I guess this must be the place

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

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

So.

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

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

I am happier now.

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

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

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

don't look ahead, there's stormy weather

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

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

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

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

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

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

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

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

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

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

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

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

don't call me daughter

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

is this the real life, is this just fantasy?

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

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

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

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

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

don't let them change you or even rearrange you

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

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

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

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

Very dark forces.

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

watch me unravel

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

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

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

the weary kind

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

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

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

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

coming up now, out of the blue

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

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

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

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

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

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

Life's too short to even care at all

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

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

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

because I never was cool

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

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

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

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

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

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

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

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

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

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

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

*

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

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

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

Judy sucks a lemon for breakfast

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

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

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

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

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

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

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

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

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

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

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

if you don't know what to make of it

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



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

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

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

we all walk the long road

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

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

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

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

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

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

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

somebody that I used to know

Everyone has been writing that it was inevitable, but it brings a tinge of sadness nonetheless. Sepia Mutiny is coming to a close.

I've been giving a lot of credit to that blog for putting me in touch with some fascinating folks on the web, but if I really trace it back, all the way back, right to the point of its absolute essence, it wasn't actually Sepia Mutiny. Here's the truth. It was blogs. Yes, that dead dinosaur, this format that I can't seem to quit.

Manish and Anna and Abhi had these amazing, lightning-rod blogs that I and many others read voraciously. I thought Sepia Mutiny was pure brilliance when it started; I thought if you combined such forces, nothing could stop it. Maybe that was partially true. But I saw the price that was paid. Each of their blogs dwindled down. With the exception of Anna, when they did blog, their writing became less personal. And frankly, it was those little moments, the little glimpses inside, those were the things that made me so drawn to the community.

I have always contended that I don't share commonality with people who watch Bollywood movies. It's not idli or samosa or sarees which tied me to anyone. What interested me were their voices, the shared experiences. Things we found funny, that we could only appreciate because of our joint experiences. The way Amardeep could dissect an interesting piece of writing. J-money's sassy commentary on food or television or movies or her parents would remind me of some long-lost friend I never knew I had. Or supplesomething's poetic prose. Or maitri's infallible no-bullsh*t breaking-it-down here's-the-way-it-is observations that would make me want to cheer. The little-sisterly feeling tamasha always brought out in me.

Those were the things which caught my interest, made me want to better know these bloggers. In the beginning, in those early days, right before Sepia Mutiny, these bloggers inadvertently encouraged me to blog. And maybe there are too many, and plentiful, and enough voices now. Maybe we don't need Sepia Mutiny, and maybe we don't need blogs. But me, I'm never making any real connections over Twitter. I'll never find myself endeared to someone by discovering their Facebook page. It's the blogs. It's the words. I'm a sucker for words. I'm a sucker for way, way greater than 140 characters. I'm a sucker for more is more. I won't really miss Sepia Mutiny, because I haven't been reading it for years. But I will miss what Sepia Mutiny promised, and the people who brought us Sepia Mutiny. And I already miss all those voices who've grown quiet.

Me, I'll stay in the ancient times, in this echo chamber, with words, words, words. Manish and Abhi and A N N A taught me how, so blame them.

you gave me a lift

Everything takes perspective, I guess. Like how good a bowl of cereal tastes when you haven't been able to tolerate food for 24 hours.

Or, I had to work a night shift last night. I despise them. Not for the actual work, which is actually rather fun. Nights are creepy and cool in the hospital. You learn by doing what you have to do. Nights always provide the biggest contrast as to how the past several months have shaped me- phone calls that used to fill me with panic and dread are now met with gentle reassurance and a short visit to the bedside to confirm suspicions.

What I despise about night shift is the way it pummels your body and turns your circadian rhythm into the Elaine dance. There's no getting around that one.

But it was only for one night. And also, the morning before I left for night shift, I took a listen to The Shins play Simple Song on SNL. I'd heard the song before, but to be honest, the video that had been released for it had been a bit distracting, so I had not really appreciated it until I saw them perform it live.

It wasn't some powerful and rousing rendition necessarily. But it must be said- if you throw a swell of guitars like this into a song, and the lyrics and vocals are equal to it, consider me a goner. And a line like you feel like an ocean being warmed by the sun and love's such a delicate thing that we do with nothing to prove, which I never knew are fairly hard to beat.

The actual video is kind of goofy and distracted me initially, but I do think it has a bit of a point. It's certainly entertaining enough to watch.

But really, I was just pleased at 3 in the morning to have a little guitar and drumbeat to keep me moving through the hospital. Sometimes all it takes is a simple song.

I've got chills, they're multiplying

I couldn't help myself with the title of the post. It's really the only reason I decided to write today. It's pretty impossible to talk about food poisoning in any kind of entertaining way.

When I was in Peru, SP, AL and I all got a nice, nasty episode of food poisoning right before trekking the Inca Trail. SP was the first to recover, and went out in search of Gatorade powder to keep us from dying during our hike the next day. I had been lying on the bed in misery. But I had also not eaten in over 24 hrs. And there was a roll of delicious Peruvian cookies sitting on the night table.

SP came back to the room to find me guiltily eating the cookies. I paid for it shortly thereafter; I was definitely not ready to be ingesting sugar. She shook her head and asked me what was wrong with me. I have no willpower I guess.

I eyed some cookies this evening, and laughed, thinking of what SP would say. I didn't eat them. My stomach's not quite ready for that, and the muscle aches and chills are settling in, so I am going back to bed, after I force down a little ginger ale. Not the best way to spend my one day off, but at least I wasn't at work when all of this happened- that would have been mortifying.

it was dark and I was over

Today at clinic, a patient found out at the front desk that she didn't have insurance anymore. As a result, she no longer qualifies to come to our clinic. She had just been to the Emergency Department yesterday because she had a UTI and she had not been able to see a resident in clinic quickly enough (although, now that we know that she has lost her insurance, she would not have been seen by a resident anyway). She got antibiotics from the Emergency Department, but she wanted to be seen today because she was still having pain.

Also she has HIV.

Last time she was seen for her HIV, her CD4 count was great, which means her immune system was intact. She was on antiretroviral therapy, and it was working well. All we could do for her today was check her vital signs and make sure she wasn't dying in front of our faces, and tell her that she could go to the Emergency Department if she started to feel worse or developing worrisome symptoms.

If you follow this out to its logical conclusion, you have the dizzying, frustrating, enraging headache that is US healthcare. Patients without insurance do not get seen in the primary care setting. Preventative healthcare falls to the side in these patients, the most vulnerable ones, I might point out. As a result, they get sick and they come to the ER. Sometimes they aren't really sick and they come to the ER. But they come to the ER because they don't have a primary care physician to weigh in one way or another. This patient isn't acutely sick right now, so she probably won't get much out of a visit from the ER today. But thanks to losing her insurance, she won't be able to take her HIV meds, and her CD4 count will most likely plummet, and eventually, she will turn up in the ER with an opportunistic infection, having developed full blown AIDS. Good job, America.

As part of my residency, I rotate through the Emergency Department, and it also turns me into a rage monster, because again, a ton of the patients who turn up don't really need Emergency Services. They do not need a CT of their abdomen, seventeen labs and 12-hrs of monitoring, only to be sent away without explanation by a shrugging, tired ER doctor. They need a primary care physician.

But they're not likely to get one any time soon.

I'd like to complain some more, because there's an entire separate rant about how Internal Medicine programs pay pure lip service to encouraging residents towards primary care, while wholly supporting a system that actively kicks out the desire for anyone to do primary care. But I am tired. And frustrated that I contributed to the problem today because the system tied my hands behind my back.

heartbeats

Today one of my patients asked me how long I'd been a doctor. I get that question frequently in resident clinic, because they know we're all in training. Sometimes I want to answer that I'm not one yet. Other times, I want them to stop giving me a hard time. Today, I just told him how long, which is not very long.

The patient asked, "Do you like it?" I said I did, and that I didn't take it for granted, and that I was lucky to get to do something I love. He nodded fervently and said, "Yeah I used to be a computer repairman, and I used to just jump out of bed every morning, I was so excited to go to work every morning."

I thought that was nice, and a nice surprise.

Towards the end of our conversation, he was sort of starting sentences but not finishing them. I said, "Is there anything else going on?"

He asked defensively, "Like what do you mean?"

I shrugged. "I don't know. You just seemed like you had something more you wanted to tell me."

He then told me he was embarrassed. I thought, here we go, and braced myself for some unnecessarily explicit conversation about sexual dysfunction. As usual, I was wrong. He told me he was embarrassed because he'd been clean for a long time, but this past month, he'd been feeling down, and done cocaine a few times. A tiny little detail that changes the entire appointment- the guy has a mechanical heart valve and an underlying condition that makes him prone to cardiac problems. He absolutely can't be smoking cocaine if he wants to stay alive.

Interesting where conversations take a doctor and a patient behind closed doors.

it feels like years since it's been here

Maybe I have just noticed this because I'm finally on a rotation in which I get to see sunlight (and not just by peeking through patients' rooms while I am rounding, which for the record, I have stooped so low to do), but around here apparently spring has sprung. It seems too early, almost unnatural. There was no real big freeze this year, it seemed, although there probably was- I seem to remember a few days during which I raced from the hospital to my house fearing that I was going to freeze to death.

But all of a sudden, there are blooms everywhere, and the sun is warming everything, and I don't really know why the expression "everything's coming up roses" exists, because it seems to me that it should be daffodils. Roses are delicate and fragrant and fancy and romantic, sure. But daffodils are bright, screaming yellow, and they seem to be the first thing that bursts forward in the spring, announcing warmer days ahead. You don't have to wait around for someone to get you daffodils. In fact, they're best encountered growing out of the ground, a chance meeting as you're walking down the street. Or in my case, when I opened the door this morning, I found that my very own front yard was bursting with a little row of daffodils.

When I was young, and living in Boston, and first learning to really love things, the spring would call to me like the Pied Piper, and I would walk out of my room as if in a trance and wander aimlessly further and further away from home. And on those days, it seemed like quite a heady indulgence, to stop at a florist on Newbury Street and buy fresh daffodils, then carry them home and set them in a blue vase and set them by the window, and stare dreamily out on the Charles River. I am not quite at my leisure to do that anymore, but I get to cast a wistful glance at those daffodils without feeling like I'm splurging.

Which makes me quite happy. Simple things do sometimes.