we MaDe it!

Green for medicine, orange for Texas.

The last thing I ever made in my Dallas kitchen.

Graduation Cupcakes

What you need:
-4 years that fly by
-the perfect ballpoint pen
-countless hours in the carrels, library, Starbucks, and hospital hallways
-smiles, laughter, hugs, tears
-births, deaths, weddings, breakups
-lives saved, lives lost, patients and families of all ages, race, and walks of life
-humility and wonderment at being blessed with this opportunity at all
-amazing friends and loved ones to travel the journey with you

What you do:
1. Begin medical school in a strange new city with absolutely no idea what you're getting yourself into.
2. Be lucky enough to meet the most generous, strong, beautiful, intelligent, and loving people along the way.
3. Find yourself --- in the midst of zero hours of sleep, at 4am on call, with people dying all around.
4. Have faith that beginning residency --- in a strange new city with only a vague idea of what you're getting yourself into --- will bring just as much adventure and growth.
5. Bake bittersweet cupcakes. Frost, then top with an upside-down mini-Reese's peanut butter cup, a Ghirardelli chocolate square, and an M&M. Anchor with frosting.
6. Share with friends, and know that this isn't "goodbye," it's "see you later."

the fisherman

"Pura vida"
Costa Rica, April 2009

On our first day in Costa Rica, we took a sweaty, cramped, 4-hour bus ride from San Jose to Manuel Antonio on the Pacific Coast. We were the only tourists on a bus full of locals. Partly inspired by wonderment at this intimate glimpse of daily life, and partly attempting to distract my lovely travel companions from waves of nausea, I remembered a story and re-told it (poorly, I might add). Originally seen on a wall at Jimmy John's.

An American businessman was at the pier of a small coastal Mexican village when a small boat with just one fisherman docked. Inside the small boat were several large yellow-fin tuna. The American complimented the Mexican on the quality of his fish and asked how long it took to catch them. The Mexican replied, only a little while. The American then asked, why didn't he stay out longer and catch more fish? The Mexican said he had enough to support his family's immediate needs. The American then asked, but what do you do with the rest of your time?

The Mexican fisherman said, “I sleep late, fish a little, play with my children, take siesta with mi esposa, Maria, stroll into the village each evening where I sip wine and play guitar with my amigos. I have a full and busy life, senor.”

The American scoffed, “I am a Harvard MBA and can help you. You should spend more time fishing, and with the proceeds buy a bigger boat. With the proceeds from the bigger boat, you could buy several boats, and eventually you would have a fleet of fishing boats. Instead of selling your catch to a middleman, you would sell directly to the processor, eventually opening your own cannery. You would control the product, processing, and distribution. You would need to leave this small coastal fishing village and move to Mexico City, then LA and eventually NYC where you will run your expanding enterprise.”

The Mexican fisherman asked, “But senor, how long will this all take?”

To which the American replied, “15-20 years.”

“But what then, senor?”

The American laughed and said, "That’s the best part. When the time is right you would announce an IPO, sell your company stock to the public, and become very rich. You would make millions!"

“Millions, senor? Then what?”

The American said, “Then you would retire. Move to a small coastal fishing village where you would sleep late, fish a little, play with your kids, take siesta with your wife, stroll to the village in the evenings where you could sip wine and play guitar with your amigos."

The allegory --- its message intensified by Costa Rica's "pura vida" motto, gorgeous beaches, volcanoes, and local friends made along the way --- fueled many a beer-hazed philosophical discussion that week.

As med school graduation nears, I remember why I first began this blog after college. Starting this project seemed both a reminder to distill my often absentminded musings into concrete ideas, and an efficient way to keep in touch (at least passively) with friends far and near. Maintaining a blog is a different beast entirely. I began to reflect (and write) less frequently during the busy clinical 3rd/4th years of med school --- ironically, the years yielding to date the highest highs and the lowest lows I've ever experienced intellectually, emotionally, and physically. I have no doubt that residency will push the limits even farther, and I hope I will take the time to reflect along the way (read: the blog is back!)

That said, life isn't always so serious (though I often am), and most of what ends up on here is trivial shit just for entertainment. Mostly mine, but hopefully yours as well.

A few more from Costa Rica.







To Alberto, Rodolfo, Diego, and Harlem: thanks for being our fishermen.

on repeat

The stench of stale cigarette smoke. The residual foam clinging to the sides of the pint glass. The disposable conversations with disposable people you meet once and know you'll never see again. The "now-ness" of it all, living in that precise moment, filling your time and your mind with temporary distractors.

Why do people do this shit over and over and over again? Are they, like me, trying to silence the issues that really matter: the ones that might just break your heart and your spirit if you let them?

lost in thought

Is it incredibly morbid that I feel most alive when my patients' lives hang by a thread? I've come to realize that what inspires me most in medicine is life and death, quick decisiveness, saving lives. In all my current apathy, it's almost like I need the intense (melo)drama and adrenaline that comes with caring for a patient who is literally fighting for each minute of his/her life. It makes me think. It makes me care. It makes me appreciate.

And when they often die, it makes me incredibly sad.

I often joke that I don't believe in moderation, but it's mostly true: I will work out either every day or not at all. I often binge eat. I won't study at all for 7 weeks, then cram like a maniac for a week straight. My emotions have always been rather extreme as well, and recently have become closely linked to the work I do. I don't know what's the lesser of two evils: being so apathetic in life as to mimic melancholic depression, or feeling alive only because of a constant melodramatic reminder of how fragile we all are.

I don't know what I want to do with my career. I fear that following my passion for life/death will lead to throwing my entire emotional reserve into my work with nothing left for myself and/or relationships. On the other hand, the daily grind of boredom, apathy, and leaden paralysis is getting me nowhere either.

intent

A few days ago I performed my first D&C. Granted, it was an incomplete abortion (a miscarriage in which products of conception are not completely expelled and require evacuation) and was not done expressly for the purpose of aborting a fetus. Like any other surgical procedure, it felt oddly impersonal and detached. The patient, draped in sterile fashion with only the surgical site exposed, appears merely as a body part. All members of the surgical team, covered in hats, masks, long sterile gowns, gloves and shoe covers, appear mostly anonymous. The procedure itself - simple enough that I was allowed to perform much of it - is a series of well-rehearsed steps. We were in the OR probably less than 30 minutes.

I couldn't help thinking the whole time, though, that this D&C wasn't done any differently than when performed specifically to abort a pregnancy. Clearly, medical abortion is a giant ethical and moral debate with infinite arguments about what constitutes a "life"; however, from a strictly surgical perspective, it really doesn't feel any different. Like law and murder/manslaughter, it all seems to fall back on intent. Parsing out intent vaguely intellectualizes the whole situation in the first place, yet abortion draws fervently emotional responses. It's easy to debate medicolegal issues like euthanasia and abortion in the intellectual sense, but in person (in hospital?) nothing is black and white. If everyone could see things like this, I wonder if there would be more open-minded, gray people.

On that note, I leave you with this article published yesterday in the Times, written by an retired OB/Gyn discussing his experience before Roe v. Wade.

down

Death happens. No big deal. Even this early in our medical careers, it's unnervingly easy to shrug it off when trauma patients die right in front of you, when you discuss patients in Morbidity & Mortality conferences, when geriatric patients pass away. As inhumane as it sounds, there were definitely times when it was like - oh that Level I patient was DOA. Oh, my DNR patient coded. Now then, who's up for coffee?

Somehow it's different in young patients, though I know it's technically not any different. Somehow it's more tragic when teens end up paralyzed in MVCs. Somehow it's more heartbreaking when children die before organ donors become available. Today I found out one of my old patients was sent to hospice. Later today my school-aged, previously healthy, now quadriplegic and vent-dependent, patient looked me straight in the eye and said "Please kill me. I want to die."

God. How do you forget something like that?

my new home

Today is Tuesday, 5pm. Since Sunday I have spent 45 hours at the hospital. This is somewhat absurd. Please direct all mail to my new home at Parkland Memorial Hospital ER, Trauma Hall.

My last call was Sunday before Labor Day... trauma call is always worse on weekends or holidays when people are out drinking, boating, firing guns, etc. This ended up being 33 straight hours of being awake and running around, barely sitting down for 20 min to eat dinner. It drove me beyond the point of utter exhaustion and took everything out of me physically and mentally. It's so surreal... your entire body and head hurt, you can barely see or think straight, and you hope the adrenaline of life-and-death will get you through the night. Two Level I traumas were pronounced on the spot late in the night; by that point I just felt empty, emotionless, and numb to the smells of blood and sweat and death. After the patient was pronounced and the time called out, we all robotically returned to our work - peeling off bloody gowns and masks, returning to paperwork, and dreading the sound of our pagers going off signaling the next case on its way to our ER.

By the time a drunk, psychotic, frighteningly combative patient rolled in at 3am - physically restrained by 5 policemen on capital felony charges - I was shocked by how weary and unemotional I felt. This guy was seriously scary: he was foaming at the mouth, eyes rolling back in his head, bleeding profusely and flinging blood everywhere, spitting, reeking of urine and vomit, speech barely intelligible, cursing and lashing out at anyone nearby, violently jerking at his handcuff restraints. Even now the thought of him scares me, but I guess the weariness took over at the time; I just yelled at him to lay down and hold still while I dressed his gunshot wounds. One of his policemen pulled me aside later in wonder to comment how much it looked like I totally had my shit together. Yeah right. More like I was too tired and my brain too slow to be scared. When I finally went home at 1pm the next day, laying down and feeling the blood rush back into my legs was literally orgasmic.

Is this what the culture of medicine does to us? Belittles weakness and demands superhuman concentration after over 30 hours of being awake? Makes us feel indifferent to human suffering and death? People dying right in front of us, their relatives screaming in agony, patients in excruciating pain, and we're too tired to care? I don't want to become callous by disconnecting mentally, but at some point it's the only way to get through the night.

this time it's personal

Peds is over. I want more. It's not just the kids - the whole family gets involved and it's all such a warm fuzzy feeling. When kids get better, it feels like you're releasing such potential back into the world.

I had been following one notoriously difficult patient for several weeks on two different services (my team jokes that she "followed" me to my new service). She was constantly surly, listless, bitter, uncooperative with all of the nurses/doctors, her parents were impossible to track down to obtain consent, and to top it off, she was a medical enigma.

After 3 straight weeks of seeing her, barely making any progress (medically or otherwise), she was finally scheduled for a procedure on a day when her parents couldn't be there. She looked up at me, confessed she was scared, and shyly asked if I could go to the procedure with her and stay at her side until she "fell asleep" (from the anesthesia). I began to visit her more and more often outside of my required morning rounds. Our team ended up diagnosing her definitively, and I discharged her on the very last day of my peds clerkship. She was a completely changed person - smiling, energetic, relieved to know "what was wrong with her"... and thanked me for listening and being nice when no one else did.

I know it's cheesy, but I'm convinced there was some element of fate there... how else to explain her being on both of my services AND leaving exactly when I did? I'd like to think I made a difference in her life (and I do hope I did), but she definitely made a lasting impression on me. It's all too easy to become impersonal in this line of work.

Tomorrow I begin my first day of trauma surgery. On call, no less. So really it's my first two days, all wrapped up into one very long day-to-night-to-day.

ripple

I couldn't tell you exactly when it happened, but somewhere along the way, the stakes have risen exponentially. Suddenly, a single exam becomes the road sign in the intersection of the future, pointing you in one direction -- or, a la glass-half-empty, blocking off other directions. Suddenly, the consequences of decisions are weightier than previously imaginable (and will soon be literally life-or-death). Suddenly, the naivete of youth is no longer a credible excuse for irresponsibility.

It was never just about me, but I've been fortunate that most of the mistakes in my short life have been relatively self-contained. Make mistake, undergo distress, learn lesson, move on. No one else gets hurt. That isn't to say that I haven't committed my share of emotional warfare as well, but I can honestly say that I've done my best to play fair and minimize damage to others; I have few regrets.

But suddenly, it really really really isn't about me. It was naive to assume that my decisions, good or bad, wouldn't - or couldn't - make a huge difference to someone else. In a way it was simultaneously self-centered and self-deprecating, to believe that I was so insular that no one else could possibly be affected by my choices. Sometimes it takes some perspective to realize that you could be standing in the center of a ripple. And it's scary to think that as the stakes rise - there's no telling how far the ripple will reach.

pride

It can feel so good, so empowering, that little defense mechanism we call pride: it makes you invincible and impervious to anything that anyone could do to possibly hurt you. And when the day is over, you get to walk away intact without so much as a glance backwards, head held high, never showing a single sign of weakness, never letting on that maybe you're not really okay. That maybe despite your best defenses, you slipped and you fell... just a little bit. Maybe you even convince yourself. Or maybe deep down you know it hurts, but none of that seems to matter when pride is at stake. It's like some bizarre cartoon where you throw your heart and your reason up in the air and run diving to catch your pride.

The thing is, when does pride cross the line from self-protection to shutting everyone out? How do you know when you've gone too far and your preemptive barriers, intended only to block out the bad, block out everything and everyone? You sit inside your walls... alone with your pride. And maybe that's what ends up hurting the most.

wake up

Once in a while, you see yourself as the world does, and then you wonder how you were so clueless and naive all along. In that moment of shock and self-doubt and -loathing, it's hard to remember that maybe a rude awakening is a good thing. It's an opportunity to grow and change. To admit to your character flaws. To be constantly reminded of the enormous blessing of friends and family who see through you and know your ugliest faults... and graciously accept you anyway.

venus and mars

How girls deal with issues:
-obsessing
-imagining every possible scenario
-coming up with a plan for every possible scenario
-trying to talk about it but running into a wall of passive aggressiveness from other party
-never actually talking about it due to said passive aggressiveness
-continuing to obsess until 1) resolution (I've heard mythical stories that resolution actually exists but have yet to see it myself), or 2) excessive amounts of time pass and the issue fades

How guys deal with issues:
-passive aggressiveness
-inaction
-unresolved awkwardness
-ignoring the issue until it fades, i.e. excessive amounts of time pass
-what issue?

Lesson #1: Clearly the guy wins every time, even if he has to wait >6 months for the issue to fade.
Lesson #2: Lack of resolution does not bother guys.
Lesson #3: "Women are crazy; men are stupid." This is a true statement.

addictions

-12-packs of fat yellow Sharpie Accent highlighters
-12-packs of blue PaperMate FlexGrip Elite ballpoint pens
-nytimes.com
-my bed, excessive pillows and all
-Eatzi's four-cheese gourmet bread
-Ben & Jerry's New York Super Fudge Chunk
-the way reading J.D. Salinger makes me feel
-people-watching while "studying" at coffeeshops
-wallowing in angst and ennui
-online browsing/shopping at shopbop and shopepic
-the post-workout/post-shower feeling (but not the process)
-lean, chiseled, scruffy, dark-haired men (extra points if a musician)

year in review

2006 was, to say the least, tumultuous. Not saying that I don't recognize the value of the "life experiences" I supposedly tucked into my sleeve in the process... but drama is exhausting. And I'm exhausted. If there's anything at all I truly learned about myself, it's that I somehow always end up living my life at the farthest ends of extremes: complete stability or complete wreck, total health nut or fat slob, whirlwind mania or apathetic immobility. At the risk of perpetuating the MS2 hypochondria stereotype, I truly think I may be subclinically bipolar. With a touch of borderline personality thrown in for good measure.

Now at year's end, I think I have found myself at all the bad extremes in my personal life: physically, emotionally, mentally; and on the flip side, at the 24-7 studying extreme in my professional life. Some of it I will attribute to the strange bubble world of med school, in which I (and many of my peers, I'm sure) put our current needs behind those of our future careers. It's so easy to say "I'll think about my body, my health, my mental/emotional stability, etc. when this test is over." I say it all the time. Except that tests are constant. Work will be constant. Family will eventually be constant. I can hardly handle my own life, much less that of someone else, which was proven to me in a very painful way. And though it seemed inevitable and the only right choice at the time, it still kind of scared(-es) me. So much so that in retrospect, it was the catalyst for a lot of self-destructive immaturity. Quarter-life crisis, anyone?

In college, I had the time to aim for all the good extremes in all aspects of my life... you could do it all: study, have fun, work out, make ample time for friends/family/relationships, even indulge several hobbies. I was never very good at prioritizing and time management (understatement: I'm terrible), but who needs to prioritize when you have all the time in the world to get everything done? Turns out, I'm not all that well-rounded and balanced when I'm crunched for time.

So. My resolution for 2007. (Yes, I'm buying into the whole "new year, new me" bullshit. What of it?) Balance. I'm not going to pretend that I'm always going to be great at everything. Because I won't. I'm not going to pretend that I won't put myself on hold during exam weeks. Because I will. But, if some of the time, I remember to take care of my body, my mind, my emotions, then maybe I will find a bit of stability that's been sorely missing in my life for much of the last year.

thankful

I originally meant to update about the excessive eating and shopping I did over Thanksgiving break, but then something happened today that put everything in perspective. I had to come back up to Dallas a day early yesterday to see a patient today. While I wasn't dreading having to see a patient, I wasn't exactly thrilled to cut my break 25% short for medically-related purposes.

Though I knew before walking into the room that my patient had cystic fibrosis, I was completely unprepared for what happened in the next hour or so. For as much as I knew about the damn chloride channels and the 1 in 2500 prevalence and the CFTR del. F508 mutation and the pink-staining fibrosis on the glass slide; for as much as I was prepared for the clinical findings and organ failure; for as much as my history and physical revealed an almost textbook presentation of CF: I was shocked at how much this REAL person affected me. You can read and study for hours on end (and we do), but I didn't realize until today how much the words we study are only abstractions. We throw around all kinds of words for disease manifestations and don't even bat an eye when discussing terminal illness, yet somehow in the sterile safe world of the lecture hall and the carrels it all seems so far removed from humanity.

And then this afternoon, my patient broke my heart. He is only slightly older than me, but the CF has already progressed to advanced stages with multiple organ involvement/transplant. He looked much sicker than I expected. In the next hour, we discussed everything. Everything. I wondered if any of the doctors before me had had the time to learn about him as a person, not just his disease. He hadn't been able to finish high school, work, meet people his age, or experience a normal life. He spends most of his time these days watching TV at home, waiting to succumb to a disease that, years ago, already claimed one of his younger siblings. By the time I finished the history and performed his physical exam, I wanted to cry and felt stupid that there was nothing I could say or do to make anything any better. There was nothing that medicine could do to make anything any better, other than prolong his life and maybe quality of life. We can only hope to make a difference sometimes. Today all I could do was listen to him pour out his life story.

He loves Sean-Connery-era James Bond movies and "Law and Order." I know it would be inappropriate for me to go back and visit him in the next few days and give him a DVD or two. I know he would hate the "sympathy." And yet I can't stop thinking about him and the damn DVDs.

I hope I never forget what this feels like. I hope that the next time the sleep deprivation and stress get me down, I will remember that this is why I chose to study medicine. And most of all, I hope I remember to be thankful for all the blessings in my own life.

perspective

Without fail, every year of my life has gotten "more difficult." This is not necessarily a bad thing, unless it continues indefinitely, in which case old age is not looking so good. I thought I worked hard enough in college, until thesis came along and showed me a new level entirely. Then MS1, which I'm sure I bitched about appropriately. Oh how naive I was. MS2 has raised my tolerance exponentially for continuous studying and thinking it is normal to spend literally every waking moment (except showering and sometimes eating) at a desk with my syllabus and a stack of books. I think my greatest wish right now is to have the ability to not have to stop to eat or sleep.

Currently subsisting on coffee, tea, more coffee, Cheez-its, Chunky Chips Ahoy, and the 24-hr Jack-in-the-Box near campus.

The scary thing is, I'm sure next year I'll look back at MS2 and STILL say "Oh how naive I was."

constant thoughts

I try to smile every day. I try to laugh and be happy in public. I try to remember that life is a funny thing and sometimes shit happens. And most of all, I try to convince myself to trust the decisions that I've made, and trust that I made them for what were compelling reasons - even if the rationale is now beginning to blur in my head. Time offers such a safe distance from the immediacy and passion and certainty of these things, but I need a black-and-white reminder of why things had to turn out this way. If anything, time turns things into shades of gray for me, leaving room for doubt and what-ifs, snatching what little conviction I had in the first place that this was the right decision. And if/when I finish rationalizing one way, I go back and rationalize the other way.

E et al. have always teased me about rationalizing everything. Everything. Most of the time it's quirky and harmless, and perhaps even a source of amusement to those around me. But in "real life" and crappy interpersonal situations, it really complicates things unnecessarily and turns around to bite me in the ass.

Please note the numerous bite marks on my ass.

and if i hurt you, then i'm sorry
please don't think that this was easy
and then you bring me home
cuz we both know what it's like to be alone

sociological thoughts

"[Ivy League admissions directors] are in the luxury-brand-management business, and “The Chosen,” in the end, is a testament to just how well the brand managers in Cambridge, New Haven, and Princeton have done their job in the past seventy-five years."

"In the nineteen-eighties, when Harvard was accused of enforcing a secret quota on Asian admissions, its defense was that once you adjusted for the preferences given to the children of alumni and for the preferences given to athletes, Asians really weren’t being discriminated against. But you could sense Harvard’s exasperation that the issue was being raised at all. If Harvard had too many Asians, it wouldn’t be Harvard, just as Harvard wouldn’t be Harvard with too many Jews or pansies or parlor pinks or shy types or short people with big ears."

-Malcolm Gladwell, from a recent New Yorker article about Ivy League admissions
http://www.newyorker.com/critics/atlarge/articles/051010crat_atlarge

While on some level I wish I felt indignant and felt the need to disagree with this elitist portrayal of The Great Institutions that are the Ivy League... I can't because I don't feel that way. Whether or not we want to acknowledge it, much of the exclusive Ivy image revolves around the stereotypical old money prep-school WASP-y athlete a la F. Scott Fitzgerald's era. All you have to do to see living, breathing proof is show up at the 50th or older Princeton reunion. [as an aside: If the Ivy League DID base admissions on academic credentials alone, wouldn't you expect the Ivy League schools to have a reputation/atmosphere equivalent to MIT or CalTech? The fact that they don't shows that other forces are at play here...]

The craziest thing is, I love and romanticize the aforementioned stereotypical image - despite the fact that I would never have been a part of that, 1) because I am Asian, and 2) because I am female. At the risk of sounding sexist/racist/un-PC all at once, there is no doubt in my mind that the first Jewish admit, the first African-American admit, the first female admit, the first low-income admit, etc. all were (reasonably understandable) fodder for shock and outrage among alumni. Obviously everyone adjusted to the times and came out fine, but it seems the "problem" (I use this word loosely) now threatening the stereotypical Ivy image is the risk of those minorities becoming too much of a presence on campus, and possibly overpowering the presence of the legacy admits. Of course I am grateful for the continually changing face of the Ivy League, for to it I owe my admission and education; but at the same time I can't help but mourn the dying blue blood image of an era I have admittedly only imagined.

In a weird hypocritical way, I am enamored of the stereotypical old Ivy League of which I could never have become part, while simultaneously recognizing the merits of homogenization (on racial and social income level grounds) of an elite academic institution. All I'm saying is, it's a Good Thing that many people (and in particular Dean Malkiel at Princeton) support equalization and diversification of the Ivy League and want to attract more scientists/minorities/low-income applicants/insert non-stereotypical applicant here. But at the same time I don't see why it's such a bad thing that older alumni and others want to preserve the classic preppy image of the Ivy League, even if that means admitting athletes and legacies on a preferential basis. Come on, where do you think all of Princeton's money comes from, anyway? I am not a sociologist, and this is a controversial subject to begin with, so don't shoot me. In any case, what do I know, I'm just a lowly first year med student with no marketable skills.

p.s. Professor Howard Taylor would have a field day with this New Yorker article.