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.

I held my breath and you said something

Once upon a time, and it feels very much like a once upon a time situation in the sense of how far back (but not really, not really), I lived in a breathtakingly beautiful city. Inescapably beautiful. Punch-you-in-the-face, Tim-Riggins, Jordan-Catalano beautiful. My daily drive to and from work was an art school short film.

When you live in such a place, I think you tend to become lazy. You are used to the constant assault of picture perfection. Just before I left, I could walk down the street without being knocked off my feet. In the beginning, I remember talking with my brother at a rooftop party in San Francisco and blurting out, waving at the vistas all around me (and admittedly a little better with the help of spirits), "I think we've found the promised land!"

Which, in retrospect, is interesting, because it wasn't the promised land at all. It was a perfect moment. There is no promised land, I'm sorry to say. But there are perfect moments. Some of them are big. Like when you say goodbye to your best friend in an airport in Germany and know you'll never be close again. Or when you graduate from college and there are bubbles in your chest that are a mixture of nervous anxiety and optimistic excitement. When you hold your niece for the first time. When your cousin, after just doing something amazing, tells you that your support and encouragement inspired him towards that. When you make the decision to completely overturn your life to pursue a pipe dream and that moment that you realize the dream is going to come true. A first kiss. Then that first, intentional kiss. A perfect night out on a New York summer night. Sitting around a fire in the middle of nowhere in Maine. Standing over a roaring waterfall in Argentina.

There is a lot I don't have in my life. But sometimes we miss the trees for the forest. From the outside, perhaps it seems I don't have very much. And yet if you strung together all my perfect moments, it could be just as beautiful as the fog settling over the Golden Gate Bridge on a perfect San Francisco fall morning.

In San Francisco, the beauty was blatant and intentional. I loved it. I'm not sorry. But I realized that there are other kinds of beauty. Believe it or not, New Jersey was beautiful back when I lived there so many years ago (and probably even now). And where I live now is very much the same. It is easy to overlook. When I first moved here from San Francisco, I just viewed it as a means to an end. Good enough, but nothing special.

I don't feel that way anymore. It's not a beautiful place. That is true. But yesterday, I realized a cherry blossom tree has been growing in my front yard for the last three years and I never noticed it until then. In the fall, little yellow leaves gleam against the sun and sprinkle down onto the sidewalk on my way to work. In the heavy rains, everything turns a deep shade of green. Today, when I was walking home, another day of working late hours and not getting home before sundown, these very large dark trees waved out to me against the midnight blue sky. And it's not a beautiful place. But it will do.

***

Once upon a time, and this really was once upon a time, that far back, so far back that sometimes I can't believe I've been alive long enough for it to have been that far back, I used to get these letters (paper letters, no less) from the love of my life. Or what I call the love of my life, but I'm not dead, so who knows, that remains to be seen. We were all angst in those days, and back and forth's of what if's and maybe's and if only's. He was a very good writer, and I blame (or credit) that as to why I fell so hard for him. He had that Hemingway economy; he could explain better in five words what I couldn't quite put my finger on in five hundred. Once he wrote me a letter, and I don't honestly remember what it was he was turning over in his head or confessing to me. It was something that at the time twisted my heart in knots, but now it just seems likely to have been variations on a theme of wanting something to work out that was never destined to work out. He wrote some very anguished lines, the specifics of which I don't remember.

And then in the next paragraph, probably more to himself than to me, he wrote, "Pause. Take a sip of tea." And the entire tone of his letter changed after that.

Such a stupid, simple little phrase. Sometimes I don't actually fix myself a cup of tea. But I think of that saying all the time. I sometimes think he was put in my life just so that he could deliver that line. For lo and behold, I can be the queen of hyperbole and overanalysis and anxiety. I used to get crippling stomach aches when I was a child from just the thought of going to school. And every once in a while, I get into such spirals. A shame spiral, or a rage spiral, or a stress spiral, and I think the sky is going to fall on my head, and I hear this violent crescendo leading up to some fatal moment.

Then I take a slow, deep breath, let it out and calm myself. It's not always a cup of tea. Sometimes it's Dylan telling me, "all you can do is do what you must." Sometimes it is going to bed and forcing myself to believe that tomorrow is another day, another chance. Come to think of it, he and I read Candide together in college, and I don't know if all is for the best in this purportedly best of all possible worlds, but I do know that taking a breath, pausing, taking that sip of tea, it's a good way to cultivate your gardens.

endless numbered days

I feel this every day, but some days I feel it more than others:

"For it is true we can seldom help those closest to us. Either we don't know what part of ourselves to give or, more often than not, the part we have to give is not wanted. And so it is those we live with and should know who elude us. But we can still love them - we can love completely without complete understanding." - Norman Maclean

Sometimes my heart feels so full and at the same time so useless.

destroy the middle, it's a waste of time

I'm having another one of those episodes.

I am not posting much these days. Work is exacting an impressive toll on me, more than I thought it would. The other day, I realized I don't have a lot of patience for drama in my social life because work is enough of an emotional rollercoaster. I almost cried in a patient's room (and for the record, in case it's not been made clear before, I usually have non-functioning lacrimal glands as a general rule. I remember one time I was upset about something personal, and tried to cry, thinking it would help to let it out, and nothing happened) because she said she felt badly about being nervous about undergoing a stem cell transplant. The woman is in her late 20s, has 5 children, had a full-time job, and developed acute myeloid leukemia, and after she managed to get a remission, she relapsed just as she was getting lined up for a stem cell transplant. It's fine to write it like that, and make it sound like it's all happening to her. After all, in the end, it is all happening to her. But she was 25 weeks pregnant when she first came into the hospital, and I was the one who got to tell her of her diagnosis. I got to explain the not-benign chemotherapy regimen and its side effects, which we administered to this woman while she was pregnant. I got to tell her that her the good news that her repeat bone marrow showed no evidence of leukemia. I waited it out with her from afar as she delivered her baby and then I'm the one who got to rip her away from that new baby to give her consolidation chemotherapy to keep her leukemia away. I'm the one who got to arrange transfusions for her when she finally got home. I'm the one who got to discover that she had an allergic reaction to transfusions and needed a special suspension of platelets to keep from having hives and rigors. And I'm the one who got to tell her that the leukemia was probably back. And now it is, and she is getting chemotherapy again, and she tells me she is nervous. I involuntarily laughed and then choked up all at once. It was highly unprofessional but she didn't mind. I  told her it was okay to be nervous- her doctors are nervous for her and we're not even the ones going through it. We had this uncomfortable moment of silence in which it was clear we just were no longer doctor and patient- it's an odd thing when you cross over like that. All of a sudden, we were in a different territory. Two people navigating a difficult journey together, different stakes, different roles, but both in it, all the way in it. And I knew, just at the same moment, that this was very dangerous. So yeah, I don't need a lot of drama with this sort of thing a natural byproduct of my career (which doesn't even feel like an appropriate way to describe my job, but it would be pompous to call it anything else).

And I find, yet, that I have capcity for so much rage still. About stupid things (like television shows, and I have since deleted that portion of this post, because after posting it, it suddenly seemed stupid and unimportant) and horrible things, like three innocent people getting shot in North Carolina, one Indian grandfather being injured in an arrest, and the disturbing fact that the man was stopped because he was mistaken for a black man (thinking about the reality of what that means enrages me on so many levels that I have to step away and take a deep breath). But all that rage gets quelled by the sad realities that I often see with this work- sudden deaths or long, drawn-out expected deaths. I treat cancer patients so they know what they're contending against, but it doesn't make it all that much easier. Life is short, and precarious. The world tends towards entropy. I wish we didn't have to contribute to that entropy but sometimes it's important to shift the focus to what you can't control. I am going to strive to do better.

better be home soon

I feel this big shift. It happens, not commonly, but it happens, in time. The plates move, and the tides turn. I hit a real low recently and thought I had made a lot of bad decisions in my life - maybe it was time to regret everything, and give into the very real temptation to wallow in misery.

Unhappiness is not the same for everyone, it really isn't. For me, it's not a sustainable condition. When I really feel unhappy, really (not ennui, not melancholy, not a moment of navel-gazing overanalyzing), I cannot be in that state for very long. It is not productive, it's almost paralytic. Yet it's also not, because it pushes me into reexamining the whole of my situation, because there is only one direction to go from there. Well, there are two directions to go, but only one that I can afford nowadays. At a certain point in life, you simply no longer have the luxury to go further down, darker, deeper. Not that you can always avoid it. But I know some years back, I could have looked at this point and seen it as a choice.

Now it is a matter of figuring out how to make that shift. That part used to be easier. Sometimes I yearn for the naivete I used to have. The business of getting yourself on the right track, it's more complicated than it used to be, when you're stripped of the notion that everything will work out. Not everything, in fact. So then, you have to figure out what needs to work out. If you can figure out what realistically needs to happen, it can in fact happen. That part does feel certain.

A family member recently wanted to get me something- this family member has a habit of making big purchases as a way to demonstrate affection. And it's not for me to judge, because I have my own odd ways of expressing (or not expressing, regrettably) my feelings. But I really thought about it, and the problem is, I don't want anything like that. I don't have an iPad mini or an iPhone 6 or an expensive pair of shoes, but it's not really because I can't afford it. Fellows get paid a measly sum but I don't really have much cause for spending, so I am not holding my breath to make ends meet. But what I don't have that I really crave, that I never appreciated until I became a physician, is time- which I know is awfully cliche to say. It is the end of the year, and when I fell down into the hole where I often find myself in December, I realized the real problem was that I just didn't have the time to scrutinize my life for long enough to determine what needs to change. But I guess that's the thing about time though. You have to make it - sometimes conjure it up even, if necessary.

just for a moment, let's be still

Lately I have been thinking that I could just start a blog called "this week in heartbreak" based on my job. For example, this week's contenders would be:

• The elderly man who has leukemia that just won't respond to any therapy, who is universally adored in our unit. I had to perform a bone marrow biopsy on him this past week and he thanked me and told me I did a good job. Also every time I go to see him, he always says he is glad to see me.
• The couple who are in their 70s who sit side by side in the hospital room, like they are trying to reenact those scenes in When Harry Met Sally where elderly couples recount how they met. They met in Staten Island, childhood sweethearts.
• The woman who was just diagnosed with breast cancer, who I met in my clinic for the first time yesterday, who ended our clinic encounter with "I am so glad you are my doctor." This was particularly heartfail material because about forty five minutes prior, I was seriously considering quitting due to not feeling good enough.

But I can't write about such things without it sounding awfully schmaltzy. I love, love, love my work, but at least once a week, more often multiple times a week, I question my competency. Everyone tells me it is the nature of the beast and all that, but it chips away at me, and usually by the end of the every week, I have a pit in my stomach and feel doomed.

Which is why, on my day off, I often find myself trying to do something in the kitchen. Because that's a place where I've spent a lot of time over the years. I don't follow recipes well, and I don't write down a lot of the details of how I make things, but most of the time, I can still produce something salvageable. And when I really want to feel accomplished, I make caramel. I have written about why it is therapeutic to make- it requires undivided attention and a feel for things. You can't daydream about chemotherapy regimens and lab results while you are making caramel, or that bastard will turn on you and take you down.

And now it is fall, and it is the season for caramel and all things apple. Last week I experimented on my day off and made a cake with grated apple and roasted sweet potatoes. It was okay (mostly because I covered it in brown sugar frosting), but it was not a keeper. Last year, I used smittenkitchen's recipe for apple cider caramels. I tinkered with it, but not much, because her recipes are fairly airtight. Those were tasty caramels but they were the kind of caramels you wrap in waxed paper and give your friends, and they love you forever. So, you know, kind of perfect. But I was not trying to make those types of caramels today. I wanted a caramel sauce. And I also did not feel like dealing with a candy thermometer.

Making this sauce was a process. First, I had to boil down 4 cups of fresh apple cider until it's about 1/3 to 1/2 cup. Then I deviated from the recipe, so all hell broke loose. But it's also different when I am in the kitchen, because the only downside of failure is a waste of perfectly good ingredients. So I just plugged away and sure enough, I managed to make a thick, apple-intense caramel.

On my next day off, maybe I will figure out what to do with it.

***

To switch gears a little, in my last post, I was writing about how the choices we make come with a price and we have to pay for our dreams, and the artist formerly known as piedpiper pointed out that this is more of a universal plight than I had perhaps suggested. He is right. And I was reminded of it this week, because someone very near and dear to me came out of the closet. It broke my heart a little that he felt he could not tell anyone sooner, and it was heartrending to hear that his family had put a lot of pressure on him not to tell anyone about it. He sounded so happy when he told me, and I realized how this must have weighed on him for such a long time. Already, he is having to pay a lot and in his case, it is not even a dream he is living, just his life.

good is better than perfect

Sometimes, this work gives one pause. Okay, not sometimes. All the time. But for different reasons, at different times. Sometimes, it's the work itself, sometimes it's the system in which we practice, and sometimes it's the repercussions of the work.

There are some matters which I find difficult to articulate for two distinct reasons- 1) it is so specifically personal that I am not sure I should be sharing it and 2) I have an irrational fear of being misunderstood- irrational because who cares and also hardly a handful of people read these words and most of them are fairly non-judgmental types.

For several years in this blog's history, actually, I wrote in an abstract away about this Goal I had, this big dream I was pursuing, and I knew, even as I was writing about it, that it would be a letdown when it was discovered that all I wanted to was become a physician. In some ways, the most unoriginal idea a brown nerd could dream up, really.

So I have no coolness factor. Oh well. That is no surprise, that has never been my area of expertise. What I did have was a deep certainty that I was doing the right thing for myself. And it is a good thing I did, because it was a long play. I mean, a longgggg play. Studying for the MCAT (while working full-time), going to medical school and 'carelessly' tossing away many of my savings in the process, three years of indentured servitude as a resident, all to get to this point.

All for the privilege of treating cancer patients. And it is a privilege. I can say that without a doubt, without reservation, and there are days when my rib cage feels like it is going to crack wide open from how full I feel from the satisfaction of this work. That is true.

But here is what is also true. This choice has cost me. It has cost me money, that is probably the most trivial of the losses. It has cost me friends. It has cost me family. It has cost me my own health. These are things we joke around about as physicians. But these are very real losses, and they exact a price that cannot be quantified and cannot be recovered.

Many, many years ago, I was still trying to figure all of this out, what I was supposed to be doing with my life. I knew I was not supposed to be working in a chemistry lab synthesizing molecules someone else told me to make. So I thought what I needed to do was get my PhD in chemistry. I started working on a research project in my spare time, after work and on the weekends. And I will never forget that my friend K casually remarked that she had stopped inviting me to things because she figured I would be too busy. It crushed me. I suddenly felt like I was really missing out, like the sacrifice of trying to pursue my PhD was too great to give up happy hours and weekends with my friends.

I trusted that feeling, I trust it still. When I decided to go to medical school, I kept giving things up, one by one, and it was frighteningly easy to do. Some of it is by design. Medical school is a wrecking ball, is a cult, is the Borg, is a hurricane. Medicine is a tidal wave that sweeps you out to sea, you drown and after a while, you learn to breathe under water, that is what I think.

This past weekend, after a particularly taxing week that made me question my stamina to complete fellowship and come out of it a competent oncologist, out of the blue, two friends of mine from the east coast texted me. They were drunk at a pub crawl. An annual pub crawl, a pub crawl I used to attend with them, many a year ago. They were planning an impromptu trip to New Orleans, and did I want to come?

Yes! I wanted to go. I missed them. I missed the outside world. My patients make me miss the outside world when I talk to them, and they tell me about their trips and their family and their dogs and their hobbies. They remind me of all the things I have set aside. So I wanted to go, and I cheerfully suggested February, when I had the sort of schedule that would allow me to take some time off.

My friends thought this was funny, and pointed out they were thinking more like next weekend. I had forgotten the meaning of impromptu, see. There is little in the way of spontaneity when you are a fellow. You have a schedule and you have responsibilities. They suggested December, and I thought about the patients who were scheduled to see me then. I am their doctor. I have obligations.

Everyone has obligations. Children. Pets. Mortgages. Everyone has them in some form. This time, I was not crushed when I told my friends I could not escape to the Big Easy on a moment's notice. I was sad. Because I miss my friends, and in an ideal world, I would love to be able to take off with that kind of spontaneity. But dreams have a price, and I knew, right from the start, that I would have to pay. So I have. And I will not apologize for that. As I have stated, there is nothing I want to do more. If I won the lottery today, I would do exactly this job. It is an obligation, this work, but it is a responsibility I have wanted, a purpose I have craved. I cannot pretend to regret that.

But what I will do is try. Not try 'to have it all' because I think that is a dream that we are fed to feel constantly like we are not succeeding, like we are something less. There is no having it all, there is no balance. Life is too messy for that, and chemistry has taught me that equilibrium is a dynamic state, that we are constantly being pushed in one or other direction away, but there is a pull, and it is not a pull away from the center. So I am just going to try not to let go of everything, not to be quite so weightless. I am going to try to find that steady state.

caught between the scylla and charibdyes

A patient of mine- and now I really know what it means, for a patient to be mine, because he is mine, my responsibility more than anyone else's- came to my clinic yesterday, huddled in blankets and pale and miserable. He had been discharged from the hospital less than a week prior, and had a terrible hospital stay. He has a fairly rare tumor, and he was admitted to the hospital to undergo a cycle of chemotherapy, but ended up staying in the hospital for nearly a month because of a number of complications.

I was supposed to see him to assess whether he was ready to be admitted for another cycle of chemotherapy. I had seen him two weeks before, and he was not crazy about being stuck in the hospital, but he was smiling and joking around and frequently holding my hand. Yesterday he was irritable and weak and growling about not wanting to go back to the hospital.

In clinic, you're always on a schedule. There are always patients waiting to be seen. There is always a tightrope of trying to be present, mindful in the moment of seeing a patient, give them your undivided attention, but keep them focused enough to not fall far behind schedule. Then a patient sits in your office looking miserable, with low blood pressure, a fast heart rate, and you know that your afternoon is about to be derailed.

But that would be fine. With the help of one of the nurses, we cajoled the infusion center into giving this patient IV fluids, an attempt to stabilize him so that he could avoid being hospitalized for the day at least. An hour later, I checked on him between patients and he was feeling a little better. And then we had what I can only characterize as a futile conversation.

He was looking at me like I was plum crazy when I broached the topic, and I didn't really blame him. But his situation is so complicated that we are stuck trying to make impossible decisions- subject him to the brutal chemotherapy regimen that clearly causes him problems, or let a very aggressive tumor continue to impinge on some rather vital organs. This is the conversation we have with cancer patients all the time- it's the 'how do you want to die' conversation and it's the hardest of conversations, especially when you're in your first year of fellowship. It's a difficult conversation to have when someone is feeling well. When they're feeling this poorly, it's very nearly worthless.

A lot of people view medical oncologists as chemo-pushers, as physicians who will administer toxic medicines to their patients even if they look and feel terrible. I don't view myself that way. I have no aspirations to become that sort of physician. I don't believe in treating patients with medicine just so that you feel you are doing something. There's a saying one of my former attendings used to quote- when in doubt, do nothing. And I stand by that, usually.

But here in the grey zone, in the alleged cutting edge, it's not so much doubt as uncertainty. We're supposed to weigh the risks versus the benefits of providing a therapy. Many times, that is an easy decision to be made, or an easy choice to outline for a patient to make. But we sat there, my patient and I, and neither of us knew what to do. Neither of us could make a decision. He was looking for promises that I couldn't provide him. He was looking for me to push him in one direction or the other, but there is no good direction for him. I had told him from the beginning that any treatment we gave him would be to try to let him live longer, more comfortably, but it wouldn't be a cure, it wouldn't drive the cancer away altogether. But it wasn't hard to tell that he was struggling with his own uncertainty. He wasn't ready to die, he wasn't ready to consider the idea that he was already in the process of dying, so he focused on feeling miserable in the moment, in fixing that, and the matter of dying from cancer was just going to have to wait until next week. He won't be feeling much better next week, of that I'm sure. But maybe one of us will have more of an idea of what to do. That is my almost absurdly unrealistic hope. Maybe next week, I'll be a better oncologist.

your position is pivotal

For the past week and a half, I've been trying to figure out why the ALS ice bucket challenge is bothering me. Initially, I thought it annoyed me because it was one of those typical online activism deals that lull people into thinking they're doing something when they're really not. But that's not the case- the challenge asks people to donate and raises awareness and has significantly increased research funding for ALS.

And we live in very exciting times for ALS and other neurologic conditions. It's a field in its germinal phase, with so much to be discovered, so there is very real hope that with proper funding and devotion of research efforts, there could be better treatments to these very debilitating conditions.

So raising funding and awareness for ALS should not upset me.

Yet it has been upsetting me. All of this week and last, it has been upsetting me. Then I recollected something.

This was in the late 90s, and I was working on the east coast, and I had this coworker MM who was Serbian. At that time, I'll be quite honest, I didn't even know that. I thought I was a real hotshot for knowing she was Yugoslavian. So it was coming on the weekend, and somehow I was always the person trying to goad us bridge & tunnel crowds into Manhattan to do something, and that weekend was no exception. Friday night, we were young, I sent out an email to a bunch of my friends and coworkers asking them to go out dancing. Everyone wrote back except for MM.

Finally, the day before we were going to go out, I'll never forget, MM wrote back a short, but positively scathing reply, and I'm paraphrasing here, but she wrote something very close to the effect of 'how can you expect me to go out dancing when NATO is bombing my home town?'

I still remember this very short, very sharp email to this day because I recall that I felt sucker punched by it when I received it. At first, I felt certain I was the victim. I was just trying to get some friends together. I wasn't in charge of those bombs being dropped. Not like they asked for my vote. Not like I would have voted for it if they had. My, she was sensitive, it seemed. And given that there was nothing any of us could do, what would be the harm in going out and having a good time?

Well. Wasn't I an idiot in my youth?

There was nothing wrong with sending out an email to go out dancing, or wanting to go out dancing, even in the context of bad things happening elsewhere. If we all froze every time something bad happened in this world, something truly horrifying even, we really would mostly be homebound and petrified.

But, there was also nothing wrong with MM's outburst. In fact, it was a 100% justified reaction, and it was borne of anxiety and heartbreak and horror. And her outburst was an opportunity. To understand. To reflect. To learn. Not that she was supposed to be the great Serbian educator, spreading her knowledge of the situation there to all her little disciples. In fact, MM and I never talked about it except that I wrote back a short apology, which she accepted just as briefly, and never did we speak of it again.

It was my job to figure out why the whole situation was so upsetting to her, my job to get it. From her vantage point, it was so obvious that even questions about it revealed my ignorance and unmasked her frustration further.

I know it's quite a leap to make. But for me, when I see those ice bucket challenges on Facebook, I want to write back to all of them with a similar terse rage-filled reply of "how can you ask me to throw an ice bucket over my head and raise awareness for ALS when an entire subset of our population is being mistreated systematically?!?" And I sort of don't feel like explaining myself any further. I suspect my rage pales in comparison to that of others. But it's the job, our job, to acknowledge that rage, to get to its roots. Ignored, it just grows exponentially.

***

Here are some statistics. Something to mull over.

- The reported incidence of new diagnoses of ALS yearly is 5,600 in the USA.
- It is the cause of death in ~2 of every 100,000 deaths in the US
- Who predominantly develops ALS? White men.
- In New York, just New York, in 2013, thanks to stop-and-frisk and other major problems with the alleged protect-and-serve police force, New Yorkers were stopped by police 191,558 times.
- Of those, 88% of them were totally innocent.
- Of the total, 104,958 were black. 20,877 were white.
- According to census data, in 2011, the death rate for non-Hispanic white men from ages 25-34 was 147.5 per 100,000. For black men ages 25-34, the death rate was 212 per 100,000. I repeat: 147.5 vs 212. Make that non-Hispanic black men and that rate goes up even further to 226.7
- By the way, you know how ALS is the cause of death in ~2 of every 100,000 deaths in the US. Guess what causes ~10 of every 100,000 deaths in the US? Injury by firearms.
- A baby less than a month old - 3.45 white babies of every 100,000 die. 7.45 black babies of the same amount die.

So you know. You tell me what needs more awareness. You know... it's not a zero sum game, sure, but then again, it kind of is. That's how things work. That's how our current media environment and our current social environment works. The most popular, the most sensational thing, it bubbles to the top and everything else fades. It's not wrong- to raise awareness for ALS, to engage others in the same attempt.  You're entitled to your celebrations about the money you've raised. But so am I entitled to my rage about the tradeoff, about the things that are ignored in preference.

But I really just wonder. There are plaguing questions that irk. Like mainly-- why isn't every single person who is raising awareness for ALS raising awareness for the inequities that are simply unacceptable in this country, in these allegedly modern days?

dirty his hands, it comes right off

This is just a quick additional thing I have to get out of my head. A couple of years ago, I was sitting in a seminar about racism, institutional and otherwise, sitting with a bunch of very bored interns who were suffering through it as a necessary evil. Many of them thought it was a waste of time. I was inclined to agree with them, mostly because I don't think the seminar changed anyone's outlook, since it was preaching to the choir for some of us, and easily tuned out by the rest.

Anyway, though, there was a statistic that was quoted, and I'm not going to quote it correctly, and I'm too tired to hunt it down. But it had to do with the amount of time people spend thinking about race. The result of the research showed that the average white person thinks about race hardly at all compared to a person of color who thinks about race several times a day.

And that is very, very true. I think about that every time someone makes the always-irritating 'I don't see race' remark, because that is such a sign of privilege, to have the luxury not to think about race. I always just want to reply, 'how nice for you.'

It's exhausting. I truly, honestly despise how often I think about it, about being not-white, and not-male. And let me tell you, I myself am speaking from a place of extreme privilege, I am well aware. I have never been treated ludicrously by the police. I have not been shot. I have not been tear gassed. I live in a part of the country where I hope we would not tolerate this Ferguson noise. But then again, there was Oscar Grant. So who knows really.

And that's the thing. We just can't stop thinking about it.

hot water bleeding the colors

It would be so easy to return to blogging by talking about the new television show The Knick, which filled my head with thoughts for its full one hour.

It would also, in a different way, be easy to talk about the death of Robin Williams and talk about depression. Even though it would be an uncomfortable topic, and it would get too personal, too quickly, it would be easy because it's familiar. It's something I understand all too well. When people write of his death as sudden or shocking, I'm not sure I share that sentiment. Yesterday was a sad, sad day for the entertainment industry, and for those of us whose first taste of American television was Mork & Mindy, but it was something, nevertheless, I understood. Depression is a horrible disease; so is cancer. But it is a disease, and I understand it, and I know how not everyone can survive a disease over time. I know that all too well in my business. I know that all too well personally.

But what is much harder to write about, because I can't write about it coherently, not even a little bit, is this goddamn useless excuse for a country. See, that's the garbage that comes bubbling up into my brain when I start thinking about Ferguson. It's not just Ferguson. It would be so convenient, and it's the way of the mainstream media to always make it just about Ferguson, or just about Trayvon Martin. Special circumstances. A one-time thing. Complicated.

See. But it's not that complicated. It's just simply horrible, and I can't write a sensible thing about it, not one, because all I see is rage and ugliness and this frustrated, weary, defeated anger. Like I just give up. Like who would ever have a child in this country? Like who bothers to fight in this stupid system?

There's something that's happened to me in the last several years, since I have become a physician. It is a bit different from the normal course of a physician. Because most people start medical school when they are quite young and they are just forming an opinion of the world. And so they have some opinions, perhaps, and then they have many more based on their experiences in the medical profession. For me, it's been a little different. I knew who I was when I went into the field of medicine.

But here's the thing- I knew who I was, but I didn't know who other people were, not completely. Oh I did for a little while. For a brief period of time, I worked in a research lab in New Jersey, and I was the little meek Indian nerd mixing solvents in the corner, and because I was quiet, I would hear all manner of ridiculous talk about forming a militia and Hilary Clinton being too big for her britches (this is back when she was the First Lady, whooo hoo, the memories) and how people were making too big of a deal about this OJ thing. But that was just a brief glimpse, and I thought they were just some lab nuts, because I got into the corporate field where people largely keep such opinions to themselves. And then I moved to San Francisco, and at that time, people were comparing Gavin Newsom to Ronald Reagan so I was working with a bunch of folks who were genuinely, truly surprised Kerry lost the election.

So I wasn't really prepared for what happened when I became a physician. I had always been a little bit of a listener, because I was always interested in what people were really thinking, and I had found that if you kept your mouth shut for long enough, people's true natures would come out. So the last several years, well, I have seen some things. It's a weird relationship. People just give you their two cents. I don't know why. It's not like telling your doctor that climate change is a hoax has any bearing on how they treat your diabetes or your multiple myeloma. Still, I don't know, I guess because it's a safe space, when that door closes, when it's just you and your physician, the truth must out.

I don't know why I'm writing all of this down. I guess to say- I've seen inside the minds of a lot of people, and we're broken. Not all of us. But more than there should be. It's 2000-and-freaking-14 and I've still got to listen to a pack of white men tell me that Obama's a racist who only cares about black people. I still have to patiently explain to these old white men that I was born in America, and even after I've explained that, they've still asked me if I "plan to go back to India?" Oh, but it's so, so much worse than any of that. My colleagues have made disparaging racist remarks- which they attribute to working in an environment where we see minorities 'take advantage of the system.' Bull-freaking-shit. The system has taken advantage of them. Our entire system is so broken that our most vulnerable population, socioeconomically, racially, are set up to be the sickest, and to have the least access to proper preventative healthcare.

This is around the time that my brain starts to feel close to stroking out.

There is subtle stuff too. Like how the white male in a program is encouraged and mentored and pushed to succeed, while the minority is scrutinized or left to his or her own devices. But there is just that one case, right? It doesn't apply to every place, right? There is subtle stuff in treatment too, like how there are disparities in the outcomes of non-white patients, but ohhhhh, we can't attribute that all to racism. It's just one study. It's just one outcome. And then another, and then another, and then how many apples have to hit Newton on the goddamn head before he starts to think there's something to gravity?

This is why I haven't written. I can't. Not without losing the thread, without going off kilter. I can't talk about it, because I would be dismissed as ranting. Or better yet- a hysterical woman of color, that's pretty much the best way to get invalidated out there. And anyway, I don't know what to do anymore. I don't know what it will take to change things. I don't know if anything will change. Whatever is all I can summon to the audacity of hope. You be audacious. I'm inconsolable, and angry, and defeated, and I don't even know what I'm trying to say anymore, so I'm just going to stop. But not in my head. I'm not going to forget Brown or Martin. I'm not going to forget the Japanese kid who got shot for jaywalking when I was in graduate school (a solid 10+ years ago, in California, I might add). I'm not going to think of them as just one case.

and it's getting nearer, soon it will all be true

As the Monty Python quote goes, 'I'm not dead yet.'

Real life pummeled me but good the last few months, the final push before residency ends intermingled with personal drama. Distracting me from the 'what's it all about' that usually occupies my mind at times like these. Because in my life, because of these odd back roads I've taken to get to where I am, there have been a lot of beginnings and endings, or chapters, if you will.

I've had this theory, and maybe it's a theory that only applies to my life, but I think there are but a few people you can hope to carry along with you as precious from every chapter of your life. I've always held this belief, but I think it's become more nuanced for me now. Because there are people in my heart from different chapters in my life nowadays who I haven't spoken to in years- and that is okay, because such are the realities of life, time zones, delineating circumstances.

Even though I've always had this theory, I think I expected to come away from medical school with a solid handful of people that were mine. Instead, it turned out to be one person, and it wasn't the person I expected. But it was the person who probably understood me (and still understands me) the best from those days. There were other people to whom I thought I was closer. But they faded away, or turned out to be false, or whatever it was that actually happened- they were gone in the end.

When I started residency, I was more wary. I expected to just keep my head down and work. I didn't take stock of the other residents the way I did in medical school. The work was plenty enough to keep me busy, too busy to worry about likemindedness and comraderie. And then- it just happened. And still, it took a while, it took some evolution, some shuffling of chairs, but in the end, there are more than I expected who really get me.

Sometimes I wonder how much of that is the world, and how much of it is the barriers I put up against the world. I've always been someone who gets blue and brooding when people don't understand me, even while knowing that part of the reason is that I don't explain myself, I don't show myself. I think the maintenance of this blog over the years is probably a perfect example of that- I very much doubt most people who know me IRL would guess that I spend (well, used to spend) time writing, contemplating, musing. And that has always been okay, because I haven't necessarily needed someone to understand everything about me.

Yet, I have to say, it's something. It's one thing when you're in a romantic relationship, and someone puts up with all your nonsense. But it's quite another to have friends who have seen you at your worst, when you're really on the verge of falling over the edge, and for them to have this breathtaking grace of being there for you. Not just that- but letting you be there for them too. The latter is something I've realized more and more as I've gone through my medical training. It may be the only thing I've really, truly come away with, this bit of wisdom- that you are doing your loved ones a favor when you let them help you in any small way.

I suppose that's what I have learned from taking care of patients these past three years of residency too. A lot of residents get burned out, talk about how thankless the work is, how the benefits have now been outweighed by all the burdens of medicine. I get that. But I have spent time talking to my patients, talking to their families, discussing impossible decisions about the last days of their lives, and I never feel like it's a weight on my heart. It's a strange profession these days. Patients have increasingly unrealistic expectations of their doctors, and doctors in turn have unrealistic expectations of their patients. I've realized that so often, patients actually are really in charge of their own health. And I've also realized that they deserve the credit more than I do, more often than not. But none of that really matters to me in the end. I just like my job. I like the being there. They need me, I need them, whether either of us likes that.

Anyway. I'm getting my head screwed back in straight, and I'll try to blog more. But it occurs to me that the blog has been this strange chapter that is separate from the rest of my life, that intersects other chapters, neither a prequel or a sequel, almost just the same tale told in a different voice. And this chapter too- I'm lucky to know some of you from this chapter, I am sorry if I have taken some of you for granted, but you mean a lot to me too.

don't you waste me in the ground

Strange things I've realized of late. For one thing, revelations always seem to occur when I work in the ICU. Let me be clear- I don't enjoy being in the ICU. It's not my thing, patients that are that sick and that tenuously sick- in the sense that they may, at any moment, turn the corner from sick to threatening to die. And yet, aside from working with cancer patients, the ICU is the only other experience I have with talking so openly and frequently about death.

A woman today said, "I don't know how you all do it," and it was meant to be a compliment, but I could not stop thinking about it as also a little bit of a criticism. The woman was the wife of a patient we were taking care of, who was not doing better, who had been quite clear about his intentions and wishes, and who we had just decided to extubate to let nature take its course. People have this impression that when you are "on life support," it is simply a matter of turning off the machine or taking the tube out, and then death follows. But like everything, it's not often that simple. I had just finished explaining what the process of taking the tube out would look like, what might happen afterwards, although we often can't even predict that. There is so much research out there in medicine, and yet that moment of death and dying remains mostly a mystery- people hang on unpredictably or pass just as unexpectedly.

But here's the other odd thing I've learned during the course of my residency. It's not really about what's happening, the details of it. As physicians, especially when we're in training, we have this tendency to fixate on that, the specifics of the problems a patient has and how we are failing at fixing them. This morning, the intern on the team presented the patient's problems and our plans while the patient's wife stood nearby. His wife then turned to me and said, "I didn't understand a word of that." After explaining to her what was going on, I went back to see her with the attending, and that's when we talked about his overall goals, and decided it was time to focus on his comfort. When she said, "I don't know how you all do it," she was grief-stricken and wondering how we saw such things regularly and treated it like a matter of course. I wanted to tell her that inside, it doesn't get any easier. That it haunts us too, that we couldn't make him better. That every patient we admit afterwards, we treat with all the more reverence, knowing how challenging healing can be in the very, very ill patient. I wanted to tell her too that sometimes I don't know how I do it either-- not in a conceited way but in the sense that I don't know why I'm not in therapy or in a deep depression over the things I have seen. Let me tell you- the ICU is 50% hopelessness, 25% idiocy, and 25% success. That's probably a generous estimate of the latter, by the way.  I can't explain why, in the process of training, you learn to just deal with these realities of treating patients.

In the end I didn't tell her any of those things, because yet another thing you realize about death is that, as a physician, it's definitely not about you. Your job is to walk the balance between being there and staying out of everyone's way in those final moments.

Of course, then I go home and bake three dozen cookies, and realize that, oh, all of this does most definitely affect me. Which brings me to the much smaller realization which dawned upon me today. Lately, some of my friends/co-workers have been suggesting coming over to bake with me, or for me to come bake with them, and the thing is- I don't want to. I'm not trying to hide trade secrets or anything. It just occurred to me today that I don't really like sharing the process of baking with anyone because I find it relaxing, and it's one of those selfish things, almost like my form of meditation. I can't really imagine finding it so peaceful if someone else was there. Which probably says a lot about me and my attitudes about people, come to think of it.

Anyway, more navel-gazing at some future date. I have some more hopelessness, idiocy, and (hopefully) success to face in the morning.

no single bite could satisfy

Lately I haven't been traveling to faraway places. I have not really had much vacation time, but also the motivation has been sorely lacking. There are lots of reasons. Probably, primarily, just sheer exhaustion from residency. It's tiring and I don't like to drag when I'm at work-- so I will work my 30-hour shifts, while grumbling all the while, mind you, but at some point, it all catches up to me, and when I want to decompress from it, the idea of going on an involved vacation seems more wasteful than anything else.

But not to whinge. Because honestly, I am well aware of my good fortune. It just so happens that I live in a place that allows me to get to plenty of what I want and need. A stay-cation is all the way justified around here, because a short drive gets me to the ocean, the mountains, the vineyards, and my niece.

Even then, I did some real staying. Some time at home in my kitchen, and now I am well aware of my age, because I was much more pleased to spend a day tinkering around with making pie crust than I would have been flying somewhere.

I bake a lot because it's something that's actually become rather expected. And that's fine, because it still doesn't feel like an obligation, but rather a routine, that has a soothing quality to it from the very rote of it. But every so often, the scientist part of me itches to experiment, and I want to learn some new technique or try some new recipe. It matters to absolutely no one; I have no delusions otherwise. It's not like I'm becoming an expert at anything, and it's not like anyone else cares about any of this.

But that's part and parcel of the decadence of it all. It feels like the height of luxury, the day I spent rolling out pie dough, and learning to make pastry cream. I might have cursed at how small my wooden rolling board is, and how one of my whisks malfunctioned. Maybe I groaned at the batches of macarons that failed before I got to one that was passable. You would think that would make for more frustration than relaxation, but for some reason I have made my peace with failure. At least in the kitchen, I look at every failure as just a finding from an experiment- troubleshoot, tweak, try again. It's actually a comfort now when something fails the first time I try to make it-- then when I've figured out why and gotten it to work, I know it wasn't just a fluke. I know I can write it down and it will keep.

But still. A person likes to feel some sense of hope. So I ended that day by cooking up an industrial batch of salted bourbon caramel, which I knew would turn out - because I had failed at it in the past, of course.

it's my dream but it's yours if you want it too

The arrival of my niece has not changed my life. I didn't meet her and suddenly have a baby-fever type of revelation. She didn't make me question all of my choices and doubt all the decisions I have made in my life. She turned up, all six pounds of her, to happy parents, and I laughed at almost every thing that came out of the bro-seph's mouth. When she was a day old, he remarked "she's got a really chill personality," and I didn't have the heart to tell him that actually she was just a newborn baby. My mother turned up 4 weeks later and complained that the baby didn't play much, that she slept all the time. The woman has started her unrealistic expectations now, so I fear for that baby's adolescent years.

She looked like a wrinkly alien when she arrived, my niece. She wasn't some angelic perfection (shh, don't tell my brother and sister-in-law). And also, she's not the first baby born to people I love. I have two godsons, and many of my dear friends have had children, and I am happy for every single one of them.

But when my niece showed up and settled into my arms, I did have a strong reaction all the same. Funnily enough, before she was born, I had this irrational thought that maybe my brother and sister-in-law would hoard her, and would find me an annoyance. It was completely and totally and absurdly irrational, as it turns out. Because, for one thing, there was something my brother and I learned growing up-- there is simply no such thing as too much family.

We grew up surrounded. Two uncles, two aunts, their spouses and children, all living in a one mile radius of us. My brother and I were the oldest but it didn't detract from the importance of their presence. There was quarreling alternating with teasing. There were equal measures of tears, bruises, and laughter. And I remember, when I was younger, finding it all very suffocating-- like nothing I ever did was mine, because so many other people were involved, talking about it, their expectations adding more pressure, their bragging about anything I'd done somehow diminishing anything I did as wholly my accomplishment.

My niece arrived, and I knew I wanted to be geographically close to her if at all possible, because my brother and I grew up with the idea that you needed as much back-up as you could gather around you. And the problem then was that I wasn't sure I'd actually be able

to stay around, because that was somewhat out of my hands. Some friends, trying to make me feel better, kept telling me that being away from my niece for a couple of years would do no harm. "They don't remember anything at that age" and all that. But thing is- I knew that to be false. I can't tell you why, I don't even understand it myself, but I can tell you I'm very close to those twerp cousins who I cradled and played with and babysat in my teenage years-- they're adults now and we all live far apart, but when we get together, there's an unmistakable closeness that I treasure.
Circumstances are what they are. I would have had to deal with it, had I not lucked out, had I not been able to stay. I learned that from my extended family too- time came and they had to do what they had to do. I struck gold though with this little niece of mine. I've got a brother and sister-in-law who want her to know her foi as much as possible, and I get to stay near enough that I can see her frequently enough to be a part of her life. Looking at that kid, I did feel a sense of responsibility- to not drop her, to hold her when she fusses even if it's spoiling her a bit, and all that other unconditional stuff that comes with family. But also there's a different kind of responsibility- to find as much joy in my life, to share that with her and as many others as I can.

So the little pipsqueak did teach me something already. She reminded me what I already had known- that there is no such as too much family. Her arrival coincided with some big news in my life that was good (actually, great), and when there was this amazing outpouring of sincere happiness on my behalf, I realized what an idiot I was when I was younger and found sharing my accomplishments to lessen them. It's exactly the opposite as it turns out: knowing that so many people have supported me, have cheered me on, have held their breath on my behalf, have known what this means to me-- it's actually amplified my own happiness, and made me feel wrapped in a collective embrace that I had not known was there.

Some of that family who've been part of that embrace, they're family not by blood but by love. Some of them are you.

sometimes is seen a strange spot in the sky

Well who knows where to begin and how to end, and whether this is any kind of beginning or if it's time to end. Just three days ago, an Indian-auntie type was trying to console me "you know how people of our culture say that things work out in the end."

And I responded, like I wasn't blatantly quoting The Best Exotic Marigold Hotel, "and if it's not working out, then it's not quite the end, right?" Which earned me a nice hearty Indian-auntie cackle. She thought it was an original quip and I felt like a fraud, but it got me out of the conversation- I was tired of getting these kinds of pep talks by then.

There's some truth to it. But what of its converse? Life is not a movie or a novel, and sometimes it's such a letdown that it's not. Because I've had some drama in my life, I've had my lows, and then I have these moments-- these amazing, cinematic happy endings. Everything has come together, it's all worked out, the heroine has emerged victorious, and you could end scene and roll credits and it would be so beautiful, it could play Sundance (I keed, I keed).

Except life is not like that. Which is why this stupid blog continues on. There is this thought that in our youth, we are confused and angst-filled and struggling. Then we clear some hurdle and everything settles down, we settle down, and there is no further questioning ourselves. That's the thought, but I mean to tell you it's 100% false. Either people stop examining their lives, or they just stop publicizing all their quandaries, but there all of those doubts remain, stewing within.

Or maybe that's just me, I don't know. I thought about saying goodbye this week, to the blog, to social media, claim my happy ending, and end this story. Yet, there are still things to want in life, things to strive for, things to dream about. And so much more to experience. So instead of bidding it all adieu, I think it's better to take a moment and really savor how precious the present tense is, when you reach one of these chapter ends. When the cliffhanger will-they, won't-they ends with a kiss. Knowing that life is not like this, it is best to be grateful for the beautiful moment when you do get to proclaim "I am no man!" and stab the Witch King dead. And just like The Return of the King, there are many fake-out endings ahead, I suspect.

to find our way home, to break in these bones*

Having grown weary of a seemingly endless string of flights for the past two weeks, I opted to drive from Northern California to Southern California (and back) this week. It was illogical, really, and many of my friends told me so. But I reasoned that I'd neglected to buy a plane ticket, and now it was too expensive to fly.

I was writing down directions for the way home (I get annoyed trying to use my phone to navigate, and I do not have GPS, so yes, the world and all of its advances have passed me by), and scrawled down "then drive up I-5 until your eyeballs fall out." It is a straight shot like that. And even though it is a long, almost interminable drive, it is also mindless, and thus allows your mind to wander.

It was much needed. I had to exorcise a bunch of negativity and demons, reset my brain, examine what lies ahead. I didn't arrive at any epiphanies, not even close.

California is beautiful. There is no state like it. But then, there is no place like any other. California, I realized, has become home for me, and that long drive up and down I-5 reminded me that this might be a swan song. A goodbye, or a farewell for now. The only thing that changed along that drive is that I became more comfortable with all of the uncertainty. Take a deep breath, breathe in the sunset that tinges the sky purple against stretches of farmland and mountains, stretch that imagination and consider a different life, a new dream. But I'm just not sure of anything.

I came home, and slept, and when I woke up, I was a year older. So busy with the plates sliding beneath my feet that I didn't have time to acknowledge the passing of another year. I could have made cookies or a cake, some sure fire, trusty standby. But that's not the kind of space I'm occupying these days. So I revisited macarons, which are the most temperamental m*@!$* that a person can bake. I've already previously accepted that macarons are one of the few items that I think are worth shelling out the cash for, rather than trying to recreate at home, because they are so involved.

But I was feeling up for failure. I was feeling that sense of daring-- that willingness to roll the dice for high stakes. I was feeling extreme- I could have gone for a good, hard cry or a joyous victory dance. I was ready to accept my fate. I was ready for it to all be for nothing. And only, only when I feel like that, I think, is this possible:

There were some happy feet in my house that day.

It's not a long drive, or the baking of macarons, or any one thing that will help make this all clear. I see that much now. It's just the necessary turning myself inwards, filtering out the background noise, the external voices of right and wrong. And if I stand very still, while the macarons are baking, while the sun is setting, while the music is playing games with my heartbeat, then I'll feel the right path.

* Maybe because I am old and so an 80s vibe does nothing but make me giddy, the new Killers' single Shot At the Night is owning me right now.

I will dare

I'm a different kind of tired. Usually, these days, I am tired because I am tired- because I have worked a long shift, been awake for too long, have been running around the hospital, have been writing notes and answering pages. That kind of tired, it's an easy kind of tired in a way. All it takes is a little rest, a little sleep, and for the most part, it goes away.

This is not that. I am the kind of tired that involves waking up at 3 am in a panic, that involves never feeling quite well-rested, that involves a churning sensation in the stomach, a steady state of anxiety. There's a fatigue that comes with that. The constant nerves eventually translate to pure exhaustion, but not the kind that can be relieved by sleep alone.

I'm so close, I'm so close I'm afraid to even name it, I'm afraid to want it. I want it that badly that I'm afraid to say it out loud. Does that make any sense?

That's the kind of pit in my gut that I've been grappling with this week. Yesterday, I had my first interview, and it should have been the easiest, but it was actually the one which worried me most, because, again, it has to do with wanting, and being afraid to want, and of course, at the end of it all (and haven't we all felt this at one time or another?) the fear of not being good enough. It had gotten to a fever pitch the night before, and I was nearing hysteria. I was bouncing around the house unsure what to do with myself.

I could have prepared in the traditional way. I could have read through my CV, reviewed possible questions I could be asked, all the things they say you should do. But I'm not so sure that would have done anything to help, not for me, and my miswired brain, my weird way of coping. So instead, last night, when I really felt my fears bubbling past the surface, threatening to boil, I decided to just face a completely different fear instead-- the terror of homemade pasta.

It is ridiculous, I am aware. But when you distill it down, the fear of making pasta from scratch is really just as ludicrous and just as justified as most of my other fears. My fears regarding pasta are many. Do I have the necessary ingredients- do I have what it takes? Do I have the necessary tools? How will I know if it is right? Will it form, will it all come together? And the biggest fear of all-- will it be any good?

This recipe had coincidentally been posted that allayed a lot of my fears, as orecchiette does not require a pasta maker. Don't get me wrong. I have wanted a pasta maker, have I ever, but I haven't been able to justify getting one when I don't even know how to make pasta. I divided the recipe by 8, because this was just a test batch. This was for therapeutic purpose, strictly. And while I kneaded the dough and then tried to make the coins curl into pasta, everything within me focused on that. I calmed down.

So maybe I won't get what I want. Maybe nothing will work out. Maybe I'll continue to bash my head against the proverbial brick wall. But not all endeavors end in failure. As evidenced by the orecchiette. Was it perfect? No, not even vaguely. However, it tasted good, and I knew what I needed to do to make it better next time. And in short, I was no longer afraid.

just try to understand, I've given all I can

Closing time. That's what it has felt like recently. Not insofar as this blog goes, though I know it's mostly dormant these days. It's not a particularly deep song, but those lyrics have lodged into my head because they're apt right now- you don't have to go home but you can't stay here.

I've been trying to get my head right about leaving this part of the country, because the chances are astronomically high that I will no longer be a resident of this golden state for much longer. If this were the best of all possible worlds, then I'd live in the Bay Area, and live affordably there on the meager salary of a fellow, and be in a decent program training. But life gets complicated, the more you want, the more your heart is set on something.

Sometimes I think that love is a test. And that applies to love of work too, especially for me, because work and life are tied inextricably together for me. Don't ask me to be exuberant if work is going poorly, I can't do it, and I'm not sorry about that. Sometimes, I worry that some physicians don't take their job personally enough. But anyway, these choices end up being made. Really, you love this? Do you love it enough to leave the part of the country where you dreamed about living?

Once, the bro-seph and I were standing on the rooftop of a party in the Mission. It was clear and sunny and from that height, we could see across the city. I was floating. I gestured around and half-joked to my brother: "I think we've reached the promise land!" It did feel that way.

But it's weird. First of all, San Francisco doesn't make me feel that way anymore, I am sad to report. It's become not unlike New York in some ways. Beautiful, indisputably. And I will always hold it dear. But it's become a place exclusively for the have's of this world, and I find it hard to relate to places like that past a certain point. Moreover, though, San Francisco made some things plain for me.

I stood on that rooftop and I made that proclamation, but there was still a yearning in my heart. There was still more that I wanted, something I was searching for, and that something means I might have to move far, far away. And I wonder if all of this, everything that has happened to this point, has been a preparation for this next move.

None of it really matters. We like to think we have some control, we like to prepare, we like to think we've learned so much and are so world-wise. But in the end, change comes one way or the other and it doesn't really care whether you're ready for it or not. I'm just trying to remember that I've watched my life change numerous times, some by my choosing, some not so much, and it hasn't beaten me down yet.

But there are scenarios I would prefer, and I'm trying to convince myself to dream.

***

In other, more musical news, two Border Lines have earwormed me recently. The first is courtesy of a very funny episode of The Mindy Project. Yes, when I first heard it, I had a major nostalgia overload, but the Flaming Lips and company really prove that covers can reinterpret things in ways that are welcome.


The second Border Line, of course, is the new single by Goldspot. These lyrics really feel like the best ones the band have written to date. And even if some of their songs sound like cousins of each other, Goldspot has a distinct sound, one that tells you they're not afraid to incorporate Indian influence into their music but also that it's really woven into their fabric, not a device used for the purpose of kitsch.