a dissident is here

The healthcare system is broken, I tell the interns, when we are frustrated about a patient's care.

But what I should say is that America is broken.

That the world is broken.

Everything is broken. It reminded me of this poem by Berberova with the lines-

"And if everything gets broken, there'll be nothing.
And people have broken so much inside."

I'm feeling very empty. I'm feeling like so many physicians feel these days. Broken inside, hollow. We are the hollow men (women).

The healthcare system is broken. But I went to my patient's bedside in the hospital, and this was done during my lunch hour, because these are the kinds of things physicians are encouraged to do during their break time, while also being lectured about the importance of wellness and balance. I went because the man, who I'd only met once before, was hospitalized and found to have cancer which had spread to a part of his small intestine that was making it impossible for him to eat.

He was forced to have a nasogastric tube, and he was not allowed to eat because the gastroenterologist had tried to place a stent to relieve the obstruction the cancer caused, and it had failed, so then he was awaiting a possible surgery. He was tired and frustrated, this I understood. I did not expect him to be overjoyed to see me, or even particularly grateful.

I also did not expect him to scream at me in rage, tell me that every one of us doctors were worthless, that if he could take the nasogastric tube out, he would shove it up one of our backsides. I did not expect his wife to yell at me multiple times about not being able to give her straight answers, whenever I answered her honestly about the likelihood that chemotherapy would help him.

You feel, in these moments, like a bad doctor. You've been trained to swallow these screams and rationalize them as poor coping, difficulty with accepting a diagnosis, misplaced anger.

The wife yelled when it was becoming increasingly obvious to both me and even her that all of their complaints weren't even related to anything I could control, "look, we are looking for a punching bag, and I think you should volunteer to be that person for us!"

Yes. Sure. I went to medical school, residency, fellowship, I do research, I chose to go into oncology. Specifically because I was looking to be a punching bag. Yes. I have done years of work to make sure to avoid my family's tendency to designate me their punching bag. But therapy, schmerapy, sure, please, let me be your punching bag.

I sidestepped the conversation. I redirected the way I've been taught to over the years. People tease, "wow, you've got some tough patients," or they say "just" and they follow the just with things that infuriate me.

Just walk away.
Just set some limits.
Just don't take it personally.
Just focus on the medicine.
Just remember they've got metastatic cancer.

Because sometimes as an oncologist, sometimes as a doctor, we just have to swallow the daggers down. But here is what I was thinking about, from W Kamau Bell's Private School Negro:

"When racism happens to me... historically, people of color just hold it. This is true of all the hates. Like transphobia, like homophobia, like ableism. You just hold it, and you have to take it home. But in 2018, I'm playing hot potato. I just toss it right back. Nope! I'm out of time. I'm out of time. You tell the story."

Because the reality of the matter is this patient and his wife, they saw a woman, a woman they thought to be younger (if only they knew), a woman of color. Did they lose their temper with any of the white men on the team? Nope.

I'm sure it wasn't about that.

White people say this. Maureen Dowd says this.

It's not even 2018 anymore. It's 2019. And it is racism. And sexism.

And I am f***ing very tired, and broken. And everything feels broken inside. And outside.

But I thought of W Kamau Bell's words later today. When, after a series of pages and a nearly comical carousel of communications that went nowhere, I decided to try one more time and called the patient's wife, and the patient's wife confirmed it was me and then said, "Oh! Don't bother, we're getting someone new on the case!" Then proceeded to hang up on me. Today, I thought about W Kamau Bell's words, and I decided to hand the hot potato back to her. Because today, I fired a patient, refused to see him again, and said it was best for everyone involved if we no longer communicated.

I have never done this before.

I suspect this won't be the last time I do it.

but it's out of my control

This one is going to be discombobulated.

The patient with sickle cell lies uncomfortably in the hospital bed, rubbing her pregnant belly. She's been worried all week; this is not her first pregnancy, not by a lot, but there has been more bad news than happy ones during her pregnancies. Sickle cell patients are at a higher risk for miscarriages, preeclampsia, all kinds of pregnancy related complications. She is having a pain crisis. 

The nurse changed her benadryl dosing halfway through her hospitalization, convinced she was seeking a 'benadryl high.'

I talk to the interns about the importance of treating sickle cell patients with consistency and fairness. I talk about how they have real pain. I talk about the patients who have been perceived as 'crying wolf' who subsequently died of acute chest syndrome or a myocardial infarction. I talk about how sickle cell patients live a decade longer in the UK compared to the US; I ask the interns why that is. They come up with creative suggestions, ones that those with much more training have tried to use as explanations, about biological differences. But it's pretty much established that the reason that they live longer is that they have healthcare and an infrastructure that knows it benefits the system to treat these patients properly.

But I watch the nurse complain to the intern about the benadryl request, and I wonder how long before the interns unlearn everything I've just tried to teach them.

We walk into the room, where the patient rubs her belly. Her partner is lying in bed beside her, the two of them barely contained in the uncomfortable hospital bed. The fellow starts speaking straight to the patient, completely ignoring her partner, who the fellow has never met. I gently interject and introduce myself to the man, and he responds immediately, politely introducing himself too. The fellow awkwardly recovers.

Walking back to the rest of our patients, a hodgepodge of chronically and acutely ill patients, I think about inequity and disparities. And how it's not enough to say you try to treat every patient the same, because the fact of the matter is we just don't. There are inherent biases. Things the nurses teach you, things the residents might have taught you during training, little silent cues, and there's society at large. Every time a sickle cell patient is on my service, I am haunted by the statistics about their outcomes. I think of the patient rubbing her belly- African-American woman with sickle cell patient. I think of the maternal mortality rates in the US, and we call OB one more time and make them check on the patient.

But I worry that it's still not enough.

The best thing we did at our institution that helped control sickle cell related pain was the work of an African-American nurse who took it on as her cause to treat these patients humanely and to improve their pain. She championed an initiative to reserve a set number of chairs in our infusion center for IV pain medications for these patients, so that they could call in with a pain crisis, come in and get the needed IV opioids without waiting for several hours in a crowded ED, getting scowls and skepticism from nurses and doctors who don't fully understand their disease, and having to argue about the dosage they need.

That nurse really singlehandedly reduced the number of hospitalizations due to sickle cell at our hospital, though initially her plan was thought to be unrealistic. Sickle cell patients come to the hospital and don't leave until you make it uncomfortable for them, one resident said to me when I was a trainee. That was the perception, that was the theory. That was utter bullsh*t, that was grounded in inherent biases, systemic racism, and a lack of education.

***

We round in the morning, and it is starting to exhaust me, which always happens around this point, the 10th day of a 14-day hospital stretch. Mostly I am exhausted by what I can't do. There are five patients on our service right now who don't really need to be in the hospital. One had been living in Morocco with her husband, and returned home to California after getting out of an abusive relationship, only to find out she had an aggressive lymphoma that was eating away at her hip. But since she just moved back to the US, her health insurance is still being processed. So here she sits. Another was diagnosed with acute leukemia and didn't have health insurance. He would die if we didn't give him chemotherapy. He'll die if we let him leave the hospital since, if he walks out of the hospital, he can't receive therapy in the clinic (which normally would be the treatment). So here he sits. Another has the kind of mental health issues that are not severe enough to warrant inpatient mental health treatment (because the state has made so many cuts to mental health care, inpatient centers have had to narrow down criteria for admitting patients to only the most sick, dangerous patients), but not mild enough to allow him to be discharged safely. Here he wanders the hallways. One lives five hours away in a rural area- I regularly receive emails from desperate recruiters trying to get me to take a job as an oncologist in this particular rural area. There are clinics, but no providers, especially since we've made it harder for foreign physicians to stay in the US. The last patient will not be accepted to a nursing facility and no one in his immediate or extended family can care for him at home, especially because we as a nation do not provide enough financial and ancillary support to caregivers.

Of all the types of care you can get, a night in the hospital is the most expensive.

So yes, the system can handle single-payer insurance.

***

Call me corny, I don't care. But if you ask me which movie has stuck with me the longest this past year, it's Spiderman: Into the Spiderverse, which is now available to stream on Netflix. I watch the superhero movies, at least some of them, but mostly for mindless entertainment. Even the ones people claim are great (i.e. Bat-Bale-man era stuff), I find pretty problematic if you look too closely at its politics. No such problems with this movie. The spirit of everything good about New York is also infused into every second of this movie. The soundtrack is pretty good too.

please don't call me on my bluff

Trying to write this week is almost absurd, but maybe that's the best time to write. And when you have so many other things you should be, writing feels like an indulgence that it doesn't always otherwise.

I wanted to play Welcome to the Jungle to the new interns today, who were shadowing the outgoing interns-- this is a new thing, by the way. No more throw-them-in-the-water-see-if-they-can-swim, which makes people of my generation cantankerous about the good old days, but honestly, though that trauma made me put on my big-girl pantalones, it didn't make me a better doctor. Anyway, given this new kinder, gentler entry to the world of doctoring, I, of course, did not play Welcome to the Jungle. Never mind that most of them would not have recognized the song.

The outgoing interns, seasoned after a year of being on the lowest rung of the ladder, sailed through rounds. I've only been working with them for a few days, but they're a good bunch of them. One, in particular, has the most righteous indignation that reminds me that I really should try to get out of the way of her generation. They channel their rage sometimes with such absolute focus. This intern, H, she's got a reputation for having a temper. The first day I served as her attending, she dropped a curse word in the work room right in front of me without the slightest pause. She is unapologetically herself, and I'm torn between high-fiving her or making her my role model.

H defended her rage, when one of the men in the room (of-f***ing-course) said she was angry, pointing out that her rage wasn't focused on slights against her. It was always, always on behalf of the patient. And the thing is, it's true. A few months ago, a patient of hers was dying. Not an uncommon occurrence on the Hematology Oncology service, unfortunately. But H was trying to take good care of her patient, and so she felt that this patient's family, his parents in particular, should be notified that he was dying.

Well, it turned out H taught me something with this story. Even though I've been doing this for a while, I had no idea that patients who are also prisoners are under something called a total-blackout. This means, no communication about their whereabouts or their wellbeing to the outside world. I'd somehow never taken care of a prisoner that was dying of a terminal illness, so I was not aware that this total-blackout applied under any and all conditions.

Here's the thing. Many an intern would be pissed, and many an intern would go home despondent. Many an intern would wonder why they didn't go into Dermatology, and many an intern would tell themselves they should pick a specialty that didn't involve so much doom and gloom. But this intern, she got mad. She got Good and Mad, and she channeled her anger with zero f***'s to give. The guards taking care of the prisoner told her that their hands were tied. It was policy, nothing to be done. They said they understood the man was dying and they felt badly but it was out of their hands. H could have said the same thing. Many interns would have. But not her. She was still angry, and she demanded to speak to the guard's superior. She escalated and escalated until she was speaking to the hospital head of security.

She went head to head with him, and she did not back down. He once again reiterated the policy, and she would not take no for an answer. She said, "we are treating him like an animal." And the head of security tried to get offended and said that it wasn't fair to characterize their behavior in this way. To which H responded, "then stop treating him like an animal." And impressively, this woman on the lowest rung in the ladder at the hospital prevailed, and she called the patient's parents, who got to say goodbye to their son.

She told me of all of this because, when the man in the room had told her she was angry, I said, "rage can be a good thing." I'd also muttered offhandedly about our entire healthcare system being broken during rounds, when we spent 15 minutes talking about MediCal sending a letter to our severely immunocompromised patient with acute leukemia that his antibiotics were not covered by them and that he had the option to go to court to appeal (!!!WTF?!?!!!). She'd seen my rage, and offered up her own.

But she did something else. First of all, everyone complains about the trainees nowadays, and I understand that too. They don't work as hard, they aren't willing to sacrifice their personal lives for patient care, and they simply refuse to do some things. But they are a direct response to a phenomenon described probably most aptly in this recent NYT article - the system is grinding down physicians, chewing and spitting them out. Forcing us to fight unwinnable battles, work unworkable hours, while also telling us the problem is that we don't have wellness training. Medicine is no longer glamorous, and no longer does it even feel like a noble profession because so often our hands are tied by bureaucracy and insurance companies and government policies.

The thing is, the new generation of physician trainees, a sect of them are very much in the f*** you quadrant that's occupied by the likes of AOC. They are not having it. H was not having it. And she realized something that people of my generation have long since forgotten. She had the truth on her side. She had doing-the-right-thing on her side. My generation is so jaded about the thanklessness of doing the right thing, we've lost the ability to be brave in many situations, or we've just become discouraged from failing to change things. But H and her crew, they could change things, for the better.

Or. See, that's the thing. They could change things, or the system might break them. I remember how valiantly I fought battles when I was an intern. Nowadays, I am angry and I try to change things, but it's not with that same passionate righteousness, it's not with the hope that I'm going to change things. I have this horrible I'm going to speak my mind so that I'm on record but I know I have no power to actually get anyone to listen attitude about things, this horrible screaming into the void feeling. Will these interns become me some day?

I hope not though. I know that's the party line to millennials and the generation younger than them. That they feel these things so strongly now, but wait until you're older, you'll be the same as the rest of us. But I don't know. They seem like a different breed, and if I'm going to put my faith in anything-why not put it in them?

I don't need to be forgiven

"Your parents are so proud of you," my patient said.

It can seem that way on the surface. It might even be that way in a certain context. Yet, it always makes me prickly when people tell me this.

A lot of South Asians who are not doctors have derision galore for those of us who have chosen this profession. I know, because I shared some of that derision for a long time.

There's this folklore on shows like Master of None and other South Asian shows that South Asian parents are selfless and sacrificing and that they would do anything for their children's success. And there is undeniable truth in that. There's also something under the surface that not that many people wish to acknowledge.

As far as pop culture goes, the depiction of South Asians that hit me in the gut the hardest was Nair's Mississippi Masala. Because this I recognized- gujarati aunties gossiping to each other, shaming each other, and aunties and uncles obsessing about realizing the American dream, strictly in the capitalist interpretation. This I recognized- the bemoaning of colonial tendencies and mistreatment by Caucasians, but yet the anti-blackness. This I recognized- the daughter who vacillated between trying to placate her parents and finding it impossible to fit into the outlines that her parents had drawn for her.

A lot of damage happens in the South Asian community on the basis of societal expectations, which Hasan Minhaj beautifully captured in Homecoming King with his log kya kahenge bit. What's funny is parents have obscured this log kya kahenge tendency, and children often feed into it too, thus also not calling a spade a spade. I'm really on Twitter mostly as a spectator, and sometimes to scream into the void, but it's often tempting to call out the countless folks of my generation and those of the generation that followed me, who wring their hands about disappointing their parents, who say they felt pressured to be doctors, lawyers, engineers.

I kind of ruined things for my parents early on. I was a sensitive kid, from a young age, and it was so obvious that the only way my mother would ever be satisfied with me is if I did every single thing as she prescribed it. My mother, I should note, and we will never talk about it as a family, and certainly will never talk it as a community, and certainly she would deny it until she breathed her last breath, but my mother suffered/suffers from mental illness. So there is a very good chance that even if I did every single thing she wanted, she would have found a way to find me lacking of her approval and love.

But my mother gave me a great gift in a way. My mother and father, like many South Asians of their generation, are very social people. They came to America and craved other South Asians with desperation- some of our closest family friendships started in desperate grocery store encounters. I don't honestly know if the same social norms from India carried over here. I just know that every weekend, we went to a different auntie and uncle's house, and all the kids got shoved into a room together to amuse ourselves while the women all congregated in the kitchen and the men all sat around the living rooms talking smack.

I learned a lot about the world from those gatherings. A lot of those things, I've spent a lot of time unlearning. The man is always right, a woman who works full time doesn't care about her kids, a woman's education is not as important as a man, a woman's education should help her secure a good husband, a woman's opinion cannot be considered valid about anything outside of food and Bollywood.

And the one that people don't talk about that often. The society in which I was raised held up a belief that children existed to serve as an extension of their parents' identity, to contribute to the status of their parents. A child's accomplishment is their parents' accomplishment.

They're proud of you, they say.

Or maybe they're just proud.

When does your life become your own, I suppose?

It's arrogant to say that anyone does anything in this world all by themselves. My brother and my cousins and my family friends make this claim and it's obnoxious. Their parents have financially buffered them, allowed them to be successful. But that's the thing. You let them pay for your education, subsidize your rent, help you with expenses, help you with that down payment, provide you with free childcare- you better believe they get a say in what you do with your life.

My parents helped me too. I'm aware of that. I worked by choice, as an act of rebellion. My mom was a little more blatant than most South Asian parents, and that's the gift she gave me. She held money over my head like a bookie. If I didn't do x, no allowance, no new clothes, no movies with my friends,  no going to summer school. So I started working initially for pocket money, f*** you money, I guess you could call it.

But that wasn't enough. My mom would remind me, that classic South Asian refrain, this is not a hotel. I was living under my parents' roof, but I didn't have South Asian friends in my hometown. I had other friends in high school, friends who got kicked out of their houses, friends who worked to make rent, friends who contributed to rent. So I still knew I had it easier than a lot of people. And I also knew I was a coward, because I wanted to get to college, and I knew I wasn't going to make it there without remaining under my parent's care in high school.

In retrospect, it was amazing that I had that much insight at 15.

In retrospect, it was also amazing that I was such an utter idiot at 15.

Because my solution was impressively self-destructive. My parents' only bragging right when it came to me was intelligence. I wasn't cute or otherwise talented, I wasn't docile and obedient, I couldn't cook (then, ha!), I didn't care about wearing pretty outfits, and even though my mom made me take Bharat Natyam classes, I was mediocre at best. But I was a bookworm and a nerd, and school was not challenging in EBF, so I did well. And my parents loved to bring this up. They loved to bring up to their friends that I was taking advanced placement classes, that I was in the gifted program. Whatever they could scrounge up.

And I think adolescents in particular struggle with their identity as it is. And I felt outside of my body much of the time. I felt like I existed as a vessel of my parents' expectation. I felt like my accomplishments only mattered insofar as what my parents could make of them, what they could say about them. Maybe my parents wanted the best for me, but it didn't feel that way. And I couldn't separate what I wanted from what they wanted for me.

So I failed my favorite subject.

I went to my English class. Like the true nerd that I was, I did the assignments too. I just didn't turn them in. Over and over again, until the teacher had no choice.

My parents were livid and also baffled. I was nearly baffled myself.

But there's something good about burning your entire identity to the ground. You remain. You get to figure yourself out, figure yourself out without the constraints of expectation and pleasing others. And I did, and it was my first taste of failure as freedom. My mother, in a panic, forced me to apply for a summer study program, and she unwittingly turned my entire life around. Six weeks at 16, not living with my parents, with one professor who was a socialist and another who encouraged me to figure out what I was doing and why I was doing it. And also, I lived on a campus for six weeks with kids who actually wanted to study too, kids who were not posturing, kids who showed me that everything didn't have to be so binary- that you could study hard and still have fun. Less antics and intelligence than Real Genius, but the camaraderie was similar.

I returned to high school with a completely different attitude. My grades were back to spotless, because I wanted to get out. I wanted to get to college. I wanted to take a big bite out of life and taste all of it. And nothing was going to stop me. Not even getting rejected from various top notch schools.

It was the second to last showdown between my mother and I. She wanted me to go to the state university, and I wanted to go to the one in the city. The state university was in the middle of nowhere, and I would have a been a speck of dark dirt in a clean white page there. I knew I would have become clinically depressed if I went there, I knew it with such certainty that I fought and fought, and my father interceded for the first and only time in a battle between my mom and I, and he endorsed me going to the city university.

My mother said it looks bad, to spend money like this on a daughter.

So I got scholarships.

Anyway, all of that was a long time ago. And I had complicated feelings about becoming a doctor later in my life, mostly because I wanted to be 250% sure I wanted it, and it wasn't somehow a way to earn validation from my parents. Luckily, by the time I decided and had saved enough to go to medical school, it was at an age where it seemed more misguided, whimsical and foolhardy rather than something to brag about.

But like I said, that was a long time ago, and I had long ago given up on trying to please my parents. My father called me once and asked, what type of doctor are you, because all my friends ask me. My mother sniffed once and said, when V uncle got pancreatic cancer, the doctor didn't do hardly anything, the nurses were really the only ones who took care of him. And anyway, being a doctor isn't even something that impressive anymore among their friends- their friends' children are bitcoin magnates and tech mavens and not to mention anesthesiologists. As an academician, I once again thwarted my parents' bragging rights, when I informed them that I get paid half what most community oncologists get paid.

You'd think. You would think at this age, that they would let it go. I let it go a long time ago. I knew I had disappointed them, that I'd done nothing the way they'd wanted me to. I thought we had settled into an equilibrium. Not a peaceful one necessarily, but one with balance.

Then my parents shattered Le Chatelier's principle because I did one thing. One thing.

Recently, I bought a house. Tangentially, allow me to note, every time I write, I bought a house, I get a flashback of that stupid movie with the little moppet yelling we bought a zoo! It seems as unhinged and as stupid a decision as that. It's nothing I ever yearned to do. It was never The Goal, not even vaguely. I had let go of wanting the norm of the picket fence and the kids and the cars. None of that.

Really, I bought a house because the lease expired at an inconvenient time at the place I was living, and I realized this could be a recurring nightmare in my life, uprooting myself from place to place on someone else's whims. And my work makes that a real problem, because at the moment it demands my time in a way that does not allow for this. Also, unfortunately, rents have gone up in my neck of the woods such that it no longer makes sense to pay rent instead of a mortgage.

So begrudgingly, and with a wholly nauseated belly the entire time, I settled on buying a house. It wasn't a momentous occasion except that I did take a moment to acknowledge that not a single other person in my family had done this, bought a house on their own, and certainly not any single woman in my family. So I understood that some of my misgivings stemmed from being the first. And some of my misgivings stemmed from the permanence of home ownership (though nothing is really permanent, it just feels more permanent). And of course, a large portion of my misgivings stemmed from California being the most overpriced place in the world, and the market being exorbitantly expensive such that I've already made my peace with losing money on this whole thing.

Anyway, buying a house had an unexpected consequence. I really thought my parents were past this. But they're not. They still are very social. I forgot that my brother has been bearing the brunt of their bragging. He has ticked all their boxes, though he certainly did it on his terms. But he has the wife, the kids, the house, the job. My parents have photos to parade around, and even though they have an icy relationship with my brother, they're happy with it, because it makes a good story. And my mother and father like their stories.

So, when I bought a house, my parents suddenly felt they had a story. My parents, who have not inquired much if at all about my job or my life, were suddenly asking all kinds of questions. How many bedrooms was the house, where was the house, how much square footage was the house. And could I FaceTime with them when I closed on the house so that they could see the inside (nb I have never once FaceTimed anyone in my life)? Suddenly I was 16 again, and my self-possession flared up. I wanted to scream, this is not yours, this is mine! But nothing is really mine and nothing is theirs either. We are interconnected but also quite separate. Even if they did not help me financially in any way, they raised me, they fed me, they clothed me in those formative years. There are things I carry with me from my parents, but there are also ways in which we are strangers. And I am old, and they are older still.

Some fights, I feel like I've been having my entire life. And those fights, they're just not worth fighting anymore. I'm not going to change my parents' minds about how they view the world. They're in their 70s, and they've never shown the slightest inclination towards changing their behavior in the past. But nor do I plan to appease them completely, because that's something I can't do and still look in the mirror every morning.

When the third request to FaceTime came in, along with an urgent message asking me to post to a family WhatsApp group pictures of the house, I knew I had to address it. So I took a deep breath and told them that no, I would not be FaceTiming. And no, I would not be making any wild announcement to the family. But it wasn't a secret either, and I didn't care what they did with the information. It was not it's not yours, it's mine! It was more, I'm not participating in this, but I can't stop you so I'm not going to try. Which is only slightly different, I know. I'm sure my parents were not satisfied with this response. But it was what I could live with as a response, and sometimes, that's the best any of us can do with family.

All this to say to my patient, yes, I suppose they're proud of me. In the end, I suppose they probably are. And I guess it's not up to me to decide what they should be proud about. What I value as an accomplishment is not what they value as an accomplishment. It clearly bothers me because it spurred on this post. And yet, that I could write it down and name it, it's also a way to let it go. And I guess I don't have much in common with those South Asian folks who lovingly talk about their family's expectations. I can't think of it with that kind of romance. But it has allowed me to live honestly. And that's something, I suppose.

#1000wordsofsummer is hard when you're on a 14-day hospital stretch. But I'm still going to give it a shot. But I apologize- this is all gratuitous nonsense. I'm just trying to get some words out so that I can maybe get back into the practice of writing.

Oh and also, anyone who is going through a move and is behind on the Kondo movement knows the truth/sarcasm of 'til every room in my house is filled with sh** I can't live without in Arcade Fire's Everything Now, a fantastic live version of which exists here. 

you don't know me at all*

It's overdue, that I start writing again. When I thought about why i don't post much here anymore, I really thought about the difference in me during 'peak' posting era versus now. It's not just that the entire blogging community has disintegrated. And it's not that life has become so busy, that my writing has all been technical and scientific and work-related. And it's not even that I don't have anything to say. Though all those things have felt true.

But I realized partly, I was writing to be seen, to be heard, to be understood. Even if it was only by one or two people, or even if it was only just for myself. It's the biggest difference I've noticed over time. I used to feel so lonely and feel so despondent. That I didn't have my people, those likeminded people who felt the way that I did, who valued the same things that I did, that I understood and who understood me. And for a little while, the internet harbored this promise that maybe those people, my people, were out there, just trying to find a connection.

Really, the only person who needed to know me was me, as cheesy as it sounds. But the fact is, that's the only person who can ever know me. I remember S said to me once that he had figured out our mutual friend B, but that he hadn't quite figured me out. There are two things about that which left me speechless. First, the utter arrogance to assume he had figured B out after knowing her for a few years as a classmate, and having a few deeper conversations with her. Second, I understood why he felt he had figured her out.

Because B was like a lot of people in this world. You can take the route that society indicates. You can fit into the norms. And you can seem quite knowable. It doesn't mean you are, it doesn't mean anyone actually knows you- but you seem pretty accessible.

It was what ultimately ended one of my very closest friendships. Sure, there was also the fact that he decided to become an anti-vaxxer and I decided to become a physician at almost the same time. But there was also this- I had spent almost 95% of our interactions trying to convince him I was someone worth knowing, and trying to make him see me. When I was younger, he'd accused me once of not wanting to be known- which should have tipped me off that we would eventually disappear from each other's lives, because my whole life I'd craved to be known. It wasn't just that I wanted to be known, I wanted to be known by him. I had conjured up this notion that he knew me better than anyone else in the world. And I think we both believed it.

And then I went to medical school, and I realized he didn't know me after all, when he muttered, flippantly, "what, you're going to talk to people about cancer?" with this disbelief. Like he couldn't imagine me having the capacity to treat a cancer patient. Like he couldn't imagine me caring for patients the way which was required.

Probably the toughest part of the dissolution of our friendship was grieving that- grieving that he did not, in fact, know me after all. It was my fault too. As much as I thought it wasn't true, in some ways I didn't want to be known. I didn't have the vocabulary back then. I didn't know about code switching. Part of our friendship was rooted in white-adjacency and the wedge in our friendship was the not-quite-whiteness. Part of our friendship was very Gen X, very rooted in rebellion, and then he became part of the establishment. But mostly our friendship was based on saying we were each other's oldest friends, that we'd known each other the longest. But we didn't, not really.

And maybe we didn't want to really. Once, a long, long time ago, when we were very young, he and I were out with his family on a cold night in Massachusetts. A friend of his mom turned up, an Indian woman from India, and she was probably around the age I am now. The age of IDGAF, frankly. And she also didn't have a notion about someone like me, someone born in EBF, in white bread central. When I was introduced to her, the woman laughed and jeered my friend for not knowing how to pronounce his alleged best friend's name.

I used to sometimes try to catch her, but never even caught her name, the song goes. I'm old enough now that I've had time to think about it, and I don't really care anymore. These are problems that nowadays, you don't even have to have. We got left behind, our generation who struggled to live in two different worlds without letting the colors bleed into each other, but I am happy for those who do not have to think about such things now.

But time does interesting things. You survive and the hurt fades away, and it's no one's fault even. To some extent, I'm not trying to be known anymore, because I recognize the impossibility of it. One of my dearest friends gets angry at me sometimes, because I can be a bit passive about my friendships nowadays. I love my friends, but I don't expect a lot in return, and I don't fight it if those friendships fade away. She wants to fight. But she's a decade younger than me. She just doesn't know yet. That even the friends you love most, the ones to whom you feel the closest, even those friends may drift away because of circumstance, or because of some wedge that drives you apart despite everyone's good intentions. And it's not something sad, not really. It's basic chemistry and physics. The world tends towards entropy- things fall apart, it's scientific.

And maybe I don't have anything to say anymore. Maybe my generation is supposed to just be quiet now. And let me tell you, in my personal life, day to day, I live pretty interiorly. This blog is pretty interior, considering it's hardly read and blogs are essentially dead. On Twitter, where I'm probably most active, I'm still pretty quiet, and the real joy I have there is listening to other points of view and learning. I'll never know anyone on Twitter, I'll never really know anyone who reads this. But is that so different from the world outside of the internet?

Anyway, nevertheless, more tomorrow, when I'm hopefully less rusty,  if this #1000wordsofsummer thing works out.

*If you have not heard this classic Ben Folds/Regina Spektor duet, please correct your life here.

the weary world rejoices

The year is coming to an end and every time I have sat down with a few spare minutes to write a few words here, those wards have multiplied into an incoherent rant, and an incoherent rant is the last thing anybody needs at this point in 2017. It was an odd year in so many ways. There was this constant thrum of all the terrible things happening in the country and in the world, the constant blinding light shone on the reality of these United States of America. But I also finished my 10-year journey of The Goal by graduating from fellowship, and even better, I got my lifelong wish to become a professor. But like most dreams and wishes, the reality looks different and there have been a lot of challenges and I'm not entirely certain how it's all going to play out. But those are anxieties for another day.

I decided today I just wanted to think about the things that brought me happiness in 2017, things that were not personal (i.e. private) in nature. So here they are, in no particular order, with the usual over-explanation:

Hasan Minhaj's Homecoming King: This felt like the realest, most unapologetically South Asian-American stand-up I've ever seen. It's filled with immigrant stereotypes, sure, but Minhaj infuses it with both pride and love. He also does something that resonated with me- he takes the frustration he sometimes encounters with his parents to think through their experience, their perspective, without getting saccharine about it. Also Minhaj's set covers the truth about immigration, the otherness that is felt even in a community that is supposedly moderate to liberal, interracial dating, interfaith marriage. I don't know how he did it all in one set while also earning every single laugh. He still turns up from time to time on The Daily Show, but I hope we'll keep seeing more and more of him. He also doesn't shy away from loving and celebrating brown women, which sadly puts him in a minority of South Asian-American male comedians these days.

Tiffany Haddish: I will not even pretend that I noticed Tiffany Haddish much when she co-starred in Keanu. I also only ever watched a few episodes of The Carmichael Show, because that sitcom never really grabbed me (weirdly, even though Jerrod Carmichael played with it, it still felt too formulaic in the episodes I saw). So I was definitely one of the bandwagon-jumpers who saw her on Jimmy Kimmel and marched right out to see Girls Trip. Not to detract from the other women who were also solid in that movie, but that movie was a full-on start-to-finish Tiffany Haddish coming-out party. Lately, I've started to think of her along the lines of Robin Williams- she shows up, she's larger than life, she's quick-witted, she's hard to control, but she is hilarious and full of heart. Watch Kimmel realize he's in the midst of something out to go viral, watch Colbert develop a "Tiffany Haddish problem," watch Ellen squirm uncomfortably in her inability to control the interview, watch George Stephanopoulos get dragged into dancing with her while Robin Roberts and Michael Strayhan lose their minds, and watch Trevor Noah giggle uncontrollably while gushing over her book. You can't watch any of those without smiling. Also, the single greatest moment on Weekend Update on SNL this season (granted, a very low bar) was Tiffany Haddish randomly paying homage to Coming To America in a blink-and-you'll-miss-it reenactment.

Sally Q. Yates: One of the first heroes to emerge this year was Sally Q. Yates, Attorney General of the United States, who blocked the immigration-related executive order that was issued, got fired for it, and then patiently dealt with the House (lack of) Intelligence Committee hearings, which might have been the spark that kicked off the "woman are done with your sh**" flame war.

Kendrick Lamar, DAMN.: I'm not sure that this album always makes me happy or fills me with joy, except at its existence. Sometimes it makes me very angry, sometimes it makes me self-righteous, sometimes it even makes me melancholy. I know some people were wanting Lamar to release 2017 marching orders or something, but this was just Lamar being excellent as far as I'm concerned. Didn't hurt that he lit people on fire, got Don Cheadle to lip synch, and made a mind-bending video with Rihanna.

The Leftovers, Season 3: The Leftovers is definitely not for everyone, and there's certainly an argument to be made that it's problematic in terms of proper representation. But it's unlike anything that has ever been on television, and it's such an existential show that it has felt so fitting for our current times. Even though it is a serious and sometimes seriously depressing show, it is also absurdly funny too, including a surreal moment involving the Perfect Strangers theme song which made me wonder if the show was made specifically for me. I'm disappointed it didn't get the credit it deserved but I wonder if the show cares because ultimately for those who loved it, we loved it so hard that we were ride or die for it. Also, why knew Liv Tyler could play a very believable villain?

Maxine Waters: I don't need to say much more than: "reclaiming my time." Again, women have had enough, and Maxine Waters definitely is not interested in your nonsense.

Halt and Catch Fire, final season: This show initially pissed me off even when it had gone from pretty lousy to pretty good, in part because it was a show about the early days of technology that erased most of the people of color out of it (one season, they had a South Asian character but named him Ryan Fricking Ray, and I immediately turned off the television. Poor Manish Dayal seems destined for a string of bad casting, since he's next starring as the South Asian underling of a cocky Matt Czuchry in The Resident, which looks to be yet another medical drama with terrible casting but one-ups by also painting the medical profession to be a mostly capitalistic undertaking). But the show morphed and its final season was so amazing that I ended up being in hook, line, and sinker. It's no mistake that this show was also on AMC. The common thread it shares with Mad Men is that it's about work and the relationships that develop in the workplace. But the beauty of Halt and Catch Fire is that its beating heart was really about two women who love their work, regardless of what it costs them and regardless of their other life choices. And that's a new story.

The trailer to Black Panther: I have never been more excited about a superhero movie. Ryan Coogler has never done wrong in my book, and this movie looks amazing. Honorable mention: Thor: Ragnarok- if you have seen Boy, Hunt for the Wilderbeasts, or What We Do in the Shadows (my personal fave of the three), then you know Taika Waititi's unique voice. He elevated the Thor franchise to pure, unadulterated fun though it still had a heart. Both Thor and SpiderMan Homecoming this year leaned into diverse casting and lightheartedness, and it was all the better for it.

Ed Skrein doing the right thing: Ed Skrein was not a marquis actor, not someone with a huge name. His biggest role was probably being cast in Deadpool. He then got cast in a role in an upcoming Hellboy reboot, and fans, tired of the 'Emma Stone is Asian in Aloha, Scarlett Johansson in Ghost Shell, Matt Damon is the star of The Great Wall' phenomenon, were understandably pissed to hear he had been cast in a role that was a Japanese-American in the original comics. Then Ed Skrein, an actor who actually could have used the work and probably didn't know when his next paycheck was rolling in from film, did something no one else has done before. He apologized and took himself out of the game. It is easy to talk a good game- if 2017 showed us anything, it was that a lot of people can pay lip service to what is right. But to actually do it, when it's not easy, when there are personal costs, that's really praiseworthy.

Immigrants, We Get the Job Done, Hamilton Mixtape: Look, I'm not a Hamilton Diehard. I don't live in New York, I don't have tons of disposable cash to seek out tickets, and eventually I'm sure I'll be late to the Hamilton party and slap myself for it. But in the meanwhile, this came out, with a fiery verse from Riz Ahmed to boot, and if ever there was a year for it to be released, this was it.

One Mississippi, Season 2: this season features Tig Notaro's usual brand of humor and exploration of her own relationship, with a incisive take on sexual harassment at the workplace, but what really got me this year was the development of a romance between her stepfather, a conservative, uptight man from the South and an African-American woman who turns out to be her soulmate. To realistically portray an older white man genuinely want to better himself both to be a better person as well as to be equal to the relationship he wants, it's a rare and wonderful thing. And it's quite, quite touchingly romantic.

Jose Andres: the last time I saw Jose Andres in the media he was on Emeril Lagasse's silly Amazon series Eat the World showing Lagasse around the best eats in Asturia and Barcelona. I'll admit I was not aware of his humanitarian efforts until disaster struck Puerto Rico. And then he was very, very hard to miss. This is a man who is a modernist chef who makes his living feeding the affluent. But this year, he made it altogether clear that what he loves to do the most is cook and feed. And he translated his restaurant business savvy to bring more than 2 million meals to Puerto Ricans in need after Hurricane Maria. I can't think about it without getting a lump in my throat.

This story on NPR's Code Switch is one of those that once you hear, you can't believe it hasn't been broadcast all over the place. The fight Miss Hamilton wages to be addressed properly by the court and her unsung role in the Women's movement needs to be a bigger story. Hopefully it will be some day, but thanks to Code Switch for, as usual, shedding light on stories that no one else tell that are distinctly part of the American fabric.

Roxane Gay's Hunger: admittedly, I don't get to do much recreational reading these days, but this one is a book everyone should read, including physicians. Even though she makes some clear boundaries that delineate to deliver the message that her experience is not the same as mine, there's still a lot to which I can relate. But it's not really about relating to the book. It's about empathy. Reading her honest account about her struggles with weight and her interactions brought out a lot of the wrong reactions, in particular defensiveness about her feelings about the medical profession. But it's important to bite that down because there is a lot to learn about being a better, more caring human from Gay's honesty about how things make her feel.

That's what's made me happy this year. Probably there's been more but these are just what seemed to stick with me. I'm sure you all have your own. We should share them more these days to get us through the dark days ahead.

and I get so tired when I have to explain

Long before much of anything else, this blog was about music. I have about 743 other things I should be doing besides writing about music, but that's adulthood and this is my continued attempt to avoid it.

When I was young, I listened to a lot of different music. I think of The Smiths and The Cure and Kate Bush and Squeeze, but really, I listened to anything I could get into my ears. I think I might have been looking for home, looking for a place where I fit, or maybe looking for the words to say what I was feeling. The way we talk nowadays about the representation of women and people of color in the media and film, I was looking for something even more specific in music. It was a lot to ask out of songs, and most of the time, they fell short, but I think I wound up stitching them together into a mosaic, an endless mixtape to help me define myself.

There are songs that will always remain specific. I'll never hear Camper Van Beethoven and not be 15 again, in my friend JJ's car, breeze blowing into our hair as we blasted this song on our way to her parent's summer home, hollering about taking the skin heads bowling. I'll never listen to Edie Brickell's Circle without being 16 in my room, having one of my episodes (as I would later characterize them), feeling hopeless about everything. Chiquitita will always remind me of my masi and the way she sometimes wrapped her arm around me when I was probably 7 or 8, as if to say she was on my side when no one else was. I don't think I'll ever forget the first time I heard Public Enemy's Fight the Power, or saw Pearl Jam sing Alive, or heard Nirvana on the radio. Those are crystal clear, distilled down memories, little portals back in time.

But then there are all these songs, because I was listening to everything, songs that were background music, stitched into the fabric of pop culture and pervading into our collective conscience. Some are ever present- Michael Jackson and Prince are never going anywhere as far as I'm concerned. Some are stuck in the past- a beloved past, but the past nonetheless. And some songs are timeless, but time does change them.

I recently main-lined the final season of AMC's Halt and Catch Fire, which is a mystifyingly beautiful show that smartly gave in to the power of the friendship between two women on the show. They were not romantically connected, and they were not even like-minded. They were both really smart, they both had their own talents. Their clashes were not about men, and what bound them together was not about that either. I think it may have been one of the few dramas ever produced in which these two women's entire dynamic rested on their work.

Maybe it does not resonate for everyone because a lot of people work to live. Work is the thing that allows some people to do the things they really want to do with their family, their loved ones, themselves. Work, to steal from Halt and Catch Fire itself, is "the thing that gets you to the thing." And if that's how you feel, then you would watch this show and wonder at the tragedy of two women wasting so much time and energy banging their head against various metaphorical brick walls.

But some of us live to work. For some of us, work is part of who we are. And the beauty of Halt and Catch Fire is that it does not go the Mad Men route of translating that to mean 'alone and unable to make any social connections.' One of the women is brilliant, a loner in some senses, but on the other hand holds those connections she does have so dearly that it hurts her moreso when she loses friends. The other woman is also brilliant, but is more pragmatic, and is the woman trying 'to have it all,' with a husband and children and a career, with predictably varying degrees of success. But what's great is that even though these two women work together and then don't work together, the show is aware that both of these women need their work. You just don't see this on television in a way that feels this unapologetic, this realistic.

If all of that had not been enough, the soundtrack to that last season was littered with all the songs of my youth, but none hit me as hard as the sneak attack of Dire Straits' So Far Away.  It's played at a somber moment on the show, and it just took the first few bass notes to plunge a dagger deep into my heart. I wasn't a rabid Dire Straits fan, I didn't own all their records, I wasn't reading every bit of information on Mark Knopfler I could dig up. But their music was just ever present in my teenage years. I didn't even notice that it had taken up residence deep in my heart until that record started spinning on the show.

It's not always something you can put into words and maybe you shouldn't. The show uses Solsbury Hill later in the season to good effect, but it didn't pack the same punch, because, no offense to Peter Gabriel, but that song has been plastered across plenty of montages on television and film- like Leonard Cohen (and most memorably Jeff Buckley)'s Hallelujah, it's been used in ways that have made it harder to think of those songs in a personal way. Strangely enough, though, the use of So Far Away in this particular instance actually elevated the song beyond the show. The show uses it as people are packing. A character has died, but the song plays through the house while each person, alone, is in a separate place dealing with their demons

As the song played, my heart squeezed, thinking about life, thinking about when I first heard that song and how I hear it now. How alone I felt then, and how alone I feel now, but in such very different ways. The song is about missing someone, but because it was released in the 80s, there's this odd juxtaposition of Mark Knopfler's lamenting vocals and this light-hearted, catchy slide guitar and synth. When it was first released back in the 80s and when I was hearing it later as a teenager, I think it failed to light a spark in me because a teenager cannot understand that feeling, that kind of sadness that comes with a smile.

The song is about missing someone, being separated from them. Nowhere in the song does Knopfler propose doing anything about it. Which makes sense- he's a musician, writing from the road, undoubtedly. And you can't be Mark Knopfler and not live to work.

I'm writing all of this as I sit down to study for board exams, while juggling teaching, treating patients and conducting research. The ball that gets dropped, more often than not, in this situation is family, friends, loved ones. And it sucks, sometimes it really and truly does, and I wish I had more time to spend with the people I love and to cultivate new relationships. There are people I have lost in the process of pursuing my dreams and I miss them. More than once, I've wondered if it was worth it. It was not always one-sided; increasingly, in this world with all of its technology, we seem like we are in touch but are actually just friends on Facebook. We get older and get lost in our own little sphere of responsibilities and time constraints. There are so many reasons we're so far away from each other. But it doesn't mean we weren't connected together once. Maybe we will be again.

there's no need to say goodbye

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

I signed two death certificates this week.

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

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

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

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

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

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

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

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

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

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

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

live your life, stake your claim

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

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

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

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

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

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

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

***

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

we got no chance of recovery

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

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

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

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

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

it is my day to live a simple life

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

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

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

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

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

You can't tell me how to feel.

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

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

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

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

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

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

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

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

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

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

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

I'm reminded of these words that were sandwiched into a funny (funny because it's disturbingly true) bit that Amber Ruffin did for Late Night with Seth Meyers (she's a writer for the show, which has really found its footing in the last months):

But then you realize that by doing what you do everyday, you prove to them that you are unstoppable. They can spend their time trying to pass laws that take away your rights and silence your voice. But all you have to do is live your life right in their faces, and it proves that you cannot be stopped.

So I am relying heavily on work, and I am hoping others are too, in particular those folks that do the very good and true work of journalism and community organizing. And I am hoping those are not the last kind eyes I see from the other side.

we will meet again someday on the avenue

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

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

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

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

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

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

pushing the needle too far

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

This is not unusual in the practice of medicine.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

one flame, one bonfire, let it burn higher

I was wondering why I haven't been writing here lately. When other people have cited reasons for shutting down their blogs, they have mentioned that they are either too busy or too passionate about what they are doing to spend time on writing. And I am busy, and I do spend a lot of time writing rather dry, medical things for work. But there's more than that at play now.

There is so much going on in the world. And in my world too. It has become increasingly hard to write about some random piece of entertainment, or some random thought I've been pondering, without thinking of how insensitive it is in comparison to big things. Big things like violence and illness and injustice and inequity. It's often seemed best to just stop typing instead of typing something inconsequential when so much of consequence is occurring.

But then you watch a movie like Creed.

I know. That seems laughable. But the thing is, it matters. In America, in our culture, it just matters. Entertainment is our outlet, but it also influences our thinking, our perceptions. It even plays into how we see ourselves. It does this in ways small and large. I suppose even if none of that were true, sometimes you just have to write about what moves you. And Creed did, believe it or not.

Creed is an audacious movie, as much as it is also a formulaic one. If you want to see it as a by-the-numbers boxing movie, it's got all the requisite notes that make it clear this is a movie that can be seen as a Rocky sequel. It has the underdog, the coach who takes a chance on a kid, the love interest, the brash opponent, and the epic final match. And it does all of those things so deftly, it's easy to forget that the plot is very close to a remake of the original Rocky.

But consider what this movie is saying. Spoilers follow, but they will not really change your enjoyment of the film. The movie opens with a juvenile detention center that disturbingly resembles a high-security prison with a bunch of African-American boys who look like boys. Like true boys. And that alone is a halting visual. The movie does not flinch from the fact that there is a broken system here that dooms the majority of these young men.

And then consider that the main character has a lot of promise, but needs someone to take a chance on him. Rocky's cousin works in a local gym in Philadelphia, has been trying to get him to train his son, but ultimately, Rocky ends up choosing to work with Adonis Johnson. Yes, on one level, this is the story of how Rocky trains Apollo Creed's son to redeem himself for his perceived guilt in Creed's death. But on the other hand, and maybe this is because I've read too much about this movie going into it, but this is also the story about diversity, and how diversity happens.

In order for diversity to happen, someone has to open the door in order for you to put your foot through, and then you have to be able to stand in the room and be worthy of it (at the least, usually you have to be more than worth it, but that's a story for another time). This is as true in Hollywood as it is in science and anywhere else. Even though I hit a brick wall in STEM, and ultimately switched my leanings towards medicine, where it turns out I belong, before I hit that wall, I had a lot of people along the way who did help and encourage and gave me opportunities- I just got to the final door and it was shut. But it doesn't mean I don't appreciate those mentors, who were mostly white men, who came before them, who did help me, and who ultimately also helped me when it came time for me to switch course. I'm not grateful to them in a sense of 'oh thank you, for deigning to believe in me'. I'm grateful that they were recognizing a problem, the problem being that women did not feel welcome in the basic sciences, and were doing what they could to correct it. In the case of Creed, it isn't quite so dramatic. But Ryan Coogler pitched Creed to Sylvester Stallone, and he initially turned it down. But when Fruitvale Station came out, Stallone changed his mind and was on board.

That's not nothing on so many levels. Stallone previously had creative control, had written and directed all of the Rocky movies, for better or worse. So it's an act of trust and generosity to let someone else have a shot at it. And for that someone to be a person of color, well, that is not nothing.

You can see Coogler's love of Rocky all over Creed. Yet though the movie reveres Rocky, it makes room, it clears a space for a new lead. This is not a movie about a white guy who is a hero because he trains a black kid. If you really want to compare it to some trope, this is a superhero origin story. And the superhero is Creed, not Rocky. Even the last shot of the movie puts Adonis front and center with Rocky standing to the side. Supporting but not overshadowing, not taking all the credit. That is a thing to see.

Then think of this- how rare it is to see in a recent movie two people separated by several decades in age, neither of them trying to be older or younger than they are, and both of them benefiting from their relationship? This movie celebrates youth but also the wisdom that comes with age. This movie, to be flippant about it, respects its elders. But it's also grounded in the now in so many ways.

The fact is, the Rocky movies were never popular because everyone loves boxing. We never watched professional boxing growing up, but my family watched all the Rocky movies with fervor. Boxing keeps getting featured in movies because it is dramatic and because there's something essential about it. Creed gets to the heart of that, as Rocky explains to Adonis that you're really fighting yourself in the ring. The opponent is there in the movies because an internal conflict is not as entertaining on the screen. This movie's theme is about finding a reason to fight and then having the courage to give it everything you can, and every person in the movie is fighting for something, and it's the right thing. Even the supposed 'villain.' This is not Rocky IV. Everyone wins in some way or another.

And then, there is a whole different level to this movie. And that's what is playing out in the theaters. I went to see this movie in a town in California that is truly one of the most diverse places in America, in every sense, not just in terms of race but in terms of socioeconomics. All of Thanksgiving weekend, I had been trying to get some Indian friends to see Creed with me, and they all wanted to see the new James Bond movie or the new Hunger Games movie. In fact, they were a little offended that I would rather see Creed. It's interesting to me, this South Asian tendency to lean towards identifying with white culture (except, of course, when it comes to rap music, in which case, South Asians suddenly become Straight Outta Compton). But honestly, I just identify more with Creed (it didn't hurt that a hospital scene had some throwaway scenes with an Indian doctor who got to have an Indian name and no accent), and I've realized these small things matter. I am not giving my money to big studio films that don't reflect what America or the world look like, not anymore. I see those movies sometimes on television, but box office matters. And I was nearly giddy sitting in the theater today which was chock full of people of so many different ethnicities. We have a voice, we have a say, and we can and do vote with our wallets. Creed looks like it is going to be the #3 box office this weekend, which is good, but after watching the movie, it should be #1, and it should stay that way for weeks to come.

I think of how those Rocky movies have mattered to me, as a child and as an adult. They were about a lunkhead who didn't have much going for him but his heart and sheer will to keep at it. Strangely, that's meant something to me at various difficult times in my life. The new hero, Creed, has more complex things to say and says them well, and I feel like it makes a difference in ways that we don't even understand right now. And in this increasingly horrible world where so many terrible things are happening, we need art to give us hope sometimes, and to open our eyes at other times. So I don't care if it's just a dumb piece of entertainment. I've got no regrets, except I wish you had seen Creed too.