Ask the Questions that Have No Answers: the Mad Farmer Liberation Front

sent to me from a dear friend who clearly knows how to speak to my soul -

to keep in all of our minds while we quest:

Manifesto: the Mad Farmer Liberation Front (Wendell Berry)

Love the quick profit, the annual raise,
vacation with pay. Want more
of everything ready-made. Be afraid
to know your neighbors and to die.
And you will have a window in your head.
Not even your future will be a mystery
any more. Your mind will be punched in a card
and shut away in a little drawer.
When they want you to buy something
they will call you. When they want you
to die for profit they will let you know.

So, friends, every day do something
that won’t compute. Love the Lord.
Love the world. Work for nothing.
Take all that you have and be poor.
Love someone who does not deserve it.
Denounce the government and embrace
the flag. Hope to live in that free
republic for which it stands.
Give your approval to all you cannot
understand. Praise ignorance, for what man
has not encountered he has not destroyed.

Ask the questions that have no answers.
Invest in the millennium. Plant sequoias.
Say that your main crop is the forest
that you did not plant,
that you will not live to harvest.
Say that the leaves are harvested
when they have rotted into the mold.
Call that profit. Prophesy such returns.

Put your faith in the two inches of humus
that will build under the trees
every thousand years.
Listen to carrion--put your ear
close, and hear the faint chattering
of the songs that are to come.
Expect the end of the world. Laugh.
Laughter is immeasurable. Be joyful
though you have considered all the facts.
So long as women do not go cheap
for power, please women more than men.
Ask yourself: Will this satisfy
a woman satisfied to bear a child?
Will this disturb the sleep
of a woman near to giving birth?

Go with your love to the fields.
Lie down in the shade. Rest your head
in her lap. Swear allegiance
to what is nighest your thoughts.
As soon as the generals and the politicos
can predict the motions of your mind,
lose it. Leave it as a sign
to mark the false trail, the way
you didn’t go. Be like the fox
who makes more tracks than necessary,
some in the wrong direction.

Practice resurrection.

flow of gratitude

(me on Mt. Washington, Sept. 2010)

"when you can't run, you crawl,

and when you can't crawl,

you find someone to carry you"

-cptn malcolm reynolds,

from firefly

coming home for the holidays always feels like being dunked into a pool of gratitude - it doesn't even feel intentional, I just feel flooded with thanks. with each year, I feel like there are more places I call home and more people I feel grateful to come home to. As I get farther on this path to becoming a doctor, and especially as I prepare to embark on a year living out of a suitcase calling different states, hospitals, and rented condos home, I realize just how important it is that we carry each other.

as the new year approaches, I find myself reflecting on the past year and creating intentions for the next - hoping I'll live just a little more closely to my values. Here are some lessons from 2010 and intentions for 2011 inspired by the many wise people in my life.

lessons and intentions:

*

get outside

*

strive for more impact on people, less on the earth

*

be a good loser, winner, and beginner

*

connect to a greater community

*

and a smaller community

*

call on your support systems when you need them

*

remember your inner child

*

try something that seems too big, too hard

*

remind yourself that you don't have to believe everything you think

*

reacquaint yourself with your internal rhythm

*

there are many ways to stay in touch with people; try them all

*

everyone wants to feel competent, valued, and loved

*

when in doubt, choose happiness

what are your intentions for 2011? what did you do well in 2010?

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"A process cannot be understood by stopping it. Understanding must move with the flow of the process, must join it and flow with it."

-Dune, by Frank Herbert

shoutout to the BLT

so my ridiculously awesome sister has started an incredible blog about strong women living a healthy, active lifestyle. She has delicious recipe ideas, easy and effective workout moves to mix up your routine, tips on what sweet workout clothes you need to get moving, and profound reflections on how to keep all that moving going on.

she seriously rocks it over there, so check it out for yourself and definitely write comments about your favorite workout clothes/moves/recipes - she LOVES it.

Check it: The BLT

how old are you, really?

yesterday we visited "nursing homes" as part of our current study of medicine for the geriatric population. I went to possibly the nicest version of a retirement/nursing home that has ever been created. In order to move into this community, you have to basically prove (via medical screen, interviews, history) that you'll be able to live completely independently for at least 2 years. Most people move into to condos that surround a central restaurant/pool/gym/community center area. The residents who live here are involved in the greater community, some work part time, many volunteer, and lots are involved in the running of the community itself.

But, if at any point the residents need more assistance, they transition smoothly into (what I think should be called level 2, but they call:) Residential Living, where you move in to your own room in a big lodge-like building. But the rooms are still individual, you can still access any part of the entire campus, but there's a closer restaurant/gym/pool in case you don't want to leave the building daily. The hallways are full of open doors with a sign with the person's name, umbrella stands, small tables and chairs, photographs, bookshelves - altogether, much more cosy than any hotel or college dorm.

If you have a stroke or your health deteriorates in any other way where you need even more assistance (incontinence, decreased unassisted mobility, trouble eating independently) - you can move to (what I'm calling level 3, but they call:) Skilled Nursing Floor. Which still looks like hallways of rooms in a lodge that are more individualized, except that the beds are all the same and adjustable, so that the nursing staff can easily move people. This is usually the final move for most people and the people there looked very settled, but there is a fourth level (3.5?) called Long-Term Care, which is specifically designed for people with dementia. This area has been designed to be easily navigable (e.g. circular hallways, so no one can get stuck in a corner).

I went to one of the condos in the Independent Living section that looked a lot like the condos my grandparents live in (near the tennis courts and pool, where they play almost every day) - and how I imagine many sections of Florida might look: nice, clean condos all filled with people over the age of 65 hanging out and enjoying each others company. Except all the people know that they're going to live there until they die.

or maybe that's not so different at all.

I spoke with a wonderful man named Henry who was 75 and had returned from a tennis match with a friend a few hours earlier and was headed to a board meeting for an organization downtown later that evening. He had moved into the community three years ago because he slipped and fell off a roof in his more remote home and realized he didn't feel completely competent living so far from help. He also saw his father move through (the levels of) the community and how his autonomy was preserved as much as humanly possible. He was certainly not someone I would have suspected would live in a "nursing home" community, but he was so happy with his choice.

We talked a lot about the concept of internal perceived age versus external physical age. Henry told me that his assignment for me for the next few weeks was that whenever I was sitting around a table with a group of people to ask them all about their internal age. He said, "you'll be surprised - some people your age will say they feel older, and people my age will often say much younger than you think". I asked him about his internal age - and he said (without hesitation) - 36. When I asked him about why and also, "why not younger, like, 25" (which we're learning is the peak fertility, peak physical shape, etc). He said, "oh no. 25 is crazy".

yup. wiiiiise man.

what's your internal age?

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From my tea this morning, yet again:

"to me, old age is always 15 years older than I am"

-Bernard M. Baruch

warming the belly

Q: What's your favorite thing to cook/eat during the winter?

A: soup!!

Because all I've been craving in this cold weather is SOUP of all kinds, I looked up the BASICS of how to make soup and came upon this great article by Mark Bittman about how to make many types of delicious soups with relative simplicity. I love his style and plan on referring back to this a lot in upcoming months/years.

1. CREAMY

Creamy Spinach Soup

Put 1 chopped onion, 2 peeled garlic cloves, 3 cups water and salt and pepper in a pot over high heat. Boil, cover, lower the heat and simmer until the onion is tender, about 10 minutes. Add 10 ounces chopped spinach and 1/2 cup parsley leaves; cook until the spinach is tender, 2 to 3 minutes. Add 1 cup Greek-style yogurt and purée. Garnish: A spoonful of Greek-style yogurt and chopped parsley.

Squash-and-Ginger Soup

Substitute 1 tablespoon minced ginger for the garlic and 4 cups chopped butternut squash for the spinach (it will take longer to soften). Skip the parsley and substitute half-and-half or cream for the yogurt. Garnish: A spoonful of cream.

Curried Cauliflower Soup

Substitute 1 tablespoon minced ginger for the garlic, 2 cups cauliflower florets for the spinach (they will take longer to soften), 1 tablespoon curry powder for the parsley and coconut milk for the yogurt. Garnish: Chopped cilantro.

2. BROTHY

Vegetable Broth With Toast

Put 2 chopped carrots, 2 chopped onions, 1 small chopped potato, 2 chopped celery ribs, 2 garlic cloves, 10 sliced mushrooms, 1 cup chopped tomatoes (canned are fine), 10 parsley sprigs, 1/2 ounce dried porcini, 8 cups water and salt and pepper in a pot over high heat. Boil, lower heat and simmer until the vegetables are soft, 30 minutes or longer. Strain and serve over toasted good bread. Garnish: Chopped celery leaves.

Egg Drop Soup

Beat 4 eggs. Boil the strained stock, lower the heat so it simmers and add the eggs in a steady stream, stirring constantly until they’re cooked, 1 to 2 minutes. Stir in 1/4 cup chopped scallions, 1 tablespoon soy sauce and 1 tablespoon sesame oil. Skip the bread. Garnish: Chopped scallions.

Rice-and-Pea Soup

Boil the strained stock, lower the heat so it simmers and add 3/4 cup white rice. Cook until tender, then add 2 cups fresh or frozen peas; cook for a minute or two. Skip the bread. Garnish: Grated Parmesan.

3. HEARTY

Bean Soup

Put 1 1/2 cup dried beans, 1 chopped onion, 2 chopped carrots, 2 chopped celery ribs, 2 bay leaves, 1 tablespoon fresh thyme leaves and 6 cups water in a pot over high heat. Boil, lower the heat, cover and simmer until the beans are soft, at least 1 hour, adding more water if necessary. Season with salt and pepper. Garnish: A drizzle of olive oil.

Chickpea-and-Pasta Soup

Substitute chickpeas for the beans and rosemary for the thyme and add 1 cup chopped tomatoes (canned are fine). When the chickpeas are almost tender, add 1/2 cup small pasta. Cook until the pasta and chickpeas are tender, 10 to 15 minutes. Garnish: A few chopped rosemary leaves.

Spicy Black-Bean Soup

Use black beans and substitute fresh oregano for the thyme. When the beans are done, add 1 tablespoon chili powder, 1 dried or canned chipotle and the juice of a lime. Garnish: Cilantro and sour cream.

4. HEARTY

Minestrone

Sauté 1 chopped onion, 1 chopped carrot, 1 chopped celery rib and 1 teaspoon minced garlic in 3 tablespoons olive oil for 5 minutes. Add 2 cups cubed potatoes and salt and pepper; cook for 2 minutes. Add 1 cup chopped tomatoes (canned are fine) and 5 cups water. Boil, lower the heat and simmer for 15 minutes. Add 1 cup chopped green beans; simmer for 20 minutes. Garnish: Chopped parsley and grated Parmesan.

Mushroom Soup

Substitute 1 1/2 pounds sliced mushrooms (preferably an assortment) for the potatoes; sauté until they brown, 10 to 12 minutes. Substitute ½ cup white wine for the tomatoes, skip the green beans and add a fresh thyme sprig with the water. Garnish: A few thyme leaves.

Tomato-and-Garlic Soup

Use 2 tablespoons minced garlic and substitute 2 tablespoons tomato paste for the celery. Skip the potatoes and green beans; use 3 cups tomatoes and 3 cups water. Cook the tomatoes for 10 to 15 minutes. Garnish: Lots of chopped or torn basil.

to listen

"the first duty of love is to listen"

- Paul Tillich

this was the quote attached to the string of my teabag when I woke up this morning to snow lightly falling down over the farm across the street and a whole long list of lectures I haven't gone through yet. and it made me think.

there seems to be a bit of a dip in moods lately all around me - and I'm not sure if it's that we have less daylight or that the cold and holiday season make everyone feel a greater need for comfort and connection, or if it's that we're approaching real studying for the Boards and then starting in all separate directions - literally thousands of miles apart - to start our core clerkships which will be the first time we're really taking care of patients - but I find myself walking around with a knot in my throat a lot of the time lately and I can't quite pinpoint why.

and when I talk to friends about how they're feeling - about life, about school, about relationships - everyone seems to feel one step off, one moment removed, just a bit too often. I keep thinking and asking about the things that seem to help. Is it working out? eating well? sleeping enough?

I think it comes back to just listening - either feeling like you're being listened to, or that you're being a good listener. and, according to my morning tea, the listening is actually loving, which makes it feel even more critical.

I think the knot might have just loosened a little bit.

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Sleeping in the Forest

I thought the earth remembered me,

she took me back so tenderly,

arranging her dark skirts, her pockets

full of lichens and seeds.

I slept as never before, a stone on the river bed,

nothing between me and the white fire of the stars

but my thoughts, and they floated light as moths

among the branches of the perfect trees.

All night I heard the small kingdoms

breathing around me, the insects,

and the birds who do their work in the darkness.

All night I rose and fell, as if in water,

grappling with a luminous doom.

By morning

I had vanished at least a dozen times

into something better.

delayed childbearing: a serious medical risk??!?

this was the "welcome back from restful break with your family" slide I got this morning:

look at that steep curve drop off right around age 25... and just keep dropping. this week, so far, has been focused on infertility and breast cancer - and many a professor (both male and female) has blamed "delayed child-bearing" as a cause of both. This entire week, in fact, has been one big lecture on all the things you're at increased risk for if you don't have children as soon as possible.

for the record, delayed child-bearing is what basically everyone in medical school will have to do, because WE'RE IN MEDICAL SCHOOL right now, and for most of us, it seems unclear how pregnancy would fit in right now. I don't feel like our professors seem particularly sensitive to this.

gahhhhh....

choking on yogurt (and other learning experiences)

Last week, we had a series of lectures on health and healthcare for people with disabilities. It began with a brief introduction lecture after which we were divided into small groups designed to teach us about what it might feel like to have a disability. Each group attended a panel discussion about living with a disability (mine was on children with autism) and a simulation lab of some of the difficulties of specific disability (mine was on swallowing disabilities).

In the swallowing simulation we had to do an exercise where we held tongue depressors between our teeth on the right side, and had to try to eat yogurt using just our left hand in order to mimic what eating after a stroke would feel like. It was not easy and definitely not a pretty sight; it turns out, when you can't close your mouth all the way, you produce a lot of spit that comes straight out of your mouth and drools all over your shirt. There were other groups that had to race around the medical school in wheelchairs, only to discover that one of the elevators was permanently broken; another group wore different glasses distorting their vision while navigating through a cafeteria.

The panel I attended was with four other students, and two mothers of children with autism, one who had brought her son. Having just had a lecture on autism, it was awesome to have REAL people talk about their REAL life experiences. One of the mothers talked about how kids with autism present differently because they are attuned to different senses. For example, she did a mock case with her son where he came in and said, "my tongue hurts". So like the good medical students we are, we started asking him questions:

when did it start? (a few weeks ago)

does it always feel like this? (a lot of the time)

when does it hurt? (mostly at night time)

what makes it start hurting? (mostly night time; I wake up and have to touch my tongue)

what does it feel like? (really hurts on my tongue)

does anything make it feel better? (sitting up, sometimes, and touching my tongue)

does anything make it worse? (dunno)

has this ever happened to you before? (nope)

etc.

except what we didn't ask him was: does anything else hurt too?

(to which he would have replied: my stomach - because what he had was acid reflux but because he was so sensitive to the sensation on his tongue, he didn't mention any burning pain in his abdomen. so cool to think about, also because I think probably a lot of kids don't present with the same symptoms as adults.

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mom to her son, who is an autistic 2nd grade: "honey, there are all these terms for kids with autism. do you want to be known as 'an autistic kid' or a 'kid with autism'?"

son: (thinks really hard for a moment) "I want to be known as a kid with autism AND ENTHUSIASM"

mom: done.

7th graders teach medical school

because a lot has been going on, this post is mostly lists, but I wanted to make sure I got these thoughts out there - and those of you who know me well, know that sometimes I think in lists!

a day of medical taught almost entirely by 7th graders - pretty much the greatest idea ever.

example: one girl is trying to answer a question about her favorite subject in school. while she's thinking the boy next to her goes, "well I know what her favorite activity is: kissing brian samuels". She rolled with it so well, and just dismissed him with, "actually it's soccer" ohhhh 7th grade.

then we asked them how doctors could be better with adolescents. they had great suggestions including:

*don't use big words we don't understand

*ask us questions that don't sound like you're interrogating us - like, about not just our medical health but our LIFE

*wait for us to talk - sometimes it takes us longer

*ask about our friends

*ask if we're worried about anything

*don't talk to us like we're not real people who know a lot

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"I guess this is going to be a jigsaw kind of year"

-from one of the poems read to us by the 7th graders today

let's talk about sex

yesterday we practiced taking sexual histories of standardized patients in small groups. We saw three different "patients" (a standardized patient is basically an actor-patient): a teenager who came in for birth control but was engaging in group oral sex with a group of other high schoolers, a man in his 50s who was concerned about his medication causing erectile dysfunction, and a woman who had just started a new relationship in her 50s and had all sorts of questions about what were "normal" sexual practices.

it was pretty fascinating stuff. the things my group learned were pretty effective in taking a sexual history, no matter what the situation is to:

*start by talking about confidentiality and safe spaces - to sort of set the tone for openness.

*make sure the person feels safe (and get details on how they're making sure they're safe) - whether this means barriers to prevent STDs or feeling emotionally safe in whatever relationship

*make sure the patient feels comfortable

*don't forget entirely about medical problems (for example, erectile dysfunction can be caused by medication side effects, but also by drinking more alcohol, as well as some vascular diseases)

*make sure you answer all the questions or figure out resources where the questions can be answered

*be careful about defining normal - we decided to stick to "normal can be lots of things, but what we want to make sure is that it's making you happy and that you feel safe"

any tips ya'll want to add?

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"we are recorders and reporters of the facts - not judges of the behavior we describe"

-alfred kinsey, zoologist, sexologist

medicine | heroes

heard a great story this weekend from a friend of a friend who is working like a madwoman in architecture grad school about her favorite doctor story.

when she lived in NYC, she biked from brooklyn to manhattan as her daily commute to work, often amongst throngs of other bikers. One day, she was biking over a bridge, when this guy speeded past her on his bike, and before she had time to be annoyed, his bike was lodged in the metal fencing of the bridge and he was sprawled out on the concrete on his back.

according to her, all the bikers (and walkers) stopped immediately in shock and were moving towards calling 911 when a short man on a road bike skidded to a stop in front of the man lying on the ground, dismounted from his bike, took off his helmet, walked past the open-mouthed bystanders, bent over the man's body and said, "Hi. My name is Daniel. I'm a doctor and I'm going to stay with you until we make sure you're okay".

this friend said at that moment she wasn't sure if she wanted to be like him, marry him, have him as her father or create a shrine to him - but in that moment, a calm comfort fell over the people on the bridge and everyone knew everything would be okay.

at what point in this "becoming a doctor" journey will I feel capable of that?

What a powerful goal though, right?

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"I think of a hero as someone who understands the degree of responsibility that comes with his freedom" - Bob Dylan

The Science of Monsters & Adding Chunks (aka Learning about Babies)

We started a new class last week that is designed to fill in all the gaps in our medical knowledge following the entire life cycle - so we are starting with pregnancy and pre-natal health and moving toward neonatal health to baby health.

I vasolate between being petrified and So Entertained.

some random pieces of knowledge I've stumbled upon this week in lecture, small groups, or conversations before/after:

*the concept of baby self vs. business self

the theory that children (and adults) can be totally together at work (or kindergarten) but have occasional (or not so occasional) breakthroughs of their "baby selves" where it becomes all about feeding their exact desires at that moment. Our super prestigious professor told us that he needs at least ten minutes of "baby self time" when he gets home from work before he can effectively interact with his family. I've started saying "okay, BABY SELF TIME!" whenever I feel like I just need to go into total comfort mode.

*teratology = the study of the things that can disrupt normal gestational development; directly translates as "the study of monsters" - horrible (except that I get a really warm and fuzzy feeling about monsters lately, which I've tried to check when it's people calling other people monsters).

*TIPS for PARENTING:

(disclaimer: I'm so not a parent, this is straight from my professor)

(1) figure out what you can and cannot control; what you can: how you act, the environment; what you cannot: your child

(2) get Crazy, because sometimes it works (one professor told us about one family's response to their child throwing a tantrum on the floor of aisle 6 in a grocery store was to drop their bags and get down on the floor with him, screaming and waving their arms like him. apparently the child stopped and walked into the next aisle, like "who are those craaaaazy people?"

(3) choices are really important for helping kids feel empowered, and also helping them feel like the world isn't created to thwart their fun, but that they are participating in it and shaping their world. but the choices don't necessarily have to be real choices. As in, not: do you want to me to check your ears? (most kids would say NO WAY) but "do you want me to check your right or your left ear first?" is a real choice that still gets you to where you want to be.

(4) also, a note about Choices is that if you give a child 2 choices - they always pick the second. at least until they are 2. Our professor's advice was to take advantage of this as much as possible. As in: "hey toddler of mine, do you want to watch Barney or THE DARK KNIGHT?

(I'm totally reviewing his lecture when I have children)

*a discussion of intellectual disability and developmental disorders

check out: www.imtyler.org

more on abilities and disabilities soon...

oh, and in case you're wondering what else has happened in my life that I forget to blog about, check out the lovely krista terminalis post on October.

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"cause I'm a man and not a boy, and there are things you can't avoid - you have to face them, when you're not prepared to face them"

-fight test, by the flaming lips

halloween medical school style

does this reveal the nerdiness factor? friends and I dressed up as characters from the (nickolodeon) TV series, Avatar the Last Airbender (not the movie, the movie was awful). A bunch more friends and I watched all 3 seasons of this cartoon/anime show all throughout our course on nutrition, metabolism, and the GI system last spring. It felt like such a homecoming to watch more episodes in preparation for our costumes (which we MADE!!!) Check out our pose below -we're earth and water bending (in case, for some crazy reason, that's unclear).

we are missing Adam, who would have been:

next year.

and for some nerdy fun, a link to characteristics of characters in scifi/fantasy series

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"Azazel: I see you are the surly, temperamental one who instigates, Wolverine. You cannot be the leader, then."

— The Uncanny X-men Issue #432

Pregnancy = a disease? and insult? an infection? trauma? underlying condition?

there are a few major themes of medical school that are consistent throughout whatever system about which we're learning, including:

- smoking increases your risk of everything,

- diabetes is only bad if it's not controlled, but if your glucose is high, it's involved in every organ system fast,

- don't mess with the kidney too much or you're not going to get better until you get a new one, and

- pregnancy is terrifying.

the photo above is from a real lecture that we had this morning and is supposed to be representing the "insults" to the heart that can cause systolic heart failure. Along with the pregnant belly on that slide is: coxackie virus (major cause of endocarditis), a glucose molecule (representing diabetes), Jack Daniels (not explaining that one), a bottle of erythromycin (which is a chemotherapy that is cardiotoxic), and mercury (which we all accept as a poison).

Other fun lectures that have really driven home this point include one that told us that our peak fertility is 24 (average age upon entering medical school: 26); another that explained in excruciating detail what happens to the pelvic floor after birth with the ever-so-lovely "hammock hypothesis". This isn't even getting into all the drugs you can 't take during pregnancy for fear of what they'll do either to you or your baby OR, maybe most terrifying, all the congenital birth defects we learn about - starting with chromosomal abnormalities or lungs that don't develop because the kidneys don't develop. And then all the things that can go wrong after birth: babies who have blood in their urine might have a disorder that will result in deafness, babies who start out walking fine but get progressively more and more fractures, babies whose hearts don't pump or stop working, not to mention all the things that babies are at greater risk of contracting, which is pretty much every illness.

whew. and I'm not even planning on being pregnant any time soon. It would be nice for at least one lecturer to acknowledge that at least half our class is female between the ages of 22 and 32 and planning to be pregnant sometime soon (if they haven't already), not to mention all the men in my class who will be fathers, and they could just say, just once: it's most of the time okay - or not just okay, but beautiful and magical and like nothing else you'll ever experience.

and then they could tell us all the scary stuff.

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"Childbirth is more admirable than conquest, more amazing than self-defense, and as courageous as either one."

-- Gloria Steinem

to give you my first born son

Every week I meet with a group of Bhutanese community members in our area who have recently moved to the United States as refugees. Some arrived a year ago, others a mere 22 days. We work through this "medical orientation program" that I developed with some of my fellow medical students. The program is designed to methodically go through seven important topics about health care in the United States so that they will be better equipped to use the system as they need it. The topics include everything from making appointments to confidentiality/consent to surgery to how to use the ER to mental health. We break into small groups and play-act a lot of scenarios as well as use lots of photos and props. At the end, I always ask them the two main questions of the session and somewhat pray in my head that they get them and the night hasn't been in vain.

One aspect of the program that I really enjoy is a consistent reminder of how hard it is to not understand and to not be understood - and how much more scary that is for someone who is not feeling well. On my first day of the previous session (our first), I asked one of the participants to tell me how to say "thank you" in Nepali, the language spoken by the Bhutanese community. I figured, if they were going to have to try to stumble through English every day all day, I could at least show them that their language would be hard for English speakers, and I thought maybe it would make them smile to hear me use Nepali words.

The man I ask tells me that "thank you" is said, "dhanyabad" (I'm not sure if I'm spelling that correctly). I ask another person who sort of speaks english - to confirm that my pronunciation is correct - "dhanyabad mean thank you?" (she nods yes). Awesome. At the end of the session, after I've asked the questions and wrapped everything up, I say - okay, "dhanyabad, we'll see you next week!" Everyone giggles, I assume at my pronunciation, and nods, Namaste, on their way out. I repeat this every week with the same response of giggles and nods and Namastes.

the final session arrives and one of the interpreters comes up to me and says, you know, Erica, I've been meaning to tell you - I know you think that dhanyabad means thank you, which it does. I just don't think it means it the way you mean it. We use dhanyabad to mean that we are really, eternally grateful. Look, it means, like, "I will give you my first born son I am so grateful - or something". GAHHHHH! and so then I feel like a total idiot and try to explain, but by this point, they all know me and have laughed it off that no one really accepts nor tells me another word for thank you.

so I keep saying dhanyabad and hope that it's just become a sort of inside joke, or at least that it makes them feel like, hey - we're definitely not the only people who have a rough time learning a new language - look at this crazy lady.

hey, if it helps them feel better able to take on the American Medical System, I'll take it.

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"On my fifth trip to France I limited myself to the words and phrases that people actually use. From the dog owners I learned "Lie down," "Shut up," and "Who shit on this carpet?" The couple across the road taught me to ask questions correctly, and the grocer taught me to count. Things began to come together, and I went from speaking like an evil baby to speaking like a hillbilly. "Is thems the thoughts of cows?" I'd ask the butcher, pointing to the calves' brains displayed in the front window. "I want me some lamb chop with handles on 'em."

-David Sedaris in "Me Talk Pretty One Day"

(a must read for anyone who has ever tried to learn another language for the first time while being in a country surrounded by it and only it)

10/20 in 2010

this week has been full of lots of decisions and realizations. I have finally admitted that I am taking the Boards and that it's okay to start at least thinking about them, I turn 25 really soon (a quarter century crisis approaching?), and we're choosing our clerkship rotations, which will set up the next year of my life (starting in February). often in medical school (and maybe just in life?) everything feels like it rains down at once.

so while I'm still figuring out where I'll be and how I'll keep all the important people in my life in my life, at least in terms of what I'll be doing, the next year of my life will look like this:

Psychiatry 02/28/2011-04/16/2011
Family Medicine 04/18/2011-06/04/2011
Pediatrics 06/06/2011-07/23/2011
Ob/Gyn 08/01/2011-09/17/2011
Surgery 09/19/2011-11/05/2011
Internal Medicine 11/07/2011-12/23/2011
Neuro/Outpatient 01/09/2012-02/25/2012

friends and family, note all important dates and which rotation I'm in, because it may be a big factor in how I can celebrate those important days. I'm already worried about missing my cousin's wedding (August 2011). stay tuned for updates on where I'll be.

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"am I right side up or upside down/and is this real/or am I dreaming?"

dave matthews, crush.

(I feel like I may have used this quote before, but it's one that for some reason often pops into my head at times of transitions)

The Choices We Make: Preference Theory

While visiting friends a few weekends ago, I talked with my friend Rachel about her research this summer in Europe on the ways women figure out the factors involved in their decisions on when to have children and if/how to reenter the workforce. She introduced me to this as an area of research (how cool) - and told me about Preference Theory, a theory created by Catherine Hakam about how our economic situation has shifted women into three categories of preferences regarding how they balance careers and families: 1) mostly career, 2) mostly family, 3) somewhere in the middle.

Hakim suggests that the features of our economic situation that lead to this choice being possible include:

*women being able to control their own fertility through contraceptive use

* women have access to all levels of the workforce

*there are more white-colored jobs (which may be more appealing to women)

*the creation of less typical work hours jobs (part-time, by contract, working from home),

*changes in social attitudes that support women making different choices

Hakim performed two huge studies in europe about how women made these decisions - or determined which preference category they fit into - with interesting results. She concluded that questions about women's preferences can predict employment and reproductive choices, but that this is not true in the reverse - that women in serious careers don't necessarily fit into the "career focused" preference group. She concludes this means that women don't rationalize their choices to fit with their preferences. It's a little confusing to me and I think may be confounded a bit by the age of the women she's asking - to predict (ostensibly, younger), and to reflect (most likely, older). But the times are changing - which you can read about in another article to check out, by another friend of mine working on these topics at the Center for American Progress in DC.

I'm so curious about the questions she asked people to determine their preferences. I was trying to think of my own (maybe you could help?):

- are you interested in being the primary care-giver?

- what percentage of caregiving are you interested in?

- how far would you like to go in your career?

- when do these promotions happen in relation to childbirth?

- what are you looking for in partner in terms of childcaring? (how important is this to you?)

- what are you looking for in a partner in terms of career aspirations? (how important is this to you?)

As all of my friends and family (male and female) start to get more serious about career paths and/or about families, there are lots of conversations about where we all fall on that spectrum and maybe more applicably, how do we work the middle?

thoughts?

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"it's generally a good idea to carry possibilities in your pocket;

you never know when you might need them"

-Mary Anne Radmacher

Getting Physical

that's me in an apple tree!

friends at an apple orchard showing off all the yummy apples we picked.

This past summer I read Cutting for Stone, by Abraham Verghese, a fictional novel about a mission hospital in Ethiopia. I found myself envying the main character, Marion Stone's, introduction to medicine through learning to differentiate different pulses and what diseases they suggested. It's a technique used by many eastern medical practitioners, including Ayurveda. Some important types of pulses that we glazed over in my class, but if read correctly, signify serious disease include:

-pulsus alternans = alternating strong and weak pulse = usually signifies a problem with left heart systole (the major pumping action of the heart) and carries a poor prognosis.

-pulsus paradoxus = when there is an exaggeration in how much the BP decreases on inhalation = can signify COPD, cardiac tamponade (when the sac that the heart is in fills with fluid)

-pulsus parvus e tardus = the pulse is weak and late, relative to expected = signifies aortic stenosis

While we do learn physical exam skills along with every unit of material, and while our approach is very much learning how to fit together the pieces of the puzzle, I sometimes wish we had even more hands-on puzzling things out and that there was more emphasis on that process. Because how do they know we're listening to a heart correctly? Or counting the pulse correctly? No one really checks...

Last week, I practiced my first full history and physical on a standardized patient. It took almost two hours, including the feedback session afterward. It's designed to prepare me for next week when I do the same full exam at the family practice office where I work. Although we had learned and performed all of the exams before, I found that having to go through all of them all together was great practice because there's some awkwardness in transitioning from "okay, now I'm going to look into your ears" to "now I'm going to listen to your heart" to "now I'm going to stick my fingers all the way up in your armpit to feel for your lymph nodes now" or "now I'm going to press my fingers into your stomach - all over your stomach. All of these are incredibly important exams and in order to do them well, you have to be comfortable listening or feeling until you ACTUALLY hear or feel something, which often requires some patience and tolerance of awkwardness on the side of the patient, but also from us (especially at this point in the learning process, but probably forever).

Too many medical students (including me) and doctors have a hard time with that. In a new article in the NYT this week, Dr. Verghese argues for the importance of a good, solid physical exam. In the article he talks about diagnostic gaits, silver stool samples, requests patients make that can suggest a certain disease (if someone says, "hey doc, don't bump the bed" - consider peritonitis, an infection of the abdominal cavity lining), and the power of standing at the bedside of a dying patient (something no test can do). My personal favorite parts of the article are his questions to the residents working with him:

• Name five things that are better outside the body than in. (the answer appears in his novel: fluids, fetuses, foreign bodies, feces and flatus)
• Name at least 10 ways alcohol affects your brain (I wrote about my experience with this question with the neuropathologist at my medical school where I also thought it was an awesome question.

Best line in the article?

"Doctors and writers are both collectors of stories, and [Dr. Verghese] says his two careers have the same joy and the same prerequisite: “infinite curiosity about other people.”

yup. and that's why I like having a blog.

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And in a tribute of sorts - two of my favorite quotations from Cutting for Stone:

"You live it forward, but understand it backward."

-Abraham Verghese

"The key to your happiness is to own your slippers, own who you are, own how you look, own your family, own the talents you have, and own the ones you don't. If you keep saying your slippers aren't yours, then you'll die searching, you'll die bitter, always feeling you were promised more. Not only our actions, but also our omissions, become our destiny."

-Abraham Verghese

find yo mojo

(this is my sister's bf, phil, finding his mojo surfing in marblehead;
he is my favorite person to talk with about: rocks, oceans, and dinosaurs)

I took part in a panel discussion last week designed to give the first years some ideas about how to cope with their Human Structure and Function course - the most intense (time, energy, and brainpower-wise) time of medical school so far. There were about 10 other second year med students on the panel, each with their own advice about how to cope and succeed. Some of it seems medical school specific, but a lot of it was just good life advice.

Some tips included:

1. repetition is everything
2. repetition is everything
3. don't study what you have already learned (as comfortable as that feels)
4. start getting comfortable with doing things differently than the people around you - not everything works for everyone.
5. get a little bit selfish with your time, space, and energy - don't do things that don't fuel your fire, as much as they might work for other people

and my personal favorite: 6. FIND YO MOJO.

One of my fellow students said this to emphasize the need to find something (or somethings) to hold onto in medical school that a) make you feel like a whole person (not just a medical student); and b) make you happy. Another friend of mine refers to this process as "reconnecting to the source". I kinda dig that because I do think there's a global (communal?) energy that can move through all of us if we just choose to tap into it. not that it's always easy to tap into.

the moments where I feel the most tied to that energy are definitely the happiest and most fulfilling. Sometimes it happens as part of medical school - like when we learn something that just seems SO COOL or SO RELEVANT; sometimes I go out seeking it - like on a sunrise hike or in a yoga class; and sometimes I stumble upon it, while singing at the top of my lungs in the car or reading a New Yorker article while sipping tea in my kitchen. moments when it just feels like the world is a good and righteous place, and I'm exactly where I should be in it.

what makes you feel like a whole person? what do you find yourself doing when you feel like less than your best self to try to get back to it? how do you reconnect to the source?


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"sometimes you must leap, she said gently,
and grow your wings on the way down"
-unknown

gatorade = diarrhea you can drink (aka welcome to renal physiology)

Life is a struggle

not against sin,

not against the Money Power

not against malicious animal magnetism

but against the hydrogen ions.

-H.L. Mencken, Exeunt Omnes, The Smart Set, 1919

and that's sort of how it feels today. I write a lot about the profound parts of medical school or the cool parts of being on the way to becoming a physician, but leave out a lot of the grueling details. We just started learning about the kidney this weak, which is arguably the most complicated organ in the body, and it's just not that exciting. It's super important - don't get me wrong - kidney failure is one of the worst medical complications one can have, so far as I understand it - but it's just not that glamorous (as much as our professors try).

our morning was all lectures on acid-base physiology in the kidney and began with the same quote that this post begins with: life is a struggle against H+ ions. The reasoning behind this was what our professor then proceeded to explain to us for the next um, four hours.

then I spent most of the afternoon reviewing the lectures from this morning to try to figure out just what IS the difference between metabolic acidosis and respiratory acidosis and are we more afraid of acidosis or alkalosis in general?

(answers: metabolic acidosis is caused by having too great a concentration of HCO3, whereas respiratory acidosis is caused by having too great a partial pressure of CO2; and we are MUCH more afraid of acidosis than alkalosis because it can make your heart stop).

luckily it was pouring and studying at my big kitchen table while drinking a hot water/OJ/ginger/honey combination that is supposed to help me feel un-sick was pretty alright.

and for fun (because life isn't JUST a struggle), an article from the newyorker about what it would be like if all the dieties got together and planned the world according to feng shui. amazing.

and PS: "gatorade is like diarrhea you can drink" is a direct quote from one of my professors - but I have to add that it's not like all diarrhea, only the kind that has electrolytes in it.

yup - medical school makes for strange conversations.

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"But there is suffering life, and there are defeats. No one can avoid them. But it's better to lose some of the battles in the struggle for your dreams than to be defeated without ever knowing what you're fighting for."

-Paolo Coelho, author of the Alchemist (and many other books)