Yet again we're the only ones

Well, let's get it in before the end of the year, because here it is. The year came to a close quickly, before I could really wrap my head around it. And this is maybe the funniest year of them all, with the joke being on me, since I have to go to bed prior to the transition of 2012 to 2013. Such is the reality of my two week stint in the ICU.

About that I'm not sorry though. The holidays put on too much pressure, demand too much conformity, and I have no use for such things nowadays. Besides which, the ICU teaches you all about perspective. Family meetings every day, bad news broken on a steady schedule. Updates that end with hope or heartbreak. And of course, patients falling apart right in front of your face.

Some people have bad luck. Some people keep making the same mistakes over and over again. Some people are the few fortunate ones. Then there are those of us who get to watch it all unfold, who see that entire spectrum, and there is a certain privilege in that.

But the amazing thing I've learned is that perspective only comes to you if you are receptive to it. Even the anvils that the ICU deliver upon your head can go unheeded by those too caught up in their own nonsense to pay attention to it.

This year was so very necessary. That's the only way I can really describe it. I'm starting to understand how much the low points in life are intertwined with the higher ones. Despite my Eeyore-like exterior, my handle is brimful and the song which is the inspiration of my namesake is a pun about hope. This is the secret I keep for you and for myself. This is me, equal parts realist and dreamer, equal parts resigned and reaching. I have the capacity to be kind or to be cruel, and I try, try, try to do the right thing, to make the right choices. But I understand why sometimes others would see it differently. This is me, equal parts deeply flawed and perfect. None of that would be so, if it weren't for this past year.

I hear the bells

Sometimes I think my continued insistence of posting here is much like those cantankerous old writers who insist they only ever use a typewriter. But I still think there's too much brevity in the new world. And I refuse to believe people are only interested in soundbite-sized thoughts. Some thoughts require more explanation. None of my thoughts, mind you, but some thoughts.

Here are some thoughts I have had this week:

In geriatrics clinic yesterday, I heard the best stories. The first involved a retired police officer who had developed dementia. His younger wife is his primary caretaker, so we were asking her how things have been going. She told a story of how her husband had wandered into the neighbor's house one day and told them that a crazy woman was in his house, trying to order him new clothes. She shrugged and said, "in fairness, it was Cyber Monday, and I had tried to buy him a lot of new shirts." They'd had a laugh about it. She finds it hard- her husband had just retired five years ago, and they had plans to travel and enjoy their time together, but the dementia had changed all of that. But she was remarkably amused by all of it. The next patient I saw had more advanced dementia. He was mostly non-verbal. His wife and I sat down for a while to chat about how things had been going. She almost made me cry three times, and I don't have a heart, let me tell you. She takes care of her husband every day, helps him bathe, takes him with her everywhere because he can't be left alone. But she was so remarkably serene about it all. She said it wasn't that bad a task, because her husband is very sweet and he doesn't ask for much, and his suffering seems much worse than hers, in her opinion, and after all, he tells her every day that he loves her very much. Geez oh pete's, you guys. I'm not made of stone.

Every time I hear the melody of "Castle on a Cloud," I turn into a 14 year old dork, unreasonably excited about Christmas day. There was a time, in high school, after I'd gone to New York for the first time, and seen the Broadway production of Les Miserables that I was full-on geeked out on the musical. Then I thought I'd pretty much gotten it out of my system and that it had been an adolescent thing. Then I watched NPH and Jason Segel reenact The Confrontation and giggled, and just thought I found it amusing. Then I saw Jackman's determined expression as Jean Valjean, and I realized, nope, I'm still a geek. I'm going to be that annoying person in the theater, I can tell already.

Even though I rarely wear dresses or get dressed up in general, I have somehow become obsessed with sweater dresses. I own three now. I've been forcing myself to actually wear them, which is actually a bigger undertaking than it should be. Here's the thing- I'm happiest when no one makes any remarks about what I wear, good or bad. But the problem is, there's standard issue attire I've become known for over the years, because I don't like a lot of fuss. So when I wear a skirt or dress, there are usually no less than 17 comments made about this, and I want to run out of whatever bar or restaurant I'm in and change into jeans and a sweatshirt. I really should be more comfortable with myself, and I am about a lot of things, but not apparel, apparently.

I hope someone will yell at me if I don't come through on all these stupid holiday baking plans I have. I have lots of thoughts in my head, people. Thoughts about marshmallows and caramels and cookies and tartlets. But my head is often in the clouds, and a lot of these ideas often end up not happening. I really hope that doesn't happen this year. Otherwise, I will be mighty ashamed.

I've been at war with ants ever since the rains arrived. I'm winning, but the battle continues.

Also, there is a matter of much drama and peptic ulcer disease in my life, and I'm really glad that I've been separating myself from it. One of my married friends has been exhibiting some highly inappropriate behavior towards a guy, and it has been giving me angina for a while now. It's nice at this point in my life to trust my instincts enough to know that, even if you can't put your finger right on something, you have a good sense of what is right and what is wrong. And even though I feel badly that this friend is no longer really a friend, I don't miss all that unnecessary discomfort associated with it.

maybe just half a drink more

Yesterday was a less hectic work day and some of the other residents and I were gathered in the work room, getting some notes squared away. One of the residents put some Pandora holiday station on, and the work room became Christmas carol central. I'm not exactly a grinch. I don't like all the fuss about most things in general, but I like the holiday season. I like getting in the spirit.

One of my co-residents grilled me for 20 minutes yesterday because I recognized Rufus Wainwright in less than 4 notes. And until yesterday, I can honestly say that, although I am fond of song lyrics in general, I did not know that Baby It's Cold Outside included this gem:

at least there will be plenty implied  

if you caught pneumonia and died

That's a bit morbid!

I don't know if the carols got me in the spirit. It might have been all of us in the work room, chatting gaily, and laughing from our bellies. This time of year, I reflect on how lucky I am, even when I sometimes have this pang of self-pity. Whatever I have to complain about, I do have the privilege of having a job that I love-- and it is true love, which means that sometimes I want to spit and scream at it, and other times I am swooning, but either way, we are meant to be. I like what I do, I enjoy my co-workers, and though I might sometimes come down with annoying coughs, I have my health. My loved ones are well.

I don't know. I saw a patient in clinic today, who I quickly learned had been battling depression for a long time, and my preceptor asked him when he was last happy. He said, "never" and it wasn't a ploy. But then he said he had a period of a few years when he felt an "interior sense of joy," and that stuck with me. It seems like a good thing to have. I guess I always assumed that, should one achieve that state, that sense, that it would be permanent. I guess nothing is.

But I don't know if I believe that either.

Anyway, getting to the point. This year, I'm free enough to do a little baking in December. So I got myself in the true holiday spirit in the only way that would work for me. I made a batch of molasses spice cookies, because nothing reminds me more of the holidays than those. And I fixed myself a Domaine Canton with ginger ale. And then it was 'tis the season and all of that.

trapped between two lungs

I'm almost done yet another stint of working in the hospital (as opposed to the clinic, where I spend the other portion of my time), and it's been a strange week. After that last call that landed me a missed Thanksgiving day, I got progressively sicker. It started with an itch of the throat and some sinus congestion, then it turned into sinus congestion and a cough. Then it turned into one of the worst coughs I've ever had- at one point, I actually wondered if I'd forgotten that I have an extensive smoking history (I've never been a cigarette smoker) because I sounded like a 75 year old veteran with emphysema. At another point, after my last call, the coughing fit got so bad that I could not sleep, and my abdominal muscles were actually sore (so at least I got a work-out as a consolation prize).

It's just a virus. I know that. I tried to treat the symptoms with benign over-the-counter medications, none of which really helped. I finally started to feel better when I just gave up and drank copious amounts of Good Earth decaffeinated tea and water, and tried to catch up on sleep. I still have this barking, alarming cough that is scaring most of my patients. And I'm still wheezing, which makes me feel a bit sorry for myself.

Except medicine gives you little room for that. As a general rule, physicians won't call in sick during residency unless a limb is falling off, there's intractable vomiting or uncontrolled bleeding in play. Otherwise- suck it up and soldier on. And if you are even thinking about feeling sorry for yourself, one of your patients will set you straight.

Yesterday, that patient was a young guy, a decade younger than me, who had been diagnosed with testicular cancer this past year. He had undergone surgery, and then he had started chemotherapy because there was still some evidence of leftover disease, and each chemotherapy cycle had taken its toll. Then after his third cycle of chemotherapy, he started developing difficulty breathing, and after an extensive evaluation, it had been determined that he had a bad reaction to one of the chemotherapeutic agents. This had resulted in lung toxicity. So now this 20-something kid with a very treatable cancer is facing respiratory failure. His lungs are totally shot. Over the past month, he went from being what one of my colleagues calls a "walkie-talkie" to being unable to move without oxygen. When I saw him this morning, he was breathing shallow and couldn't say more than a word at a time without running out of air. The frail young boy that was in the bed before me just said we should do what we need to do, he was up for whatever we thought was best. It's one of the hardest things to see a patient exhibit that kind of bravery, that sort of will to live, when you know they are facing something that is largely untreatable.

So, in the end, there wasn't much to lament about my stupid cough.

home, that's where I long to be

It's black Friday, allegedly. It's times like this in residency that I feel quite disconnected to the outside world. I've no concept of black Friday. It doesn't sound like my cup of tea, though, to be sure.

It's black Friday and I'm home after a long day, and I'm worried. It's something they never tell you about medicine when you get into it. How much you worry. Constant and diverse too. Worry about the patients you just admitted, two of which don't look so hot despite your best efforts to 'fix' them before you left for the day. What if I had worked 18 hours instead of 16? Maybe then I could be sure those patients would be okay? Worry that the other resident worked late, even though I was trying to get her out early. Worry that I haven't been teaching the medical students. Worry that the attending thinks I'm incompetent. Worry that I'm losing my grip on humanity, what with the gallows humor and the complaints about 'lame' admissions. Worry that I'm coming down with something, worry that I'm not going to get enough sleep tonight to beat whatever it is that's brewing in my lungs. Just endless worrying. It's a bottomless cup. At some point, you go home and just try to think about something else. Mostly that just leads to more worrying about whether this worrying will ever subside.

Thanksgiving was a bit of a bust this year. It seems to be a running theme. That things fall apart, tend towards entropy, and I can't find the energy to be worked up about it. I was on call the night prior to Thanksgiving, and it was busy. When I got home on Thanksgiving morning, I channeled some surge of sleep-deprived delirium, and baked a pecan pie. It turned out really well, better than any previous version (50% corn syrup, 50% maple syrup, people, it is magic). Then I told myself I would take a quick nap, wake up and make apple pie. That quick nap was supposed to be 2 hours. It wound up being 7. Oops. Missed Thanksgiving dinner, couldn't come up with the energy to even bring over my stupid pecan pie to the party, because I was too tired. Brought it into work the next day, and it was consumed nonetheless. Oh well. One year without turkey and whatever will certainly not kill me.

This time of year, I am reminded of how much life has changed, I suppose. There was a time that Thanksgiving meant sitting around the table, around a big, crazy meal. Even though my family did not really get the whole Thanksgiving thing in my earlier years, when I reached adolescence I was so obstinate that we ought to celebrate things in what I considered to be a traditional manner that we all rallied together to make it happen. My mother, a strict vegetarian, even prepared a bird one year, though most of the time, we settled on buying a pre-cooked one. But the sides and dessert, we made as an entire family. In addition, we always cooked a big vegetarian spread for all of our parents. My cousins and I used to take over the kitchen on Thanksgiving and Christmas, and I have both pleasant and stressful memories of trying to herd the cats that were my crazy cousins so that we could all, together, make these meals. I saw my cousin C last weekend, and she still fondly remembers the apple crumble pie we used to make together -- and by make together, I mean that she would peel the apples, and after slicing one in a less-than-satisfactory manner, she would relinquish the rest of the task to me. I doubt it would taste as good to her now as it did to her then, but she still talks about that pie, it's etched in her memory.

One year, my aunt made us go around the table saying what we were thankful for, and it took an hour and a half, and we all complained. Some people said silly things, other people said passive-aggresive things (hi, mom), and other people said sentimental things- and of course, we teased the latter mercilessly.

We kept creating traditions in our family, and I still have fond memories of them, even though we are all scattered too far and life is too hectic and wild for us now to all be together. And as crazy and non-traditional as those Thanksgivings probably were, they were ours, and it makes me feel like home, and everything else really seems like a lame substitute. So I find I can't really be that heartbroken over sleeping my way through Thanksgiving this year.

I belong with you, you belong with me, you're my sweetheart

I could tell you a sob story about how Sandy thwarted my attempts to go on vacation. I could, I could, but I'm just not in the mood. Besides which, it would be rather ungrateful, considering all that happened to me was a change of plans. Sandy did make me sad to be so far away from the people I care about on the East Coast, but then, the East Coast might as well be another universe right now.

Instead, there's this bordering country that's become foreign too. Because, you see, it's been many years since I've been a resident of San Francisco. More years than I realized until this weekend. And every year, as I get a little older, my remarks become more vague when the subject of returning to San Francisco burrows its way into conversation. Every year, the conversation involves more "but"s than the previous year, more arguments for why not instead of for why.

It's weird, I know, to have a relationship with a city. But I do, I did. That city, I don't know how to explain it. Except to tell you that this past weekend, CS and I decided to finally make a day of it and go into Alameda to visit St. Georges' Spirits. That place was in existence the entire time I lived in San Francisco. I tasted Hangar One for the first time in San Francisco at a shoddy bar on Sixth Street, right before heading to Bhangra SF. That place was in existence the entire time I was in medical school. A friend of mine then, who has since severed ties because that's the unfortunate price of break-ups sometimes, CC had told me about it and we had talked and talked and talked about going. But we never went.

But then last week was stressful and Friday night, CS and I admired bar shelves of artisan liquor, and a plan was hatched. The next morning, it was spectacularly clear out, unseasonably warm for October, and we drove to Alameda. And suddenly, it wasn't 2012 anymore. I don't know. Suddenly, I wasn't this me, I was a different me. CS and I navigated our way to the distillery, which is in a former naval hangar, prompting us to make jokes for a solid hour about how a zombie attack was imminent, and if not, wouldn't this be a spectacular place to film a zombie apocalypse? We went searching for food prior to going into the distillery, so that our heads wouldn't be swimming later, and we marched confidently into a building with no signs just because we saw someone standing by a piano in the doorway. It turned out to be a private party for who knows what, and we took two steps in, contemplated crashing for a while, and then left, leading to another series of jokes.

The distillery seemed to be created for us. The person pouring liquor was gregarious but not obnoxious. We liked him because, despite the proximity to Halloween, he was the only one behind the bar not in costume. We liked him because he let us taste reserve liquors. We liked him because he was amused by our utter joy at tasting gin spiced with cinnamon and cloves, and coffee liquor that was so smooth it made me wonder why I didn't like coffee. We liked him because he liked Barcelona. We liked him because we were flying, flying, soaring happy, high.

We sat and ate a late lunch in the adjoining picnic area, looking out onto the water and the bay, the sun still bright, the bay teeming with sailboats, trying to get in one last seasonal hurrah. We watched as a woman not quite as adept at holding her ethanol fell right on her butt on the gravel outdoors, and we suppressed our laughter. Then we walked through a tour of the distillery, returning back to the earth, gravity bringing us back. Sober and happy and pleased with ourselves, we drove home.

And that's how I remembered the argument for why. We weren't in San Francisco, but this was what San Francisco was to me. Little discoveries, little bursts of happiness. Messy, messy, but with splashes of vivid perfection. Nowhere else, it seems, am I ever so happy. That was something long since forgotten. Because I've been happy here, I am happy most of the time. But that bubbling joy, that soaring feeling- it's a specific thing, and it's there, always there. Someday, I suppose, I shall have to figure out what to make of that. But not today.

joyful girl

You. Guys. I cannot even deal.

Here, I'll just say it. It's my birthday today. And let me tell you, from a certain angle, there is no reason to get so excited about that. It's just another year. No special milestone. No particular excitement. Last year, I took a test on my birthday, no one in my program knew it was an unusual day for me until after the fact. I made a homemade pizza, experimented with maple syrup candy, contemplated a cake, and accidentally shattered a perfectly good bottle of iced tea. I was turned very much inward, and it was fine. I don't put too much thought into my birthday until the day arrives, and most of the time, I just take stock and shrug and carry on. No reason to get so depressed or so ecstatic one way or the other, in my opinion. Sometimes I might treat it a little like New Year's, and consider what I want to accomplish for the next year.

I didn't think last year's birthday was pathetic or anything. Really and truly. And I certainly didn't have any expectations about this year's birthday.

There was this thing I'd been considering this past year. You know, it's part of this whole I bought you that ring because I never was cool feeling- something about that changes as you get older. I've worked this past year on becoming a more authentic version of myself. That sounds incredibly precious, I know. But if anyone examines their youth, I am certain they can identify times when they made choices which were not entirely true to themselves- choices that were compromises, that compromised some essential part of themselves. And I think, in the year leading up to residency, when I had decided to make do in a place where I did not quite fit, I settled so much and made so many compromises- feebly justifying all of them in order to get right with the decisions- that at the end of that year, I didn't know entirely what I had wanted or what I had hoped or anything much at all.

But the one thing, this insistent voice in my head, all of that year, that demanded to be heard was the nagging feeling that I should pay close attention to where I was choosing to do my residency and to pick the right program, the one that fit me best, the one where I would be happiest. It's funny, because it's that decision which ultimately did reveal how shallow and unimportant some of my relationships were that year. These so-called friends came at me and criticized my choices because it did not suit their perception of what was best for me. And I'd given in on so much by that point, but the nagging feeling, the persistent voice demanded I make the right choice for myself.

And it worked, don't you know. Internship was so hard, but also so rewarding. I grew closer to my fellow residents than I ever did to a single person with whom I attended medical school. I found my people, at a time when I had concluded the very notion of 'my people' was an utter myth. I really enjoyed working with these people, I really appreciated every moment I spent with them. I baked and baked and baked, fueled by all those good feelings.

None of these residents made me compromise who I am. They got to know me, dealt with all my crazy quirks, schooled me when I needed schooling, listened to my whining, whined to me. We were all true to each other. They put up with my bad days. They put up with my need to be inclusive; they might have even liked me for it.

So. Today is my birthday. I was barraged with messages all morning. My pager went off in the morning, and when I called back, three residents were on the other end of the line, calling just to wish me a happy birthday. Random residents walked into the work-room hugging me. I don't like fanfare. I don't like productions. I don't like a lot of fuss or attention. But I have also learned in the past few years that sometimes celebrations are not about you- they're about your friends, and giving them a chance to let them express what you mean to them. My friend MG is about to pick me up, and we are headed to get a GG&T before a ridiculously large gathering for dinner. It astounds me- how last year's birthday and this year's birthday can reside in the same person's experience. Even though I have to admit that this outpouring of affection is extremely touching, I'm not ungrateful enough to be down in the dumps if next year should revert to a quiet night alone. As my friend CS told me yesterday, half joking, half serious- "congratulations, you survived another year." And when you strip everything else away, there's the bare truth, and really the only correct emotion is a big crashing wave of gratitude. So today- consider me crushed.

one more time with feeling

My schedule has gone erratic again, filled with the new joy of 30-hour shifts. Fun times. Actually, they really are in some ways. It won't mean much to you if you don't work in the medical field, but I actually much prefer working a 30 hour shift than a 16 hour one. Sure, you lose sense of what time it is, what day it is, when you're supposed to be sleeping, personal hygiene. But you do get a chance to breathe in the hospital, to really think about the overall plan for your patients and how best to treat them, because you're actually around the entire day watching their clinical course.

Anyway. The down side is that all I do is work, bake, drink random alcoholic beverages (I'm loathe to admit I've been branching out from my usual GG&Ts, and recently went so far as to drink something called a Lion's Tail-- worst part is that I actually liked it!), and do laundry. Not exactly an exciting existence, definitely not one that merits much in the way of documentation.

I'm working at the VA right now though, and that place always makes my blood pressure sky rocket. Not because the vets are super-conservative and occasionally borderline racist and oftentimes borderline perverted-- none of those things ultimately bother me because the vets are possibly my favorite patient population out there. No, what drives me crazy is that no one else seems to be interested in their health besides the residents. Getting anything done there requires cutting through 15 layers of red tape, and usually involves losing your temper, and even then, things barely get done. Ultrasounds don't get done on the weekend. It tends to drive me crazy. One of the senior residents last year told me that the VA is where residents go "to develop sass"- and let me say, for the record, the sass is now in full effect.

But the up side of sass is that it in turn breeds rage, which in turn breeds baking. People are starting to catch on to my deal, and my friend CC, who knows how frustrated I've been with both the VA and a particularly lackadaisical intern, decided to innocently send me a link to a recipe for pumpkin cinnamon rolls yesterday, knowing full well that I would take the bait on my day off. Yeast-based baked products are not usually things I tackle on a work day because you never know exactly how long things will take to rise and fall. I had to be patient with these rolls because the recipe called for a type of yeast I couldn't be bothered to go out and buy.

Sometimes I get bored with my own baking. Cupcakes, cookies, blah blah blah. I think I've optimized and I can make what I make and I won't ever be able to improve from there. I've still yet to figure out how to make macarons properly, and it feels like a losing proposition. But on the other hand, I was reminded that I tried to make pumpkin cinnamon rolls several years ago and it was a complete failure. They turned out the weight and density of hockey pucks, and I remember being really angry that I wasted not time, but so much flour. That's not cheap! But that was a while back. This time, the result was a bit different:

They may not look like much but they are gooey and soft and light. And the cream cheese icing on top will get rid of any shortcomings they might have. So it was a good reminder that it's worth giving things a second, third, fourth, fifteenth try.

And maybe I can use the muffins at the VA this weekend to bribe someone into drawing a blood count on my patients.

we're in the wrong band

Before I tell these stories, let's just acknowledge that it is 2012. There are now at least as many women as men in medical school. You know, it's not like women are completely suffering in silence in medicine these days. However, can I just tell you a few things that I have witnessed?

• A classmate of mine in medical school was already accepted into a surgical training program. Her director actually said, "I've never had any women in my residency program have babies, and I don't expect to start now." Keep in mind that her surgical training is a five year program.
• Another classmate of mine wanted to defer a clinical clerkship in his third year, because his wife was having their second child and he wanted to be home with the children. He was fine with making up the time later, possibly even graduating later. One of the deans told him, "you've already seen one baby born. There's really not that much for the dad to do." He ultimately got the rotation off, but had to argue with three different male administrators before getting it approved.
• In residency, two of the women interns in my program are pregnant. While male residents who have children have been congratulated and slapped on the back, these women have been called 'thoughtless', 'inconsiderate' and 'deceptive' (though of course behind their backs)- and some of the people making the comments were other women.

Now, again, I'm not saying that women are downtrodden in medicine. But I've been thinking about these issues lately, and it blows my mind how messed up the whole thing is. It's an institutional, structural problem, and it's so deep-seated that even the women within the system are supportive of it. The problem is that, if you do the math, women who are in medical school and then residency are going through these things during their child-bearing years. Why are they expected to set aside that reality and deal with the consequences later in their lives? I feel like I can speak about this since I quite certainly have no dog in this race. But that decision has nothing to do with my career decisions, nor should it really.

Men are congratulated when their wives have children. Women are whispered about, painted to be selfish. There's no other way to describe it but wrong. The problem is that residency programs and medical schools do not account for people making very natural life choices during training. They don't staff residencies with enough trainees to cover if one or two people go out for maternity leave. Of course, the programs can't legally forbid women from having children, so instead, they just create this untenable burden on all the other trainees when the women need that time off. This in turn breeds all kinds of resentment, and, in the end, what you have is massively messed up thinking.

I'm sort of amazed, because I worked for so long before I trained, and in the workplace, a friend of mine and I used to joke about inventing made-up children, because women who had children were always excused to go pick up their children from daycare or working late or traveling to places they didn't want to travel. And maybe that extreme was no good either. But on the other hand, we were just kidding around, whereas my co-residents are quite dead serious when they take big objections to women having children during residency.

This all sounds like a completely a-political problem. But consider this- Medicare and the government subsidizes the large chunk of residency salaries and thereby controls the number of spots residency programs can offer. It's funny because when the soundbite came out about Romney and the 47%, I thought 'well, I'm not part of the 47% and Romney doesn't really care about my vote either.' But then I realized that I am part of the 47% because I am a resident. And if you think a resident salary is a handout, hahahaha- that's all I've got to say about that.

In other news, I went nuts last week, and baked a cake. A friend of mine invited me to his house for dinner, and I haven't seen him in a while. Last time I went to his house, I brought over an experimental sorbet that had a little too much ginger in it, and he had to politely swallow it down, so I became obsessed with making a cake beyond reproach. Well, it wasn't a pretty cake. You bake a really big cake (15" x 11" or so) and then you cut it into strips. Then you rush around frosting it because you've gotten home from clinic at 6 and you have to be at dinner by 7:15. Luckily, I'd made the frosting in advance- there are layers of caramel and dark chocolate ganache, and a pillow of milk chocolate buttercream to top it all off. Even though I warned him it was rich, my friend RS demanded a second slice, and then clutched his stomach, pregnant now with cake. Here it is, in all its messy glory:

hit the ground upright

Maitri in her usual kick-ass manner posted a comment that said everything that I could ever want to say about all the hesitation I've had for so long:

"I always wish folks Good Luck before things like this (even if I have only the slightest clue about what you're about to embark on), because whatever the outcome, dithering about it is worse. Whatever the outcome, poop or get off the pot. A lot of life is simply and honestly pressing forward into that cone of uncertainty."

Indeed, indeed, and I am here to report that pressing forward has never felt so good. I guess that's how I am. When I come to an end, I've already hashed it out and come through so many false starts and stops that I am well and truly done, all the way. I don't mind that about myself- maybe it takes me longer to get to where I need to go, but I can live with myself better as a result.

And success and failure are blurred lines sometimes. An end can seem like a failure when in fact it is a success. One train may hide another.

Either way, there's just no denying- now I am happy, relieved and happy. Out of a holding pattern, able to fly forward. And it wasn't anger or misery that brought this to a resolution. It was calm and contentment and an appeal to compassion. Which was one route I'd never previously tried, and wow, what have I been waiting for all these years?

I know I'm being aggravatingly vague; that's sort of my thing. I've removed a toxic substance from my system, and I knew I wasn't strong enough to purge it myself. So I asked the demon to show a little pity- and it did. I guess I should have been crushed, or heartbroken, but I wasn't. I felt for the first time in a long time like I was truly free.

Then I made a goat cheese, caramelized onion, and mushroom tart, and my friend MG and I drank home brewed sweet tea vodka with freshly squeezed lemonade. And life felt very, very right.

I've been here before and I deserve a little more

Wish me luck, because tomorrow is going to be something of a reckoning.

It's a mess of my own design. An agreement to walk through fire, even though it won't be enough, won't change anything.

Strangely, though, it's sandwiched, buffered with love. In the morning, I'm to go to the farmer's market with a close, old friend. In the evening, my brother and sister-in-law are paying a visit. There are others too. I'm not nearly any semblance of alone. And for that, I am so, so grateful, and feel so, so safe.

So I should not be so scared. But the heart, regardless of how strong it may seem outwardly, logically, is a fragile thing, and it won't take much to crack it a tad more. And having just rediscovered this belly laugh, the one that comes from within the heart and tells of exuberant, unfettered joy without any 'except for's, I am not so inclined to lose it.

As a talisman, my kitchen's become a tornado zone. I made cookie dough, but I had much bigger aspirations. There was orange juice left over from a recent brunch, and it's been taunting me in the refrigerator for the past several days. I'm a little bit of a priss- anything but fresh squeezed orange juice gives me pretty bad stomach aches, so I avoid it myself. A little web research and I had found an orange cupcake recipe to hack. I already have made a light, subtly citrus-y frosting ready. I've become really taken by meringue buttercream frosting, probably because it is a bit labor-intensive, but also because it is smoother than most other homemade frostings and involves none of the nuisance of sifting confectioner's sugar. It's also excellent for icing, which has also become a thing that is a welcome distraction (update: the results below! Not very orange-y, but not bad for a first attempt.). All in all, not a bad way to keep my mind off things.

this beat was bubblegum, so I had to chew it

On a lighter note:

• The ICU nurses were huddled together near the nursing station last week in the afternoon. They saw me coming, and one of the more seasoned nurses beckoned me to them and said, "maybe you'll know," which I immediately took with a grain of salt, because the ICU nurses usually know more about everything in the ICU as compared to the residents. Especially the ones with some experience. But still, I figured I would give it my best shot. She asked me, maintaining a grave expression on her face the entire time, "can you teach me how to dougie?" It's ludicrous moments like that which make inpatient medicine a magical place.
• An elderly woman came to clinic for the first time. She had not seen a doctor in five years, she lives alone, she has no children. In getting to know her, I asked her what she did for exercise. She said, "not much, but when I feel like I'm too lazy, I put on a CD." I asked her if it was an exercise CD. She said, "No! I just put on a CD and dance alone in my apartment until I'm tired!" and burst into giggles like a 15-year old would. I really hope I'm like that when I'm her age.

There's some more ominous stuff going on. It's the balance of things. I've been waiting for something to disrupt my contentment, and here it is. But it's just a little rumble, not a true earthquake, not anything that will cause a break. At least that's what I tell myself, and if I tell myself enough, it might turn out to be true.

all you can do is do what you must

There was a time, and it's not really worth mentioning when the time was, but during that time, AL and I were roommates, and we had some friends who were marooned. They could not get back home. We had a big enough house at the time, and we invited anyone who was stuck to come on over. They went shopping in our neighborhood for a spare set of clothes, and took showers in our guest bathroom, and we fed them, then we made them extra beds, and they slept in our living room so they could go to work in the morning.

But even before then, this was something we knew in our bones. In my family, we stayed over each other's houses if something needed repairing or wasn't working. We thought nothing of it. In college, there was a chemical spill, and the largest of the dorms had to be temporarily evacuated. People were eventually placed in hotel rooms, but until they had arranged for it, there were students sleeping on the floor of my dorm room, using my bathroom, sharing our space.

It seems like the most basic of human instinct to me, this notion of, when things have gone wrong, offering shelter. And often, we can't really give it in the place where it's most needed, for various reasons. But it can still be extended when it might be of use.

I've a comfy brown couch, and a ceiling fan that keeps the air calm and breezy. In the last two weeks, four different people have come by and proceeded to pass out on that couch. It's not that comfortable. My visitors were just very tired and in need of a rest. Sometimes it's not enough, it doesn't make everything better. But it's something, and it's the something that I have the capability to do.

That's all you can really do, I find. Help the people around you, the ones willing to take your help, and hope it's enough to distract you from the other people- the ones you don't have the means to help or the ones who refuse to accept your help.

resurrection fern

Who knows whether the circumstances of my life dictated who I became. All I know is that when I'm a little sad, I yearn for company. But when I'm really in the dumps, just low down and completely inconsolable, I just want to be alone.

Maybe it's because I've had this fight before, the one between me and my demons. Maybe it's because the demons are unpredictable- they'll show when you least expect them, and conveniently when others might not be around. Maybe it's because if I rely on someone else to cheer me up when I'm at my lowest, it puts me in peril if I should happen to hit rock bottom on a desert island.

Or maybe I'm just wired this way.

I was at my very lowest over a decade ago. I remember it well. I was marooned in Southern California, and the entire length of ground beneath me had crumbled. I was in big trouble. I was as alone as alone could be. There were people around me, friends even, of a sort. But not old friends. Not true friends. Not friends I've spoken of or to since.

I was already a scientist by that point. In fact, that was the whole problem- I was a scientist who had just been heartbroken regarding science. I wasn't sure I still loved it, not after what it had taken from me. And I was all alone, and even if I hadn't been, I'm not sure anyone else would have understood. I had a strange sort of math going on in my head.

Back then, there wasn't much in the way of an internet. I didn't even have a computer at home. So I visited the stacks. That's what I started doing. Every day, each morning, I would sit in the science library with the yellowed pages smelling deliciously ancient, trying to find it again. Trying to fall in love.

The trick was not to try. Eventually I stopped trying, and eventually I started reading about things which sparked my curiosity, which made my heart beat again with purpose. Then I was saved. Which I cannot explain, and nor do I care to explain. It's one of those selfish secrets that I may never share outside of these confines.

What I do, when I'm at my worst these days, when I'm having a rough time of it, is find something I love to read. Not just something I love to read. It can't be something I just love to read- because then it would be TS Eliot or Anna Akhmatova or something which would plunge me even deeper down into the blues. No. What works for me is to read about oncology. Which, I realize full well, sounds insane.

I was yelled at today because it's Saturday night and I refused to go out for drinks and instead I chose this:

First of all, Saturday night means nothing when you are working in the hospital. I worked all day today and I'm working all day tomorrow. Saturday night is just another work night. But also, I had a miserable day. A day that needed to get better. Or else. All the way bad. I should have read about Cardiology. That's what I should have done. But that wouldn't have soothed me, wouldn't have fixed what ailed me. So I turned to what I knew would work for me.

And I think that's the trick. That's the trick to everything in life, and that's what Van Gogh must have been talking about:

Love many things, for therein lies the true strength, and whosoever loves much performs much, and can accomplish much, and what is done in love is done well.

That's how I feel. When I'm at my very worst, it's not really that I need to feel loved. It's that I need to love something. And there's so much out there that's worthy, given half the chance.

anywhere else now seems like a million miles away

At my house today, brunch was had. It was had by many.

There was a trial run last week, but that one was different. It was the first time in a while that I'd tidied up enough to have people over, and it had morphed into a gigantic gathering. Everyone descended at once (a total of 12 people, which was far too much for my 6 person dining table) and it was a little chaotic. After I finished cleaning the kitchen, 2 stragglers showed up and ate leftovers while visiting. It was a fun day, but that brunch was somewhat stressful- it's been a while since I've had that many people over (my previous residences for nearly the last 10 years would have burst at the seams with that many people in my house), and I was out of practice for entertaining for that many as well as estimating how much food to make. Everything worked out and there were a ton of leftovers to spare, but I felt a bit tired after all the commotion settled down.

Today was different. Last night, I prepared almost everything needed for the brunch. This morning, maple pecan scones were already sitting on the counter, a strata was ready to be baked, and waffle batter that spent the previous night rising was waiting to be finished. It was all so simple that I started to worry that there were additional things I should have made. The first person, GN, came over at 9:45. He looked like a wreck. He had overnight call and was just finishing a 30 hour shift when he arrived. I made him two waffles while he was gobbling up scones. He ate the waffles hot and tried some egg strata, and then promptly took to my couch, where he completely passed out for twenty minutes. By then, the next person arrived.

She brought over a coffee maker because I don't drink coffee, and I do not really know how to make it, in truth. We chatted, making coffee, and eventually GN awoke from his temporary slumber, drank some orange juice and joined our conversation.

My friend who brought the coffee maker is vegetarian, so I made her a scramble with spinach, parmesan cheese, and mozzarella, which she dutifully ate while the rest of the waffles were cooking. Another couple of friends came, and brought big bowls of fruit. A few minutes later, another friend and her husband came with a Hawaiian dish.

We sat around the table eating and talking and laughing. Another friend stumbled in, hungover. We fed him, and he got a call from another friend, so we beckoned him to join us, which he did. A few friends left. Ultimately, the party did not disperse until 3 pm, and people left with little packages of food to take home with them. A few of us lingered in the kitchen together, talking of when we would all get together next.

This may seem all very commonplace and boring. The strange thing is I think I would have found this all very commonplace and boring ten years ago. But since then, my life changed so much, the focus of my life was so different, that I didn't realize how much I missed it until just today. Everyone had told me that I'd find lasting and long friendships in medical school. I didn't entirely believe them, because my experience inherently was bound to be so different than the typical. And sure enough, I have only a handful at most of people from med school who I even feel friendly towards- and of them, only 1 or 2 who I feel truly connected to. So I honestly didn't expect what happened this past year. It turns out that, as stressful and frustrating it sometimes it is, this residency program was the right one for me. These are my people. Not all of them, of course. But way, way more than I ever would have imagined.

It occurs to me, that maybe I have cobbled together the life I have always wanted to lead. And it's not to prove it to anyone else, or because I think it's what life should be. It's because this is what I actually, truly want in this moment, and I have it. The moment will pass. Of that, I'm sure. Life is not much fun if you are not in want of something. But still- at such moments, belly full and pleasantly sore from laughter, new waffle recipe recorded in my little book of keepers, dishwasher about to start running, I just want to hold onto the present tense and be glad for it.

that solo's awful long, but it's a good refrain

The Guardian and some friends of mine pointed me towards a project that tries to capture the essence of a person through the songs with which they identify most. It was a good excuse to dust off the blog, and also, I found the assignment a little stupid because some of the questions/categories are not reasonable to distill down to one song. So I cheated as usual, but at least I'm posting for a change.

The first song I ever bought:
Thriller, Michael Jackson- Obviously, because of my impending senior citizen status, I did not purchase a first song, I bought a first album. And of course, given my age range, and how old I was before my parents would allow me and my brother records, we were united in our desire to obtain Thriller with the money we'd amassed over months. We were not sorry. Even though it heralded an increasingly commercial and ridiculous time that would culminate in Jackson morphing into a completely bizarre entity, this album will never seem like anything less than a revelation.

Song that always gets me dancing:
Just can't get enough, Depeche Mode- A silly one but true. I should point out, though, that it doesn't take all that much to get me dancing. There are a number of guilty pleasures that I could include in this list (It takes two comes to mind).

Song that takes me back to childhood:
Centerfold, J Geils Band- Look, I was probably seven or eight when I heard this song on the radio. It was one of the first songs I heard on the radio. I had no idea what the song was about, and probably even after it was explained to me, I didn't really get what it was about. But it always reminds me of being a kid, sitting on a bus, with a bunch of other kids, singing along to a song we didn't understand.

Perfect love song:
A tie between Thank You by Led Zeppelin and Nice work if you can get it by Ella Fitzgerald and I believe by Stevie Wonder and about a million other songs- just tell me that you wouldn't swoon for someone who said 'mountains crumble to the sea, there would still be you and me.' On the other hand, Fitzgerald's song lacks all angst, is so matter-of-fact about love that in some ways it is more perfect than anything else could be. And on the other other hand, Wonder's song is breathtakingly beautiful and hopeful. But honestly, I feel like there are so many songs I could include and then maybe I would have covered every good love song out there.

Song I would want at funeral:
Wishlist, Pearl Jam- if it were really my funeral, I wouldn't want dirges. And this song has a lot of yearning associated with it, which I've always related to life in general. Because I've always thought that's what this song is about- that life is all about wanting, even if it's something as simple as breathing, even if it's ungrateful to keep wanting more (thus my favorite line of 'I wish I was as fortunate, as fortunate as me').

A song that makes me, me:
Galileo, Indigo Girls- the obvious Cornershop song also comes to mind, but first and foremost, holy smokes, I am a f***-up. That's what I'm all about, underneath whatever facade I may be able to pull off in public. I am a failure. I am that person who falls in potholes, who trips right into ravines, who slips on black ice and lands smack on her bottom. But the thing about all of that failure is that it's made me who I am. You can smash me into a million pieces on the sidewalk, and I'll emerge like that oozing metal of Terminator 2, reformed, revived. I like to think all of those rather graceless face plants led me to who I am and what I am doing now. And somehow, all of that makes me think of this song.

I guess this must be the place

Today I am roasting strawberries. Tomorrow I will be a second year resident.

I still have so far to go, miles to go before I sleep, and yet I am still in wonder that somehow I've gotten to this point. It's funny (not really funny haha). Those around me, who are significantly younger, are getting to that point in residency during which they are realizing the toll this training takes, the sacrifices it exacts, and some of them are doing the math. They are realizing this isn't some job you get into for the security of it, or the financial perks, or the respect. Plenty of other jobs are just as safe if not safer in this climate. Plenty, plenty jobs pay better, especially if you take into account the years of schooling and training. And in training, you encounter a lot of people who view physicians with great disdain, and sometimes with good reason.

So.

They should have known this, I've said in the past. They should have walked in with their eyes open. But now I see how unfair a statement that is. Your eyesight, your hearing, all of your senses are just different when you are younger. Not necessarily better or worse, but different. More easily tempted, more easily disappointed, I suppose.

I've had moments too. When I've been tired. Or taken stock of how this past year has taken a chunk of my flesh along with it. I've thought of my past life and those years and wondered why they didn't satisfy, why they weren't enough. I don't have the right answer. It's too romantic to say that this is a calling or fate or an altruistic mission. I save romantic talk like that for romances, not work. I don't have an answer. I just know that I wasn't happy that way, with a very good salary and very good hours and time to contemplate my life, work out, play around in my kitchen.

I am happier now.

It makes no sense. I'm more tired now. I'm less healthy now. I travel less, have fewer indulgences. Sometimes, I feel like I'm going to have a heart attack from the stress of having this kind of responsibility. I have, in some ways, fewer friends. But I love more things. Go figure. I love more things; sometimes they are lots of little things, sometimes they are big.

I keep thinking, despite the fear pulsing through my arteries, despite the occasional annoyances, I keep thinking- I am so, so lucky.

It's easy to forget that. It's easy to forget when there are other things too. Life, for example, and the non-medical matters of the heart. I thought my heart would be at 100% when I had really sat and wallowed in the blues for a while. I thought maybe it would jump start when I had a flare of anger, fits of rage. And then I thought it would beat steady and true when I regained my full capability to laugh and feel really, truly happy. But none of it repaired the damage. It's still got this nuisance of a wound that doesn't let me take a full breath. And let me tell you, it is annoying. But then I remember medicine and know that time does more than any physician ever can. So I try to learn a little more patience, and to remember to feel grateful.

don't look ahead, there's stormy weather

This month has been one of the infrequent ones where I have to drive to work daily. Usually I walk. The good thing about walking is that it gives me a few truly calm moments to collect myself before I go into work, a chance to glimpse the sun or the moon or the stars. My walk, however, is quite short. The drives are usually long enough, and my attention span issues emerge, and I get to listen to music- good music, trashy music, new music.

Santigold's latest song is not even new anymore. I've come to the sad realization that, just as with movies, the intensity of my current work environment makes it so that I rarely have the proper mind frame to pursue cerebral music or films. I've become an earworm junkie. I actually threw a fit last year when my friend AP made me see The Descendants, which I quickly discovered was a heavy film with a little too much medicine for me to stomach.

Nice thing about Santigold or someone like MIA, for that matter, is that their earworms have some kernels of genius in them if you listen for long enough. Or in the case of this latest song, Disparate Youth, you don't even need to listen for very long. I had just finished a long day in the ICU, and was scrambling out to get out to make a 10pm movie (I'm not even going to admit what I rushed out to see, but let's say, if it weren't for the company, I probably would have been better off hanging out with the intubated patients instead). Not only was I feeling frustrated about working another 16 hour day, but furthermore, lately I have been feeling increasingly anxious about finishing internship.

Internship is hard, don't get me wrong, but it's a known quantity now. But in less than two weeks, I'll be in charge of a brand spanking-new crop of interns. In charge! That seems like such a bad idea that I have minor to major anxiety attacks about it every time I think about this.

On the other hand, there's one thing that has come to annoy me during internship, and that's full-blown whiners. We all signed up for this. It sucks sometimes, sure. But we fought hard to get to this point and we went into it willingly, so it seems somewhat ungrateful to full-on whine about it. So, as terrified as a part of me is about this new level of responsibility and the soul-crushing hours that await me next month, well, the other part of me high-fives Santigold, and sings along with we said our dreams would carry us, and if they won't fly we will run, and gets ready to steer into the skid.

the good life, let's go on a living spree

Some days are horrible and some days are wonderful and some days are neither, and I guess the thing is just to remember that it will always be thus. My friend AP, who is now two years behind me in training, text messaged me excitedly today to tell me she received honors for the first half of her first rotation. She was so happy, and I was quite happy for her. But I also wanted to tell her not to get too high. I remember having the exact same experience, I remember the elation, and then I remember the feeling of complete failure when I didn't honor something else three months later. Looking back on it now, I see it was all arbitrary and anyway not something one should use to measure one's self worth. I wanted to tell her not to get too high, or at least to know that, should she get less-than-stellar marks next time around, she should simply shrug off the negativity.

It's easier to have a horrible day as you get older, I find. I was out cultivating a drinking habit after call one evening with my fellow intern, a sweet, well-intentioned, good-hearted young intern. She was telling me that she had come to dread going into work every day. She was worrying and admonishing herself for things that weren't her fault. She was worried she was less than everyone around her. She was not competing with anyone, but she was seriously concerned that she didn't measure up. And the reason is that she is so well-intentioned, so good-hearted, and so young, that she takes every mention of criticism, every snappy remark to mean that she is a bad doctor. When in fact, she is a great physician, and probably will be one of the better ones among us. It's sad what the system does to us.

I feel sometimes like I have a forcefield though. Sometimes I get criticized and I take it quite seriously and use it as motivation. Other times, it is quite clear that someone had a bad day and I'm the lowest rung on the ladder, so here comes that dung that rolls down hill. And on those days, I get annoyed and probably my resting heart rate and blood pressure are higher than they should be. But I go home and bake cookies or cupcakes, or I knit a round, and I remind myself that tomorrow will be a better day. Or if not tomorrow, then soon. Nothing is eternal.

Unfortunately, not even the good days. Like this one, in which I woke up after a pleasant night of drinking, and the weather was so perfectly temperate that I walked to AP's house, then the two of us walked to a lovely brunch and then walked back. Then I ran a few errands. And then I baked a caramel cake.

Believe it or not, I don't have many opportunities to bake cakes these days. Most of the times, I am stress baking, and as such, I have to make things that are portable and easily consumed. So I've baked a metric ton of miniature cupcakes, a bajillion cookies. But rarely a cake. Tonight I'm going to a barbecue though, and it's a friend's birthday. I suspect she may already have an actual cake (she's a relatively new friend so not altogether aware of my cake-mania and insistence that I bake any and all birthday cakes for friends), so I wanted to make something easily consumed, a snack cake of kinds. Caramel cake indeed. I've made this before. It is the kind of simple cake that people pick at, one small square after another, until, tada, nothing but a few crumbs and a lace of caramel on a plate. It's sweet, but not cloyingly so, rich but not like a brick that sits in your stomach. It's maybe not entirely summery, but it keeps easy, so I know if I bring it, my friend and her boyfriend can have at it for the rest of the week.

I know days like this won't last either. It's just a temporary lull, a respite of happiness and fun and drunken shenanigans. There's always some stressful situation afoot, that much is guaranteed in residency (and maybe life in general). But as long as I remind myself that such days as these exist and will return, everything feels quite tolerable.

don't call me daughter

I probably shouldn't write this post. I'm tired, I'm post-call, and this is sort of the opposite of my general philosophy on posts. But I'll try not to be vitriolic.

So it's Mother's Day. And Mother's Day, well, I find it a strange day. It's sort of a Message in a Bottle (song, not movie) situation, I suppose. You think you're an isolated case, but it turns out there is more than just you in this boat.

I'm not going to go into details, because that is not my style. But I don't have a great, or even a good relationship, with my mother. All these years later, I can understand the decisions she made, the great strain she was under when she raised me and my brother, the burden of unhappiness she's always had to carry. All of that empathy allows me to let go of what I lacked in the past, and makes me slightly better equipped to accept what I'll never have.

We were never close, always like strangers. She could never understand the tomboy who would belligerently mow the lawn to prove her brother should have to wash the dishes occasionally. She never understood a daughter who preferred curling up with ACK comics rather than shopping for dresses. She could never console the awkward teenager who stuck out like the literal black sheep. She does not believe in heartbreak, she can not relate to it, she can only understand protection, self-preservation. She can not give advice. In the end, we are like two figures masked and cloaked and sound-proofed. We can't see, feel or hear each other.

Maybe it's for the best. She was the doubt in my head, the voice telling me I was never good enough, that dreams were not for girls, that I had been a disappointment for not molding into what she had tried so hard to form. When I really let her go, some of my dreams came true, and sometimes I was so happy that I thought I would have a heart attack, and sometimes I was convinced that I was good enough.

But of course, it would always be a little less, because she would never see.

Last year, I once tried to have a frank conversation with my mother about my life, in the hopes of making her a witness. She told me she had simply concluded, from my silence, that having chosen to go into medicine was a big regret of mine. Then she asked me if I had 'met anyone.' I didn't bother responding to either jab. It was the first time she hadn't sent aftershocks through my system, hadn't caused me doubts, hadn't launched me into a cavalcade of defensive arguments. I guess that's what my mother's taught me- to really know myself.

The next time we saw each other, we talked like strangers with a mysterious, dark past, mostly polite with a few passive-aggresive remarks.

I write this not because I feel sorry for myself. I've done just fine, and you certainly cannot blame your upbringing for every wrong you've ever been done. I really have let it go. But I suppose on a day when everyone else is extolling the virtues of their mother, I have to believe that I'm not alone in feeling less than celebratory on this day.

I won't look for a house up on a hill

See, and this is the part where it all makes sense. Two days in a row now, I've had some ridiculously long work days. Broke work hours two days in a row. There's been a real lack of harmony on the teams I've been on of late, and it sometimes sucks the joy out of working on a team.

So I came home late tonight, frustrated, annoyed, tired. And as I was in my kitchen looking at the latest hurricane that had gone through there (the result of a cupcake extravaganza earlier in the week- Mexican chocolate cupcakes with dulce de leche frosting and... of course a dab of chocolate ganache on top, thank you very much), I suddenly thought, in a fit of rage, screw you, you don't deserve any more baking!

Then, just as suddenly, I started laughing. Really, I find anger pretty funny. Especially anger that results in some kind of threat involving baked goods. It just makes it all the more clear how useless rage usually is, when you channel it into something that absurd.

And when I'd exhaled, and realized I still had some homemade pizza for dinner, I took stock of my day again, the last two days, and everything felt, well, just fine, and maybe better than fine.

The great thing about medicine is that there's always some weird yin-yang thing that happens that makes everything alright. You have a day in which you lose heart, because your patients are combative or keep repeating the same self-destructive pattern that lands them in a hospital bed over and over again. But on those days, you find some fellow resident, some colleague with whom to commiserate, and you know you're not alone. And you have a day in which you feel like all of your colleagues have lost their souls, are joyless, and are actively trying to make more work for you. But on those days, you have some of the most satisfying interactions with your patients. Today was such a day. And on such days, once you've gotten the Hulk-like fury out of your system, and set aside your fatigue, then you relax.

I relax and realize that, even though it may not always feel that way in the moment, I am exactly where I need to be.

is this the real life, is this just fantasy?

Yesterday, I received a page from a nurse that a patient was trying to leave against medical advice. Since I am not as cynical and hardened as I may sometimes come across, I went to find out what brought all of this on.

The man was fully dressed but for the IV in his arm, which was still dripping heparin, a blood thinner, into his system. The man had several clots in his lungs back in December. He was treated for them in the hospital but was supposed to take a pill, warfarin, at home for about six months to keep the clots from worsening. He forgot to take the pills here and there, and came into the hospital this time with big clots in his heart. Pretty dangerous, to say the least. Now the man was annoyed and wanted to leave.

I asked him why. He said the hospital was stressing him out and all he wanted to do was go out and smoke a pack of cigarettes. I tried to explain that smoking was the most likely culprit for his clots forming in the first place, and certainly we couldn't let him wander off to smoke while he was hospitalized. He said that was fine, but then he wanted to be discharged immediately. We stood there at an impasse, despite several volleys of arguments. I was the evil physician vilifying his smoking, and arguing with him even though his mind was made up. He was the uncooperative patient who did not seem to care that he had a life-threatening condition that could kill him if he left the hospital. I tried to strike up a compromise and offered him a nicotine patch. He laughed in my face and offered me this compromise- 'if I'm still alive, I'll come in tomorrow, and you can admit me again then.'

Since we don't run a prison ward, I had to let the patient leave of his own accord. It was extremely frustrating. But it struck me that this seems to be the quintessential dilemma, always, everywhere. Two versions of reality. Both of us convinced the other is deluded. I recalled so many times I've tried to change someone's mind. I'm not saying one shouldn't try- some things are obviously wrong (Kutcher, I'm looking at you). Still, when I think of all the heartbreaks I've had in life, they are all boiled down to someone not understanding me. Yet really the problem was that those people did not agree with me, did not see things my way. And as much as I can claim to see things from the other side, to empathize and relate, it doesn't really matter, because on some things people are simply of two minds and they cannot be reconciled. That's what I'm trying to accept.

As for the man, I just hope he lives to return to the hospital, truth be told.

don't let them change you or even rearrange you

Well, time flies when you're not having fun. Or when you are. Pretty much either way. That's the thing, isn't it?

Anyway, it's funny, this stupid blog. It just sticks around and takes up space, and I am often remiss about posting to it. It's foolish to write a blog like this, so turned inward and self-absorbed, for anyone else. So most of the time I write assuming no one is reading anymore, and it becomes a place to have a conversation with some conjured up version of myself.

All of that is true, and yet it always seems like magic when I find someone is reading all of this, following along with all the silliness. I can't explain why exactly but it means a lot.

I definitely reached my limit last month, and now I am recovering. The catch with medical training is that you want to change. In some ways. You want to become more competent, more confident, more facile with figuring out a diagnosis, better at having difficult conversations, more efficient. You want to become a good doctor, or at least a better one. But as you strive for that, in residency, there are dark forces at work that seek to change you in other ways. Outpatient clinics filled with patients with a million problems they have no interest in fixing and coming to you because they want a prescription for pain medications or want someone to fill out disability paperwork. (All of that would probably be a lot more tolerable if you were not so stretched thin for time that you can not give any of it your proper attention) Uninsured patients who get admitted to the hospital over and over and over again because they can't get any proper medications or care outside the hospital (good job, US healthcare, once again- very cost efficient). Attendings who treat you like you're a sucker and a sap for spending more time talking to a family about their mother's desire not to have invasive measures taken rather than spending that time running medications like pressors to keep a patient's blood pressure artificially normal when their heart has already decided it doesn't have the energy to do it anymore. And, most recently, patients who actively use methamphetamines, develop a variety of heart problems, which you spend time treating, only to be assured that the patient will reverse all of your work and return to the methamphetamine use as soon as you discharge them from the hospital.

Very dark forces.

I fell victim to them last month, and it was disheartening. I'm hoping I'll never feel that way again- never feel that frustrated with patients and my work. It's as much the fault of the powers that be. The cardiologists treat patients like all they are is a heart- they don't look at the whole patient and their context and what they will and won't be able to do when they leave. On the other hand, maybe they shouldn't. Everyone should have access to care, which includes medications they need and clinic visits that are required when they leave the hospital. No doubt, it would save money to the system in the long run. But then, and this is the very dark part, but you are basically deluded and Patch Adams-ing it up if you do not acknowledge this- there are a small subset of patients who just don't want to take care of themselves. They will drive you insane because despite your best efforts and myocardial infarctions and stents and scares, they will leave the hospital and go right back to self-destructing, and show right back up at the hospital a short time late. You have to face that fact and accept it and choose to treat everyone anyway. Ultimately, that makes you a better doctor, I think. But it's certainly not easy.

watch me unravel

Seriously, you guys, how do people do night shifts? I've now done five weeks total over the course of internship. But again, in my sixth week right now, I just want to melt into a puddle of goo. It astounds me that there are people in this world who work night shifts as a standard part of their entire career! How?!? How are they not insane? I'm only on my fourth night of the week, and I have been getting crankier and more sleep-addled by the moment.

These nights have not been quiet either. For some reason, people seem to have a proclivity towards having cardiac events at night. Endless, endless elevated cardiac markers. Because of how busy it is on this service, so far the only thing I've learned about cardiology are things I already knew- alcohol, methamphetamines and cocaine are bad for your heart. So is smoking. Also, if you walk into the hospital with chest pain, you will have to put up quite a blockade to prevent a cardiologist from catheterizing your coronary arteries.

I don't usually do countdowns when I am on a rotation but I am starting to X off the days to getting off this service, and not living like a vampire anymore.

the weary kind

Well, I certainly understand now why work hour regulations were put into effect in the medical field. For a couple of reasons actually. First, and foremost, residents are cheap, dirt cheap, salaried labor. Very hard to find a crop of people in any other field who have invested so much money in education who may as well be holding a sign that says "Will MD for Food." Secondly, people in the medical field have remarkable deficits in short-term memory. Interns have no recollection of the terrors of being a medical student, residents have no sympathy for the grueling job of the intern, and attendings can't understand why residents are running rounds by themselves. Finally, and perhaps this is the only part that has ever really justified the work hour regulations- it is not sustainable and compatible with being a good doctor.

You can work a 16 hour shift. That's really not a big deal. You can even work two 16 hour shifts. But working a relentless cycle of 14-16 hour shifts is grueling. It sucks out your soul. It makes it difficult to empathize, to keep your head on straight, to make good decisions, to communicate properly with everyone. And get this: all of that is within work hour regulations. Last week, I thought I was going to completely fall apart, and I had only broken the regulations by 4 hours total. I can't imagine what it used to be like when you could work for 100 hrs without anyone questioning the sanity of such extremes.

Yesterday, I worked from 5:45 in the morning and got home at 8:15. Amusingly, that was early this week. I took 20 minutes for lunch, but other than that, everything was work, all day long. No surfing the internet or checking my email or texting or tweeting. I never quite appreciated how hard it can be to return correspondences on a regular basis until working in the hospital. There is just no time. I don't know where it goes. It's a hundred million things- writing notes, talking to nurses, talking to patients, examining patients, talking to patients' families, writing orders, talking to consult services, talking to the senior resident, talking to the attending. It's no wonder I've done such few procedures during internship- who knows when I would have actually had the time.

Anyway, when I got home, at 8:15, I was so angry, for no good reason, just out of sheer exhaustion I suspect, that I had a scary amount of adrenaline pulsing into my bloodstream. I took advantage of it and made, without a whole lot of effort, peanut-butter chocolate chip cookies. Thankfully, I can almost make these in my sleep by now. It's like all my previous experimentation was preparing me for this year. The facility I feel in the kitchen, with my oven, is so welcome right now. Butter, flour, sugar, eggs. Right now, it's the only thing keeping me from becoming unhinged. So I appreciate it.

coming up now, out of the blue

A running joke among my fellow interns is that every time I drop a piece of paper from my white coat, it inevitably has a recipe scribbled on it. I don't even know how these end up in my white coat pockets, as it's not like I wander around the hospital collecting recipes. Still, I do tend to scrawl down experiments. Most of the time, there is something about the recipe that does not quite satisfy me, and thus it winds up shoved in random pockets or in the circular file.

There is a little notebook I keep in my kitchen. It looks from outward appearances to resemble a journal, and every once in a while, someone will come upon it and think they are about to discover weird, random musings (when the silly geese could just come here for that!), only to be confused when they open the book.

In the little notebook are the keepers. Recipes I've either used a million times, or ones I've wrangled into submission. If it goes into the book, I know it's the real deal. It may not seem like much, but there are now 21 recipes in there (plus a back page with little random skeletal notes about the proper ratios to make basic ganache and cream cheese frosting). To me, though, that seems like a lot, that many no-brainers, foolproofed solutions.

The 21st recipe was a chocolate ice cream recipe, very close to this one but with a few changes in ratios and techniques. Third time's the charm, and in this case, every time I've made this, it's caused a commotion. It's extremely rich, but anyone who loves chocolate would not view this as detrimental. Ice cream has the added benefit of having cream in it, which is advantageous because I am lactose intolerant, and therefore am rarely tempted when I make it.

Cookies are what I bake when I want to make something, and have a deadline. Cakes I bake for occasions. Cupcakes I bake when I want to make something but feel like fooling around with frosting. Things like ice cream are really more cooking though they involve sweet things. They're a process, the sort which I used to fear and avoid. I've written about this probably a million times, I am nothing if not repetitive. Yet I'm always surprised when things that used to frighten me now actually provide me a sense of comfort. Some people meditate or go to yoga. I've tried those things, but I find learning to temper eggs much more relaxing.

Driving through the Bay Area recently, Young The Giant's Cough Syrup was playing on the radio, and it continues to amuse me how often the lyrics of songs are completely in opposition to the general feel of the music. This seems to be more frequent recently, or maybe I'm just noticing. It worked though, because it lulled me into listening to the lyrics more closely. It gets everything right and wrong, this song, I was thinking. It so perfectly captures how a feeling of hopelessness can lead you to the exact wrong conclusion as evidenced by its opening line:

Life's too short to even care at all

Which is perfectly wrong. The fleeting nature of everything should make us find it all the more precious. But when you're tired and feeling down, I think not so much. And then of course, for those of us who are older, this one's also a sucker punch:

I'd run away to some fortune I should have found by now

There is a weird feeling that you should be free of angst by a certain point in your life. Then you find that the angst is still there. But honestly, in the periods of time when I haven't had angst, I've been suspicious. Was I not paying attention? Was it there and I just didn't notice it? Then I think that some people outgrow it, but some of us never will. Some of us will always have a little inner conflict, a push and pull and insistent questions that nag. I guess I've periodically thought of it as a curse, but maybe the trick is to accept it and befriend this constant companion.

because I never was cool

One of the other interns is also interested in Oncology, and we were talking about how who people are sometimes makes more of a lasting impression on us. She thinks it is because we appreciate how fleeting everything can be. I'm not entirely convinced. I've certainly met plenty of oncologists, I am sad to say, who refer to patients as "the lady with ALK-positive NSCLC that didn't entirely respond to crizotinib" or the like.

Probably it's just a subset of all physicians who process patients as people instead of diagnoses and conditions. I tend to remember a face and a name first, their diagnoses second, which to some, would make me a peculiar and maybe not-very-good physician. To which I respond with a resounding and unapologetic 'oh well.'

When I was a medical student, I was much more quiet and reserved than I am now (not that I am now bursting with fruit flavor). I was acutely aware of being judged and evaluated by everyone around me, and moreover very frustrated with the notion that I was not contributing much to the overall mechanics of the team on which I was supposedly working. My solution was often to give in to the ancillary nature of the role and become invisible. It comes rather easily to me.

So, having stayed at the same institution for residency, I am never much surprised when I am not remembered. It comes in handy, most of the times, because the senior residents and attendings have no recollection of my bumbling incompetence from those previous days. Last week, on a lark, I told one of the senior residents that I remembered very clearly taking my very first board exam, and seeing her at the test center. I remembered because that's how I remember things- people, conversations. I remember because she was taking her third board exam, and had told me not to be nervous. When I had wryly remarked that it seemed these tests never ended, she had bemusedly replied that they didn't end, but that the stakes became lower and you stopped studying for them over time.

She, of course, did not remember any of this, at all, and looked at me as if I was some strange stalker for remembering.

Last month, I was at a conference at one of the hospitals that we rotate through, and an elderly oncologist sat down at the table, engaged in discussion with all of the interns and residents and medical students. I wanted to talk to him afterward but he was surrounded like a rock star after a show. I remembered him too. As a medical student, he used to gather all of us into his office once a week in the early morning. Often, he brought us pastries and coffee. Every week, he went through cases from the New England Journal with us. I was facing a time of great self-doubt during that period, and I remembered that those sessions made me remember to go back to what you cherish when things are rough. I still go back and read cases when I am having a rough day. When I am frustrated with residency, I sometimes sit down with a cancer journal and read those articles, because they're of more interest to me than diabetes and COPD management (no offense intended).

That particular oncologist had always struck me as someone who thought of people as people, not diagnoses, despite his fondness for reading through cases and explaining to us how to think through symptoms to come to a diagnosis. But there he was, surrounded by a swarm of medical students trying to improve their marks undoubtedly and a few interns who had not quite shaken their gunner tendencies. I assumed he didn't remember me anyway.

Last week, I checked my mailbox at the department office, something I only get to do about once a month because of my schedule. In it was a card from the old oncologist. His note read:

Internship is more than 2/3 over. Seems hard to believe it has been that long since you were a medical student here (September 2009). Good to see you doing so well last week.

Now, mind you, he may well send these notes out to every intern who passes through. He may have looked this up in my file. The card may have meant nothing altogether. I get that. It reminds me of a conversation I once had with a friend Y when he was visiting from NY. We were talking about how people were nicer in SF, but were more sincere in NY. He said, "I don't care anymore if they're lying- just be nice to me!" I think, as an intern, that's how you feel after a while. Who cares if it is all an act? It's an act of kindness not malice, so that sort of tomfoolery- well, go right ahead.

It's also one of those things I file away. Because I remember people, and I'm already seeing how much medical students appreciate it when you remember their names, acknowledge them in the hallways, ask them how they're doing. It sounds stupid and like basic social skills, but it's shocking how that sloughs away in many folks during residency. I keep trying to hold onto pieces of me, and this is one of those pieces I want to keep close.

*

On a lighter note, a patient came into the clinic yesterday to have his abscess repacked. He pulled out his iPhone and showed me a day-by-day documentation of the wound. I said appreciatively, "Wow, so you've been keeping a very careful eye on it?"

He waved this off and said, "No, I have a buddy who's squeamish, so I send him a picture every day to gross him out!"

Boys will be boys. Even when they're 40.

Judy sucks a lemon for breakfast

I can't be bothered to take a photograph, because it's been a lazy Saturday today. Not really lazy altogether, but lazy in the sense that I haven't been doing what I'm supposed to be doing. But then, isn't that the story of my life?

Last week, I'd discovered a tree in my backyard pregnant with ripe Meyer lemons, bursting off the branches, begging to be picked. The spring, as much as it is vibrant with life and promise, is not always a happy time. It conjures up some bad memories. It also assaults me with allergies that make my head foggy.

But when life hands you lemons, well. Problem is, I can't really drink a pitcher of lemonade.

I'd bought some ginger root that I'd been planning to grate into soy sauce and simmer with broccoli and water chestnuts. But there it was, taunting me. I took the dare. In the past, every time I'd tried to bake or cook with ginger or lemon zest, I was always annoyed to discover the fibrous little bits interfering with the finished product. I was not about to dive into an adventure of sorbet-making with the same outcome.

When making sorbet (or lemonade for that matter), you have to make a simple syrup, which involves dissolving sugar into water, evaporating a little of the water off in the process. It's the perfect vehicle for infusion. So I sliced up the ginger roughly and threw in lemon peel, added the water, and then the sugar, and heated up the witches' brew. When it had come to a simmer, I set it aside and covered the pot, and let all the ginger and lemon essence seep into the syrup. When it was fully cooled, I strained it into the freshly squeezed lemon juice. At the time, I didn't think it tasted like much, but I thought, well, at its worst, it'll just taste like plain lemon sorbet. Worse things in the world.

When I make fresh sorbet or ice cream, it's rarely a whim that just comes to fruition in an afternoon. It's a stepwise process. It teaches me patience, and also makes me believe in faith, and gives me the capacity to hope. It gives me a future to consider. All in a simple sorbet. I've stumbled in the past with sorbets. When I'd been timid and a purist about them, I'd arrived at frozen blocks that essentially amounted to shaved ice. I'd read a trick about vodka softening the sorbet. And anyone who knows me knows how quickly I'd take to that tip. Indeed, it works if you are going to serve the sorbet in a few hours after making it. And that is seldom the case for me. I tend to make sorbets when I have fresh fruit that is in season and needs to be used.

I'd read a tip some years ago about adding an egg white to the sorbet, as it stabilizes the sorbet and makes it a scoopable consistency. But I don't think I could ever risk making someone sick from raw egg in their sorbet. At the same time, over the past couple of years, I had been developing a relationship with meringue. First baking it, then making homemade royal icing with it, then making buttercream with it, and even making macarons with it. Even then, I stumbled along the way. The first time, I put nearly a 1/4 cup of sugar into an egg white (or two) and beat it frothy in a double boiler, so that it cooked into a meringue. Problem with that was 1) it made the sorbet far too sweet, and 2) it turned out to be too much meringue and the resulting sorbet was a tad too creamy.

That's the nice thing about failing- it opens up an opportunity to get it right. And the nice thing about the kitchen is that the failures can be analyzed. It's relatively simple to figure out what went wrong. If only that could be said about all the other failures in life.

This time, there were no strands of ginger root or bits of zest. This time, there was a mildly sweetened meringue, and just a sparing amount of it folded into the sorbet to give it some structure. A slight splash of Grey Goose for good measure. And as it all had a chance to chill together, the lemon and the ginger combined to pack a strong punch. The result was not too sweet, tart and tangy, with a killer zing of ginger.

It may seem awfully dull. After the letter I'd received earlier this week, that filled my head with confusion and questions with no answers, that had made one particular failure a burning cloak that I could not seem to shed, it was just the dullness I craved. Outpatient urgent care clinic, which sometimes drives me bonkers with its banality, was a welcome opportunity to diagnose a man with a viral respiratory infection, a tired housewife with muscle cramps of her calves caused by chasing her children all day, and a woman with high sugars because she wasn't taking her prescribed insulin. I needed simple problems, codes I could crack. Usually, I revel in the more complicated. But this week, I just needed to fix things.

And the sorbet came out just as I had hoped it would.

if you don't know what to make of it

This song is supposedly played out, because it has been used on various television shows and whatever, but I don't care:



This video is better than a fantasy movie. It makes me imagine there is a world in which you could be hiking along a river and come upon a commune of troubadours who sing you this slice of heaven. The video made me think of home, which I rarely think about, and it made me think of the larger sense of home, and how that word has started to lose its meaning.

Plates keep shifting, everything dynamic, all things transient, nothing permanent. Entropy is the law. Things fall apart, it's scientific. Evolution, inevitable. And even though I write about that all the time, even though I accept it as reality, I don't mind saying (and this seems to be very unhip to admit these days) that I don't care for it one bit.

I got a letter and an email today. The email was from family, said they missed me. The letter was an apology, nearly a year too late. Both were welcome, neither changed how I felt tonight. It seems the only thing constant in life is on the inside, not the outside.

we all walk the long road

The job of the intern on night float is to cover all the patients in the hospital on the Medicine service. This means that, should anything come up, the nurses page the night float intern. But it also means that most of the decisions of treatment and management have been made during the day. There is a slang among us, to do with how well you care for patients during the day: if they are well-managed and treated, they are considered "tucked in" for the night, and you tend to hear little about them over the course of the night.

The "untucked" patient at night, on the other hand, can be traced to one of two causes:

• The team did not properly "tuck" them in during the course of the day.
  
• The patient is very sick and "tucking" is therefore impossible.

It is hard to hold it against anyone if the latter reason is the cause of the various phone calls. But often it is the former that leads to the cacophony of a screeching beeper in the wee hours of the night. Last night, as the night float intern, I wound up having two extensive discussions with patients who had cancer, and it was evident that communication had not been good with the team during the day. One of the patients was an unfortunate 27-year old Punjabi woman who had recently been diagnosed with stomach cancer. Her belly is riddled with tumors. She is getting chemotherapy to keep her symptoms managed, but there is no chance that it will be curative. She asked to speak with me about why her belly continued to hurt. I was surprised to find she had not had much of a discussion about her cancer with the physicians taking care of her during the day. I had a frank conversation with her about the tumors and how she would likely continue to have swelling in her belly, and that our best bet was to manage her pain with medications as best as we could. She was startlingly young.

Looking at her, I was reminded again of why I would never want to do Pediatric Heme/Onc. I know that kiddos bounce back fast, but seeing someone that young face a terminal diagnosis takes a more palpable toll than much else I have seen in the hospital. The next morning, the physician who cares for her during the day, an intern herself, told me that she knew someone needed to have a conversation about the cancer and how bad it looks with the patient, but that she "just couldn't do it." The idealistic, wide-eyed intern I was 9 months ago would have given her the stink eye and yelled at her for being a wimp. Truth be told, it was inappropriate to put off the conversation. I couldn't yell at her today though. I felt like she was recognizing limitations in herself, maturity that she did not yet possess, and it was perhaps too demanding to want her to be as comfortable with the conversation at this stage.

An uncle of mine had a child who was born with a congenital abnormality, which affected the child's development significantly. Sometimes people would ask my uncle how he dealt with it. He never looked at it that way, though. He always said he felt lucky, he felt he had been entrusted this person with extra needs, and it was a privilege, a blessing to be able to take care of this special child.

It's not really the same, but I do sometimes feel that way about oncology. It's not that anyone savors having conversations about death and dying, about bad news and hard fights with poor odds. But it truly is a privilege, it is a blessing. If you're not equal to the opportunity, if you can't see it that way, if you find it daunting to fight the urge to flee from the conversation, perhaps it's best to let someone else do it.