughing at the chemotherapy we had attempted. She asked three times if she could still come see me if she went on hospice. When I told her she could, she was satisfied. But she died two weeks later.

As if the week was determined to mock me, Mrs. P was hospitalized.

Mrs. P is in the process of dying. She has a rare cancer that spread into the lining of her abdomen, and it wasn't even entirely clear from where it stemmed. She asked me a dozen times when we first met a litany of questions: How did this happen? Where did this start? How much time do I have? Why me? She is one of those patients who can articulate exactly the experience of having cancer and living with cancer. She would tell me about episodes of rage she had about not being able to do things she used to be able to do. She would tell me about fights she had to wage with insurance companies and her intentions to make them rue the day they messed with her. For two years the cancer behaved itself, and then one day, it just stopped behaving, undoubtedly picking up some mutation that made it grow more rapidly. Her belly started filling up with fluid and she had to be hospitalized because her nausea was uncontrolled. The surgeons confirmed there was nothing they could do.

In the hospital, Mrs. P was being looked after by a fourth-year medical student, and a senior resident. I worked with the senior resident when she was an intern. It was breathtaking to see her now leading a team of patients. Still, neither the student nor the resident wanted to have a conversation with Mrs. P about her cancer. It was fine by me. To be honest, I can be a little greedy, a little bit of a control freak about my patients. The student and resident came into the room with me, and listened as I told Mrs. P about the cancer progressing, about the lack of treatment options, about how it was time to start focusing on getting her feeling as well as we could.

She looked at me, not a somber molecule on her face. She looked at me matter-of-factly really, and nodded. "You're not telling me anything I didn't already know," she told me. And it was true. Just the week before, when she was starting to feel poorly, we had talked on the phone, and as I talked to her about some medications she could take for nausea, she had confessed to me, "I think I'm in the end run here." I'm still early in my career, but I've never heard a patient say something like that and then end up living another year. Patients always know, and oftentimes before the physician does.

Mrs. P made sure to thank me, and she said a kind word about the care I'd provided her. When the medical student, the resident, and I walked out of the room, I spontaneously told them that though such conversations were difficult, this was what made my job so worthwhile. They both looked at me like they were contemplating a psychiatric consult.

I guess I sometimes don't see it from the outside anymore. You know, Valar Morghulis and all that, so to me, what's important is the journey. And there are few more meaningful journeys you can have than the final one. No one gives a care about the physician during this journey, and let me be clear in saying- nor should they. What we do as physicians is not particularly noble. But we are lucky, as anyone is lucky, when they accompany someone down a bad path, a final path. Some patients don't find peace at the end either, they fight and are bitter about their illness until their last breath, and that's something fortunate to witness too.

Even when I don't like my job, I do love my job. And weirdly I realize it more on a week like this, when I'm assigning causes of death and giving patients the bad news that their time is almost up.

Thursday, March 23, 2017

live your life, stake your claim

Recently I moved. I had to move, because my landlords had decided to sell their house. It wasn't the best time of year to be moving. I had about 17 deadlines looming during the time I was supposed to be house hunting, and I had only signed the dotted line on the contract for my soon-to-be job about a month before I had to move. So that took buying property off the table- of course, that was a welcome relief, because even though I've been living in the same square mile radius for 10 years, I still have a real fear of committing to home ownership.

I ended up renting a house that is probably a bit more decadent than I deserve. I am not complaining about that- it's a beautiful house, and I sometimes feel like I'm on vacation when I'm at home (not great for productivity except for productivity found in the sun-filled kitchen). But a funny thing happened when I got the place- a number of my colleagues expressed discomfort with me for renting the place. The comments were along the lines of "for just you?" I get it. As I said, I fully acknowledge it's a bit decadent. But I cook a lot. I like to have people over. I like to have a spare bedroom so that people can visit from out of town. It's a little decadent, yes, but it's not exactly insane. Setting aside all of that, though, I also have the means to afford the place.

Still, I keep joking around that when I enter the house every day, I am pretty sure my neighbors think it's the maid coming in to do the cleaning. It's one of those half-jokes that bends a little too close to the truth. The part I don't include in the joke is that I am, currently, content to have them think that. It's easier. I'd rather have the neutral looks of someone thinking they're watching the help go in to do the cleaning than the definitely not-neutral looks of the neighborhood wondering how I have the audacity to live in such a place. I realized with this move that I have always kept a low profile in terms of my living situation, and part of it was not to do with being a cheapskate (which I admittedly am), but rather this need to remain unnoticed. It had seemed paranoid. But in 2017, it hasn't felt paranoid at all.


My cousin had a surgery and I could not be there. She chose a hospital which was a solid 3 hour drive away, and I was working on a hospital rotation. Her parents and brothers were there, but still, when there were (relatively minor) complications after the surgery, I was on the phone with them trying to sort through what was actually going on as well as how to comfort them. Two weeks after she was discharged, she called me frantically one morning while I was in the midst of rounds with a team of interns and attendings and very sick patients, begging me to drive an hour to come take care of her. She had developed a headache and was convinced she was bleeding into her head.

Within a short exchange with her, I knew she was not catastrophically bleeding into her head the way she thought. She was due for a CT scan that day. I did what physicians do. I triaged. I had 32 sick patients to take care of in the hospital as well as two patients I needed to see that afternoon in the clinic. I called a few other family members and no one else could get to her either. My cousin was not alone- her fiance was there. But he does not work in healthcare, and isn't the person to calm her down when she's panicking. I offered to come that night, which was the earliest I could be there. She was convinced she would be hospitalized by then, and she had already summoned her mother, who was flying in that evening. So, she bluntly told me, if I came that night, it would be too late.

She didn't have a bleed, not at all. She had tapered off her steroids too quickly and she had a headache as a result. I knew she was hurt by my choice to stay at work, wounded that I had not dropped everything to get to her, and a bit offended that I had suggested that she was probably going to be just fine. And I realized, once again, that medicine has this habit of creeping into you at a molecular level. For better and often worse, it becomes how you live and breathe. I was a decent doctor that day. I knew who really needed me and didn't need me.

My cousin, she didn't see it that way. To her, I was just a shitty cousin who was choosing her patients over her family. And I couldn't really blame her for feeling that way.


Every time I sit down to write anything, including the little anecdotes above, it just feels so pointless and trite. So much is happening right now that I feel like my head is exploding with both a crescendo of thoughts and a stunned silence. I can't even address the very big things happening. All I can do is keep writing something down, mostly little notes to myself in the hopes of finding some clarity in this muddled world.

Monday, January 23, 2017

we got no chance of recovery

Two weeks ago, the microcosm of safety in which I live was invaded. My cousin, who is supposed to get married in a few months, had a seizure. The day is a blur. It started with receipt of a frantic text message, then a phone call to a dumbstruck fiance, followed by throwing a bunch of things into a backpack and driving to the hospital with my stomach churning. I didn't want to be a physician at that moment. I didn't want to know the things I knew. A woman so young, with the symptoms she had, and the timing of it, there were very few things that could be the cause. So when I heard there was a mass in her head, I was unfortunately not surprised.

There were conflicting impulses when I got to the hospital. I wanted to hug her and burst into tears. I wanted to take her hand and tell her everything was going to be okay. I wanted to see the MRI with my own two eyes, wanted to speak to another physician, wanted to review her labs. I wanted to be everything all at once, her cousin, her protector, her physician. I'm not sure I succeeded at being any of those things.

In some ways, she turns out to be lucky. When the neurologist did show me the scan, I exhaled an involuntary expletive. The mass was large enough that it had caused swelling in her brain, and shifted one side into the other, likely in part the cause of those seizures. The part of me who was a physician checked out in that moment, and it was just about this woman who was as close to a sister as I'll ever get having a tumor, how her life was about to unexpectedly change in this instant. The neurologist had to get my attention to point out that the mass looked like a meningioma, one of the few tumors you can have in your brain that is not malignant.

She needs surgery but it will be complicated because the mass is so close to blood vessels. And she was stable and not having seizures, so by the next day, there was no reason for her to stay in the hospital. She's getting surgery in a week. I am racking up the miles driving back and forth to see her, mostly to keep her distracted from the uncertainty that lies ahead. We haven't been able to talk about her wedding and its feasibility because it brings up possibilities to do with her recovery that she does not want to face right now, and I can't blame her for that.

I wanted to be at the Women's March. I spent the day instead with the near antithesis of a feminist- much as I love my cousin, much as she is the closest thing I have to a sister, she and I hold wildly different beliefs about most things. But I was thinking of the march and thinking of the power shift in this country, and thinking of the uncertainty to do with my cousin's surgery. There are patients out there, who, when ACA is repealed, will have a diagnosis such as hers, will be diagnosed with a mass in their head, and because their seizures are under control, they won't have the luxury of arranging a complicated surgery. They'll be told they're not covered to get elective surgery, they'll be told this doesn't qualify as an emergent surgery, and they'll be stuck with a tumor lodged in their head for an undefined amount of time. My cousin is very worried about whether this surgery will go well, whether it will leave her with neurologic deficits, how long it will take her to recover from the surgery. But to imagine the added stress and turmoil that would come with not even knowing if she could have the surgery? It's appalling.

Friday, January 20, 2017

it is my day to live a simple life

Not great art, sure. Although, actually, I will say that if someone acts well, they can elevate even the silliest of movies, and I think that is what Donna Murphy does in this scene.

It's also, insane though it may sound, a scene I think about all the time on days like these. What she says, I believe in deeply. I always go back to the work, and it is always what I need. To justify my existence, to prove to myself who I am, to chase away all the doubts. Always, the work.

The last couple of months have been concentrated turmoil, and the election only slightly contributes to it. I think there is more turmoil ahead. But it is a Friday, and I am going to do what I always do on most Fridays. I am going to work. My colleagues and I will talk about science for an hour. I will work on a research project. I will write some more of a manuscript. I will see patients.

One of my patients will be photographed. She told me about her granddaughter, who at 10 years old, decided on her own to grow out her hair, then have it cut to donate to cancer patients who are in need of wigs. When I asked her if I could share her story, her eyes lit up; she beamed. I realized that in the end, this is what we all crave. To have our stories told, to be heard as we tell them ourselves, to be told our stories have value, to be remembered. My story is my work, among other things. Today, I am grateful to have that work. Others are not so fortunate, and I feel how much harder this day is for them.

Friday, November 18, 2016

what's the use in worrying about the ways in which the world might come to end

You can't tell me how to feel.

Today, I told a man, and his very large family, that the man had esophageal cancer. They knew that, but I told them the even more horrific news that the cancer had spread to his liver. I have been having conversations like these for the past five years, maybe even slightly longer. Somehow, even when I was a medical student, maybe because I was older than my colleagues, I was often the designated hitter for these gloomy talks. Once, when I was an intern, the other intern on my team confessed to me that she didn't have it in her to help a family as they transitioned their mother to comfort measures, meaning our ICU team would take her off the breathing machine that was keeping her going, and give her medications to make her comfortable. Here's the thing- the other intern was a white woman, and that patient was an old Chinese woman. And that other intern said, "I just don't feel comfortable" and I gave in to her, because the patient was the important one in all of this.

But you can't tell me how to feel. I felt a certain kind of way about that entitled white woman. I did my job and I did what was best, but I did not forget.

It's been a hard time, recently, with everything that has gone on in this country for the past year, and also in my own personal and professional life. There have been a lot of things that have led me to feel both this deep despair about where it's all headed, and also a profound gratitude for my insignificance, for my quite bearable lightness of being at present, childless, husband-less, and in some ways even orphaned.

Still, whenever I've felt bad, whenever it's all going wrong, from the time that I was 18 years old, and this is the very honest truth, I've gone back to the work, and it's healed me. At one point, it was in a hood with starting materials and solvents and stir bars. At another, it was just reading science journals in a library. Last weekend, it was writing a manuscript. Today, it was a difficult conversation with a patient and his family.

A few others have mentioned feeling right back like they did after that day in 2001. I've felt that way. I never felt so divided from those around me. Even in my very own house, which I shared with two white roommates. I was hurting too. All I wanted was to hug my roommates but we weren't feeling the same way about things. They were watching news coverage on an endless loop and like so many people around me, they were hushing any notion of dissent. Even though I grew up in a very homogeneous, white-as-snow part of the country, it wasn't until that day that I really felt with finality- these will never be my people. To this day, that feeling has haunted me. I never wanted to feel that way, never wanted to believe that to be true, and I consider it incredibly sad that I do feel that still at times. Fifteen years later, I thought maybe I had been wrong; maybe the dark chapter was behind us. Especially here, in my comfortable bubble of inclusivity in this very blue state.

But I haven't felt that way for the past week. And you can't tell me how to feel.

I have treated patients who have commiserated with me about politics - some of them have told me about their leanings unprompted. I have treated patients who have come into the clinic wearing NRA hats. I have treated patients who have asked me, while chuckling, knowing they are trying to say something discomfiting, if I have seen a video that brings to question whether the First Lady is, in fact, a woman. I have treated patients who have called me "honey," have characterized me as a nurse. I have treated patients who have openly made terrible comments about minorities. I once treated a patient who had swastikas liberally tattooed all over his body. I have treated a lot of other patients too; it's been a lot of years.

I used to walk into any patient encounter with a blank slate, with the benefit of the doubt. But you can't tell me how to feel, and I can't be quite so magnanimous right now.

So I sat down with this patient today. He and his very large family, a white family from a rural area, and I wondered, for a moment, what they thought of me, if they would be happier were it a white doctor breaking this news to them. It was only for a fleeting second that I pondered it, and then I shook the thought out of my head, and gave them this very bad news, and it did not matter who they were, nor did it matter who I was, not in a superficial sense. What mattered is they were collectively a patient and his family, and that I was a doctor. I told them the bad news, and they didn't yell out "wrong!" and they didn't dispute my words as being liberal propaganda. I told them facts, and they heard them. Some places are still sacred, it turns out. Some places are still bipartisan.

We sat there, and I told them the news that I did not want to tell them, the news they did not want to hear, and they told me how beloved the patient, this man, was. As they were slowly starting to absorb the unacceptable truth, the patient's brother, a teacher, looked up at me and said, "this is some rough job you have."

I replied, "some days, it really is." It was then I really got a look at his eyes, and it turns out they were sincerely kind. You can't tell me how I feel, and it will take me a long, long time, and maybe an eternity will not be long enough to feel a true sense of comraderie, togetherness, patriotism.

I'm reminded of these words that were sandwiched into a funny (funny because it's disturbingly true) bit that Amber Ruffin did for Late Night with Seth Meyers (she's a writer for the show, which has really found its footing in the last months):
But then you realize that by doing what you do everyday, you prove to them that you are unstoppable. They can spend their time trying to pass laws that take away your rights and silence your voice. But all you have to do is live your life right in their faces, and it proves that you cannot be stopped.
So I am relying heavily on work, and I am hoping others are too, in particular those folks that do the very good and true work of journalism and community organizing. And I am hoping those are not the last kind eyes I see from the other side.

Tuesday, October 25, 2016

we will meet again someday on the avenue

Some updates- I have become one of those people who ponders things (and foolishly believes she has come upon some epiphany when really it turns out to be oxygen deprivation to the brain) while running. This is not to say that I also don't have the constant chant "please stop" running on an infinite loop in parallel with all that pondering.

I was thinking about why I have not been writing here. I thought before that maybe it was an overabundance of topics, so much to write about that I could not focus on any one thing. I thought maybe I was too impassioned and that was clouding my ability to write in some measured manner about anything that I felt to be worth the words. Then I thought maybe the blogosphere is just good and dead, and all that is left is strings of tweets and clever posts here and there. Then I thought maybe I just didn't like writing anymore.

Then I realized, as I was gasping for breath on my short run in the dark tonight, that it was something else altogether. First, I am not an authority about much of anything in the world. I suppose I could someday be an authority on my job, but not right now, and anyway, that would be a mind-numbing topic to discuss here in any detail. Second, the reason that I wrote, for a very long time, was to be understood, by others, and by myself. For a long time, I felt like every conversation I had fell short, like I didn't get to explain all that I had meant to say. Writing was a way to fill in those gaps at times.

But at some point I got older, and sure, life has gotten in the way. There is not as much time for navel-gazing these days. But I can honestly say that, were I this busy ten years ago, I still would have made time to have an existential crisis. It turns out something else happened. To paraphrase the TS Eliot poem that I so often have quoted over the years, I came to the place where I started, and knew it for the first time.

I am imperfect, as imperfect as they come. I still have plenty of moments of failure and failing to rise to an occasion. But I am aware these days, aware in a much more vivid way, of who I am, shortcomings and all. It's more than knowing, actually. I'm very comfortable with who I am. And I'm also more comfortable these days, more at peace with the notion that no one can wholly know anyone else. Not really. And that's okay. And a bunch of views into these thought-through words on a blog, they're not going to give you any deeper insight into the real person. That's what I'm starting to think. And I might be wrong, because I've certainly been wrong before.

You might not be around when I finally have something to say. Some of you left long ago, and some of you were never here. What I haven't reconciled in all of the above is that profound gratitude I feel when I do hear from someone that some hastily strewn words I've strung together have somehow resonated with them. Maybe the point is not really to be known or understood, but to recognize some commonality- and we are so fortunate, in many ways, to live in a time when that commonality can be sought out because of the many multitude of voices available to us.

Tuesday, December 15, 2015

pushing the needle too far

Today, I was in clinic and a notorious patient came in to be seen. A review of the chart had a slew of documentation preparing me from what could be in store- various encounters in which Mr. W had dismissed doctor after doctor at the VA where I sometimes train. His complaints had ranged from typical ones like frustration at the difficulties of navigating the system, to more telling ones, like accusations that he was receiving substandard care because he was at a 'teaching' hospital and that none of his doctors knew what they were doing because they were foreigners.

This is not unusual in the practice of medicine.

Mr. W had tangled with his last physician in my clinic, and it had gotten ugly quickly. He had asked her to write down her diagnosis. She had put it on a piece of paper in admittedly small and fine print, and Mr. W had peered at it with his poor eyesight and declared, "what is this, in Chinese? I can't read this." The doctor who had seen him that day, another fellow in my program, had reacted. She called him out flatly for what she had taken to be an ethnic slur. Mr. W subsequently flipped, and said "if you were born in this country, you'd know that's a common saying; people say it all the time."

As he recounted the incident to me, I wanted to tell him that I, in fact, was born in this country, and I said no such all the time.

But I grew up in EBF. The advantage and misfortune of my upbringing is that I can dissolve into a wall. I can seem non-judgmental, I can adjust, I can bob and weave, and I can avoid such missives hurtled in my direction. The blessing in that is it allows me to do my job. The curse is that I have to listen to the ugliness that lives in the deepest places in some people's hearts.

Mr. W is dying. He has a form of leukemia for which he cannot be treated, and just to add insult to injury, he has a solid tumor that has spread past its original site. He is dying without a doubt. And this is also par for the course in my clinic. Many of my patients are dying. Every one of them deals with death and mortality in their own way. Mr. W's way was to lash out and throw blame at anyone who he viewed as not his people.

Were I treating diabetes or back pain or arthritis, I might react differently I suppose. I might react like my colleague and tell the man he couldn't say such horrible things. But he is dying, and trying to school him on the ways of the world was not compatible with my job today. And so I listened to him list out every one of his grievances. I did not tell him any of his grievances were justified. I did not condone him. I just wanted to do my job. The man needed a blood transfusion, and he also needed to go to the hospital because his kidneys were now failing.

By the end of our visit, he took my hand so that he could make his way to the desk to sign his consent to receive blood. But I have no doubt in my mind, not even the slightest, that tomorrow he will be complaining about me, and talking about me as a foreigner too. I will be on that list of grievances soon enough. I know that. But I don't ever want to think I didn't treat someone to the best of my abilities because of their beliefs.

What I don't know is whether Mr. W is typically this racist, or if his illness had brought out all his distrust and underlying biases, things he would have otherwise suppressed as inappropriate. And it made me think about this country and the moment we're having. How there is so much hate and rage in the world. In clinic today, one of the other fellows was reading off headlines from his desk-

LA schools shut down due to threat of violence
Unarmed man shot in Butte County by police officer, caught on tape
Man with gun seen on Purdue University Campus
Man with road rage drives into front of hotel

I had this reflexive reaction to laugh, because that is what I do when things get this bad, when it's almost absurd. I sputtered out, "what is going on?" He looked drained as he just shrugged at me, as if to say we could only expect more of the same. And that does seem to be true. But why? Why has it gotten this bad? What cancer do we as a society have lurking inside of us that is causing these inherent biases and frontal disinhibition? Because something is going on.

In California, don't think we are immune to backwards thinking, because we are not. All the time, among my colleagues, who are highly educated white men, I listen to them bemoan the cultural competency classes they have to attend, and the unfairness of having to give a job to a minority or a woman. I have listened to them talk about how it is not right that they have to hire a minority or a woman when they 'click' more with a white male applicant. One white attending, who considers himself forward-thinking, said "it's hard out there for white men, we have to be so careful about what we say."

I wanted to ask why. Why is it so hard? Why do you have to be so careful? I manage to get through my entire day, every day, seven days a week, without saying something insensitive or inappropriate or borderline/totally racist. It takes hardly any effort at all. Why is it so hard for them? And why don't they ask themselves that question? What would be so horrible about admitting there was a problem?

Mr. W told me today the only physician worth a damn in this place was, predictably, the one white physician he had seen. Now, I know that physician, and he is a good doctor. But so was the Chinese woman Mr. W saw last week, and so were many of the other physicians he had seen. The other white men who are physicians, with whom I work, they think it is amusing when these patients come in with their racist ramblings, with their extreme distrust, with their demands to see an American doctor. They don't acknowledge that this is the very definition of white privilege; they don't recognize the toll such patient encounters take on the rest of us. Or that this is why even as a South Asian-American, which, let's not kid ourselves, is still a place of a lot of privilege, especially in the medical field, I remain at a disadvantage to my white colleagues. They will score higher on patient satisfaction surveys, frequently, just because of the color of their skin, and not once will they acknowledge that this is why they score higher. Partly, it's because we all work hard. Partly, it's because they've been raised to believe they are exceptional, and so they believe everything they've gotten is simply because they are better. And partly, it's because it's just a lot easier to believe it's fair than to acknowledge an inherent problem.

When you're living in one of the most liberal parts of the country, and you work in a profession that is at least 50% represented by women, it's disheartening to realize how far there is still to go.

My friends and I were talking once about what the cut off should be. We were talking about how, as physicians, we let a lot slide, especially in the way of inappropriate remarks, when it came from an elderly patient. We dismissed a lot by attributing their behavior to a different time in the world, when such thinking was more commonplace. We said eventually that population would simply age out, and we wouldn't have to tolerate racism and chauvinism from our older patients 10 or 20 years from now. But lately I am starting to think that's not true.

This is all jumbled up, as are my thoughts, as is my life. it's all connected, my microcosm somehow does seem to be a reflection of bigger issues. But I'm too tired to connect the dots just now. I'll keep trying to treat the racists and chauvinist pigs who have cancer. Maybe some day, someone will recognize the effort that takes.