Strange Gifts

When it was proclaimed that the Library contained all books, the first impression was one of extravagant happiness. All men felt themselves to be the masters of an intact and secret treasure. There was no personal or world problem whose eloquent solution did not exist in some hexagon. The universe was justified, the universe suddenly usurped the unlimited dimensions of hope. At that time a great deal was said about the Vindications: books of apology and prophecy which vindicated for all time the acts of every man in the universe and retained prodigious arcana for his future. Thousands of the greedy abandoned their sweet native hexagons and rushed up the stairways, urged on by the vain intention of finding their Vindication.

 Jorge Luis Borges, The Library of Babel

DNA is the great cosmic irony. It is a catalogue of existence, containing all requisites for life. And, yet, in it lies something sinister. The same code that writes life’s beginning also writes its conclusion. It creates, and in its creation lurks its own end. Irony is often subtle, but sometimes, under the gaze of the microscope, DNA cannot hide it;occasionally announcing itself right from the beginning in some gene over-expressed or conspicuously absent, toppling the ornate equations of life, as if DNA hopes for, pushes for, the End, willing itself to life in order to bring about Death — Freud’s todestrieb incarnate.

More often, however, DNA’s duplicity is less overt. The things the code writes into being, the physical manifestations of the code, succumb to the weight of time and space despite no apparent defect in the instructions. The code, in the end, is simply insufficient to the task of maintaining itself for longer than a time. Whichever form it takes, from the very beginning, the end hides in the shadows.

From the discovery of the library that is the human genome there has been hope for vindication. Somewhere in the library there must be understanding of, even absolution from, the shortcomings of famine and excess of DNA. We have explored with some success, but like the inhabitants of Borges’s library, our search and hope for vindication has mostly been met with the weight and expanse of the library. The small part we do know may not save us from the immense part we do not. What diseases hide inside of me? What skulks in my dark corners? What part of me will commit the treachery?

Those roles which, being neither those of Hero nor Heroine,
Confidante nor Villain, but which were nonetheless essential to bring about the Recognition or the dénouement, were called the Fifth Business.

Robertson Davies, Fifth Business

To accuse inert molecules of desire or even treachery is, of course, foolishness. Assigning blame satisfies, perhaps, some desire for a culprit, some desire for accountability for an apparent wrongdoing. DNA, however, only plays its part. It is neither heroine nor villain. It simply moves the plot along, without malice or kindness; malevolence or beneficence.

Still, lack of intent or culpability does not remove the code’s inadequacy. Death waits at the end despite the promise of life. The dénouement is final and inevitable. It is both variable and identical for everyone. Death takes many forms — expected, tragic, sad, welcomed, horrendous, peaceful, insignificant, significant. Death is the same, however, despite the adjectives used to describe and vary it. It is what it is — true somehow notwithstanding the tautology. Perhaps, though, it is impossible to define Fifth Business without tautology. What, then, to make of the inevitability? What adjectives will be used to modify it? What end awaits me?

To be immortal is commonplace; except for man, all creatures are immortal, for they are ignorant of death; what is divine, terrible, incomprehensible, is to know that one is immortal.

Jaromir Hladik

Referring to a man who, into adulthood, went by the nickname Boy, Padre Blazon, a Jesuit bollandist, remarked that “Whom the gods hate they keep forever young.” Blazon certainly was ignorant to the workings of DNA and, being an old man himself, potentially biased. Though despite his ignorance and age, his wisdom may apply. Somehow his training in the mysticism of the saints prepared him to speak indirectly on the science of genetics.

Stories need endings. Endings allow for completion. A story without ending lacks completeness, even comprehensibility. The stories we tell one another, the stories made popular in literature, television, film, resolve themselves. It says something about us that, generally, these stories reach a satisfactory resolution. Sure, we enjoy reading, listening, and watching stories that end hanging in ambiguity, in medias res. We enjoy them, however, not because of the lack of a clear ending, but rather because of the plethora of inferable endings that could complete the tale. Whether the end is gratifying or not, what we want is completeness. Something in our DNA seems to yearn for it.

We might desire this from our stories because we cannot ignore the innumerable, ceaseless endings in our own lives — the ultimate one most of all. We are, from the beginning, aware of our insufficiency, our mortality. The knowledge of an ending is what drives us to seek completeness. Does time complete, rather than destroy? Is death a gift?

Whereas to Men he gave strange gifts . . . he willed that the
hearts of Men should seek beyond the world and should find no rest therein; but they should have a virtue to shape their life, amid the powers and chances of the world, beyond the Music of the Ainur, which is as fate to all things else; and of their operation everything should be, in form and deed, completed, and the world fulfilled unto the last and smallest . . . It is one with this gift of freedom that the children of Men dwell only a short space in the world alive, and are not bound to it, and depart soon whither the Elves know not . . . the sons of Men die indeed, and leave the world; wherefore they are called the Guests, or the Strangers. Death is their fate, the gift of Ilúvatar, which as Time wears even the Powers shall envy.

John Ronald Reuel Tolkien, The Silmarillion

Collective Rebirth

I created this artwork during my first year of medical school for our Layers of Medicine class. It is meant to be an exploration of the connections we form through this arduous but enriching journey. This multimedia piece represents our communal metamorphosis from strangers to family and from students to doctors. Like siblings, we join together at different stages of development. We fight, learn, resolve, fail, persevere, forge relationships, and drift apart; but at the end of the journey, we are collectively reborn and transformed.

Bioethics Boiled Down

Bioethics Boiled Down

Healthcare workers are inevitably faced with impossible situations as they try to adhere to their ethical code. In a world where nearly all debates are becoming increasingly polarized, this piece seeks to depict the thin line where the pressure from one side is equal to the other and change occurs.

 

Foundation

I came across this tree when I was exploring the Washington coast during a storm.  The rain was pelting and the tree’s very ground had fallen out from beneath it, but there it stood.  From any other angle it appeared to be a normal tree, but if you stood just right you could truly appreciate how hard it had to work just to stay alive.  The human spirit, like all life, shares this resilience.  This photo reminds me to always consider the aspects of life less easily seen.

 

Patient-Centered Care: The Entire Picture

Patient-Centered Care: The Entire Picture
University of Utah and University Medical Center looking west towards downtown and the Great Salt Lake.

Bear Lake

Sept. 29th, 2018

10:30am

 

10 days before Lucas’ 28th birthday

Exactly 5 years and 3 months since his death

The fall air is slightly crisp, but the morning sun is warm shining through the thin, patchy cloud cover.

The brightness periodically changes as the faint breeze moves the clouds.

I hear cars passing along the highway below and excited laughter and shouts from the marina across the highway.

When the sun is bright my right side is warm and my right eye squints.

Directly ahead of me is the vast lake. On a map you can objectively surmise that it is large, but you can’t really appreciate it until it rests before you.

In my whole view I only see one boat. Motorized, not a sailboat. I wonder if they are aware of the danger. If so, how do they prevent tragedy? And if not, how nice it must be to live in ignorant bliss, unafraid of the silent killer just feet, or inches, away from them.

Another boat comes into my view – a sailboat.

I wonder how boaters will respond to the stickers that will soon (hopefully) be mandated on every boat and marina in Utah. Will they be grateful, or scoff at yet another regulation. I don’t care how they react. Because they will be safer.

I imagine how it felt that day. Warm. No. Hot. Over 100 degrees Fahrenheit. Most people concerned about heat stroke. That will be the hypothesis. I imagine laughter and splashes and alcohol and friends.

Another, smaller speedboat motors out of the marina.

Another appears in my right view. I see more people walking in the marina. This must be the time of day people get started.

I smell the dry, dead grass, dirt, and shrubbery around me. Fall has such a unique smell. It feels like, anticipation. Like something is coming. Summer is different. Summer smells and feels like the moment. Right then and there. You can’t anticipate in summer. You can’t know that the moment is going to invert on itself; that everything will have changed by the end of it.

I look out at the water – rippled, not glassy, in many directions. A dull, pale blue. I pick out the area that Felipe had pointed to. “That’s where it happened,” he said. He got confused. Sleepy. Weak. A textbook presentation, I now know. But textbooks don’t prepare you for the news.

I notice the bench. A dark onyx color, with a cracked design. It’s gotten some bird poop on it since it was installed this summer. But it’s surprisingly comfortable. Curved seat and backrest – conforming to the body’s natural curvature. A perfect place to chill out and relax. He loved to chill out and relax. The vantage point is high, a beautiful outlook.

A girl shouts out from the marina. I hope she’s careful.

I look back to the lake and imagine that boat speeding back to the marina, his friends’ faces frantic and panicked. They are too far out; they need to go faster. So they jump. One after another they jump from the boat so that it can go faster. A couple people stay behind to continue CPR. He has stopped breathing at this point.

The sun has moved behind the clouds. It’s a little dimmer now.

I look behind me, the mountainous hills covered in a shade of yellow and red that only nature can produce. I unconsciously move my feet and notice the dirt under the bench. The dirt and rocks are still loose. It took awhile to raise enough money to get it. His friends worked so hard – the annual golf tournament, the lobbying. I want to do more to help. But how? It’s easier not to, anyway.

They tried for an hour apparently, but it was no use. It binds too strongly. Humans have not evolved to resist it.

What is it like to be a first responder, or any healthcare professional, to enter people’s lives on the dark, inverted side of the moment? How do you communicate with them, empathize, when they are still trying to catch up with the moment?

A family is playing down on the shore. No boat. They’ll be OK. Just watch the little ones.

That night I was home alone, on a break from summer camp. I hadn’t seen my brother since before leaving for my study abroad, and had only been back a week or two. I can’t actually remember the last time I saw him. We saw so little of each other then. It didn’t even feel weird for him to be gone, like I would see him next at his birthday in a couple months. But now five birthdays and Christmases and Thanksgivings have gone by. I actually see him more often now – just in my dreams. Clear as day. I worry that I’ll forget what he looked and sounded and smelled like. But my dreams bring him back – perfectly preserved.

I’m afraid of being alone at home at night now. I can’t help but imagine the worst case scenario when my roommate isn’t home when I expect her. I hope I don’t here a knock at the door. 19 is so young. Yet just old enough to be told the truth alone. I don’t envy the role of the police in these situations. They have the hardest job. He was kind. He agreed to tell my mom on the phone when I couldn’t.

I can see why he liked this place. It’s quite magical. I thought I would never come here, but the bench is here – Sit, Relax, Remember. It’s hard, but good, to remember.

I probably won’t go into emergency medicine, but I can still be there for people during their inverted moments. Not all can be turned back around, but some can. And I’ll be there for them during both. To be kind and to tell the rest of the family the truth when it’s just too hard.




The Other Yao

Doctor Yao was a prodigious physician. For ten years, he worked seventy hours a week and saw twenty-five patients a day. Perhaps it was his destiny to work hard. His ancestry never interested him in the least, but he knew that his name meant “demanding” in Mandarin. So, he strove to be the best. In medical school, seduced by the mysteries of science, he traded the pleasures of youth for the white coat. In residency, under the pretext of being more objective with diagnoses, he avoided touching patients to evade the strange feelings that arose from the physical exam. And at work, to save fifteen seconds from every visit, he never introduced himself to the patient. Now at forty, he had almost achieved his ideal career in all but one aspect: he had Calisto.

Calisto was a passionate man. For ten years, he found a profound beauty in experiencing shared emotions with his patients. He identified with the immigrant communities he served and was honored to play a role in their triumphs and failures. In his free time, he flirted with his receptionist who had taught him phrases in Mandarin. When he realized that his last name also meant “medicine”, he dreamed of traveling to China to study acupuncture. However, after ten years he felt burned out. In medical school, he was motivated by the beautiful possibilities of the future. By residency, he had accepted the painful realities of medicine. And ever since the imposition of daily patient quotas, he resented having to reduce patient visits by fifteen seconds. He dreamt of recapturing the passion he had previously. According to Doctor Yao’s gestalt, Calisto suffered from an undiagnosed psychiatric derangement. Why else would someone care so much about fifteen additional seconds with the patient?

One night, upon returning from work, Doctor Yao sank into his favorite green velvet easy chair and reviewed patient charts while sipping his coffee. Under the light of the brand-new television, he noticed that Calisto had fallen asleep. Calisto’s head was propped in the crook of his hand while the familiar documentary about Mario Benedetti flickered in the background. At this moment, Doctor Yao became immobilized with rage. He already paid the electric bill, but where did the television come from? After turning off the useless appliance, he rabidly ran up to the bedroom. In backdrop of the deafening silence of midnight, he shouted insults at Calisto for wasting money on such a useless thing. He had put up with Calisto’s idiotic behavior for forty years and couldn’t tolerate it for even one day more. Calisto went to bed without saying anything, but upon the next morning, he had committed suicide.

At first, Calisto’s death was a small inconvenience for Doctor Yao because now nobody reminded him to sweeten his coffee. After three days of drinking nothing but terribly bitter brew, he had an epiphany. He realized that he could now dedicate himself completely to his work and wildly hurried towards the clinic. From a distance, he saw his receptionist and nurse. He felt a strange sensation in his chest, something he couldn’t describe. Meloncholy? Fear? Attraction? When they passed, they did not address him, but he overheard their hushed whispers. “Poor Doctor Yao. And to think that he used to be so nice and optimistic.” Doctor Yao had no other choice but to slow down because he started to feel a tightness in his chest, the prodrome of an infarction. However, if only Calisto were present, Doctor Yao would have recognized the signs of regret.

Breathing Matters

This piece was inspired by the discussion surrounding physician burnout and how to tackle this problem. In small letters along the bronchi and bronchioles are words describing ways to reduce stress — whether that includes meditation, exercise, time spent with family and more. The writing is small to invite people to stand and think about their own ways of relieving stress and inviting the viewer to pause.

An Hour with Rafael Campo

Rafael Campo, MD. Physician and Poetry Editor, JAMA. Photo courtesy of Dr. Campo.

2018-2019 Editor-in-Chief, Kajsa Vlasic, sat down with Internal Medicine physician and current JAMA Poetry Editor, Dr. Rafael Campo, during his recent visit to the University of Utah. His most recent publication, Comfort Measures Only, New and Selected Poems 1994-2016, was published in September 2018. He currently practices and teaches primary care medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. Join them for a conversation about his career as a physician-poet, the current state of medical humanities in the United States, how poetry can be a vehicle for teaching empathy, and why documenting experiences within healthcare can help us bear witness and not forget the patients who touch us and the time periods of our lives that shape the people we ultimately become.

KV: To begin, I’d love to hear your story about how you first began writing poetry. How did you become a physician writer?

RC: I started writing at a pretty early age. My parents were immigrants to the United States and so poetry was a way of maintaining a connection to our heritage. I always had a sense, even from an early age, that poetry had a healing potential — in the sense that it really did feel like a way to repair that fracture of being in a new country or being away from the homeland.

I attended Amherst College, a liberal arts college, and had several wonderful mentors there who really encouraged me to continue pursuing my interest in poetry while I was completing my pre-med requirements. I love science, but I also have always been passionate about stories and language — and poetry, in particular. I think I was really lucky to be in a liberal arts environment where the two were not viewed as separate. We can be very siloed in medicine, but in liberal arts settings we try to talk across disciplines and really learn from each other — which ended up being very wonderful for me.

I took a step away from poetry after I started medical school. I was at Harvard and had an experience there that was very focused on the hard sciences, with many amazingly talented scientists and researchers, but without much attention to the issues that drew me mostly to medicine. In some ways, I was more interested in thinking about the human condition: How do we make sense of suffering? How can we be present for people when they are at their most vulnerable? How can we bear witness effectively? A lot of those topics and themes were not part of my education in an explicit way. I ended up thinking I’d made a terrible mistake. I thought to myself, Why am I in medicine? This is not what I thought it would be. So I took a year off after the third year of medical school, the really intense shift to the clinical space, and instead focused on poetry.

I had some wonderful mentors at that time. I worked with Robert Pinsky, our U.S. Poet Laureate at the time, and also Derek Walcott, who won the Nobel Prize in Literature while I was studying with him. It was a really energizing and renewing time for me. I was then able to go back to medical school feeling like my batteries were re-charged and having learned that stories were valuable. Seeing it expressed through Robert and Derek’s work in some ways really helped me to re-think the value of poetry, especially in the medical context.

You recently published a collection of your poetry — Comfort Measures Only — and it’s a collection of your previously published work. What was that process like for you? Could you speak to the process of revisiting your writing and how you picked the pieces that went into the collection?

You know, it was quite interesting to re-experience my journey and think about poems I had written twenty years ago. Much of my work deals with identity issues and so, in a really wonderful way, going back through my previous work helped me to appreciate how much things have changed in our world.

I tried to select poems that reflected what was happening in medicine at the time they were written, but perhaps also pointed to the kinds of changes and kinds of progress that we have made as a profession in medicine — as well as our larger culture and in the U.S. more broadly. For example, it was really interesting to reflect on the HIV/AIDS crisis and how harrowing that time was, now that we are post-emergency. We still must remember that there are 40 million people on our planet who have HIV infection, most of whom will not have access to the miraculous treatments that prolong life. We have made really meaningful progress, however, and certainly here in the United States. It’s extraordinarily heartening — having been through the worst of it in this country, in some sense.

As I was making choices for what to include in the book, I wanted to not forget. I wanted to be sure that time of real despair, real crisis, was really represented in my work. I think poetry was, for me and people in communities most impacted by HIV/AIDS, a way of refusing to be silenced.

For many physician writers, one of the reasons for writing is that it’s a cathartic and reflective process. What are the current goals of your writing? How have they evolved throughout your career?

I think for me it’s plain hedonism: I just love to write. I love the pleasure of words and creating beauty and making art — out of language in particular. It’s really renewing for me. From the medical perspective, I do think we need to have some distance in our relationship with patients, of course. But sometimes that distancing can lead to a kind of disconnection from patients and a kind of removal of ourselves from the experience of suffering. I wouldn’t say that writing poetry for me is therapeutic, but I think it does really keep me in closer proximity to the experience of suffering that I witness in my patients. I think that’s a really important driver of my creative process.

My impulse to write is still a way for me to express aspects of myself that feel more silenced or constrained in medicine. There are so many kinds of silences and they are problematic for various reasons. We are still a profession that is not as diverse as we ought to be with the changes in the populations that we serve. So, yes, writing is a way of making those aspects of myself more visible, or at least part of the landscape of medicine. I hope to speak to the importance of diversity and wish that other physicians, medical students, and residents might encounter my work. I hope that my work speaks to the idea that we’re not so different that we can’t talk to each other, but that in our differences we see what is most essentially human about us. Speaking to each other across these differences, it’s not about proclaiming that I am X or Y. Instead, the experience of being in one community is, in some ways, not different from people in other communities. We all face mortality. We all are vulnerable in some sense. I try to represent that in my work and not emphasize the differences. I hope I can speak about what’s ultimately the same in all of us.

I really connect with that right now. It’s been so interesting being on the residency interview trail this last year. There is diversity amongst medical students nationally, but it’s also been dawning on me how much lack of diversity there is within medicine — most notably from a socioeconomic perspective. To be able to reach the level of being a physician, and having the opportunity to carry immense knowledge and skillset moving forward in our communities, requires money. It’s been a pretty humbling experience for me and makes me think, moving forward, how do we shape that landscape? How do we change it? How do we give voice to people who would broaden the shared common experience of what it is to be human and help people through suffering?

Yes — and that really is the foundation of empathy, right? We are fundamentally the same creatures. We feel pain in the same ways, we experience joy in the same ways. Our points of origin and our distinguishing characteristics are superficial in some ways. Again, I have always felt that our differences can help us appreciate even more what we have in common. In this particular moment, there is so much technology and science is even more ascendant. It’s hard to even have real conversations with others these days. With social media — I don’t want to sound like some sort of luddite — I do think it poses some interesting kinds of problems. How do we continue to foster community and a sense of connectedness when, in some ways, we are overly-connected, yet we communicate in two-line tweets? How do we have that kind of conversation that you’re describing — where we think about these kinds of issues in a deeper way? I think poetry can be a part of that.

I feel like there is a growing push within national medical education to include medical humanities in the curriculum. How do you feel the world of medical humanities has changed over the course of your career? I’m sure you have some interesting perspective as you’ve moved from being a medical student to a resident to a physician — and now teach poetry as a medical professor.

I think it’s changed in a lot of really important ways. Doing this originally, as much as I was seeking a kind of connectedness and communion with others, made me feel very alone. There were not a lot of people exploring medical humanities and certainly not many people writing poetry. There were not many physicians writing from their experiences working within medicine. So I think there has been a proliferation of voices and, as an academic discipline, there has been some really incredible work by people, like Rita Charon and others, who are proposing the humanities having purpose in the world of medicine.

But also in a rigorous way, what does narrative teach us about how we listen? How do we construct different kinds of stories? How do we use our own kinds of metaphors within medicine? Even, thinking about literary criticism and techniques that come from the humanities disciplines, how can those be applied in medical discourse? I think there’s a greater rigor around using or discussing the humanities within the medical context. That’s really exciting, too. I love creation. I love how poems and narratives can tell us stories. I am also interested in how they tell us stories, how they teach us, how we respond to them, how we learn from them, and how they shape our thinking as well. So I think that kind of work is equally valuable, if not more so, than the act of creating stories.

It’s also exciting to see the medical humanities migrating into other fields, too. It’s not just medicine. Other care providers are thinking about the humanities and the relevance of the humanities in their disciplines.

One other thing that seems newest of all of these developments is that there is more of a focus on wellness and, not just among our patients, but amongst physicians. There are a lot of interesting possibilities. I don’t think the humanities can be a Band-Aid: Oh, you’re burned out? Write a poem. But, can the context of the humanities help us make sense of the broken systems and critique the kinds of systems we have in medicine that are contributing to burn-out? When we think about the humanities, we think about morality. We think about ethics. We think about power dynamics. Who gets to tell the story? A lot of those themes are relevant to why medicine as a profession is harming doctors and creating a lot of problems for us in terms of working within the system. I feel like we’re just beginning to think about the application of the humanities in medicine. I’m really hopeful for the future.

I’m hopeful for the future, too. I’m hopeful that maybe we can incorporate the medical humanities more into the culture of medical wellness. I feel like I’m having more and more conversations with my peers about trying to figure out ways to meet the wellness needs on an individual level as trainees. It gives me hope that we’re actually having conversations about it and it’s no longer this stigmatized, back-closet idea.

Or that the struggle should be handled by sucking it up and dealing with it. “I went through it, so you’re going to go through it, too.” That’s really not a useful response. We really need to think about how we can make medical training really serve the needs of our trainees. Sometimes I have students say, “Oh, this is so wonderful, but I’m not being challenged because everyone is acting too nice.” It’s a shocking expression of how broken our system really is that we have inculcated this idea that you deserve to be mistreated in order for you to feel that you’re learning. It’s so perverse. Some kind of critique of that is necessary. I think it is a reflection of the moral problems of medicine currently. If it’s all about money and reimbursement and expertise and cloning the next gene, there’s so much that’s lost in what doctors have to content with day to day. I think the medical humanities can help us ask those kinds of moral questions and help us really think, as a profession, about what kind of profession we want to be. Are we an industry? Are we like any other profession? That’s a valid question to ask and maybe that’s what medicine should be. Maybe the humane work should be shifted to social workers or to chaplains. Maybe doctors shouldn’t be capable of showing emotion. But I think people come to us for care — not just for our expertise and a cure. They come to us for so much more than that.

You use poetry as a vehicle for teaching. What does this look like for you? How do you interact with students and how do you use poetry in medical education?

One of my favorite things that I do is lead a reflective writing workshop for my students. We usually gather once a month and a group of 15 students or so comes to my home. Usually we have a meal together (I love to bake!) We usually have a text, or several texts, that we read together and reflect on as a group. Then we write together. I love this because we get outside of the clinical space entirely — literally, because we’re in my home, but also metaphorically, because by exploring poems we’re in a different mode than we are on the wards. I love hearing my students’ responses to the poems and then reading what they write. It’s always extraordinary. It’s not necessarily about craft, but about process. At the end, it’s more about creating a space where people feel they can raise their voices.

I also teach a variety of other courses. There’s a course called “The Developing Physician” where we also do some reflective writing and explore texts. It’s done in a seminar setting where we discuss the texts in relation to topics that many consider unteachable — like empathy and compassion, professionalism, end of life, and the difference between healing and curing. Again, some of these themes traditionally have not received any formal attention in our curriculum.

I guess what I love about it most is that I get to know my students as people. I get to know about their families, their hometowns — even their pet goldfish! It’s really gratifying because that’s the joy of this work — being people together — and by presenting myself as a fellow human I hope that models a different way of being in medicine. We’re not just robots, we’re not just technicians, we’re not just in our white coats in disguise. We’re people. All of us.

What are your words of wisdom for medical students, soon-to-be residents, or anyone in the medical field as they move forward as physician writers?

First and foremost, keep your stories alive inside you. There are a number of ways of doing that. I think the most important way, keeping in mind how busy residents are, is to try to make some time for reading. Even if you don’t have the time to get out your journal and write a poem or a story, reading can be equally sustaining in that sense.

I would also share that it is not an either-or. You can be an accomplished, well-read diagnostician. You can nail the twelve things on the differential and you can still be engaged with the humanity of your patients. Don’t accept the message, if you are exposed to it, that one is more important than the other. They can happily co-exist and you don’t have to sacrifice one to excel at the other. That goes both ways, but I think for interns and residents it’s important to hear that you can stay alive — whatever your passion may be. Maybe it’s film, maybe it’s parenting. Stay true to those passions. You don’t have to sacrifice them to be a good doctor. It’s not an either-or.

The following question pertains to myself just as much as my peers. I know I have classmates who are fearful of poetry. Adding to my previous question, what are your words of wisdom, your recommendations, for physician writers who are fearful of broaching the field of poetry? I think poems are such a great way to share stories — but it’s a daunting field within writing.

It really is! Don’t bring with those experience from high school where you had that awful teacher who told you it’s all code language. We are, many of us, scarred by those kinds of experiences. I think the best poetry is utterly accessible, especially to people in medicine broadly, because it’s so visceral and physical.

The meter. When you start to hear the rhythms within poetry, you start to recognize they are the same rhythms that are present in our bodies that you hear through your stethoscopes. Poetry is actually the most gripping in admitting us to what it has to offer us.

I guess I’d say, leave those preconceptions or biases or awful memories at the door. Try it. Read it out loud. Read it in a group. Go hear a poet read. Hearing a poem in a poet’s voice can totally change it because the geography of the poem can often be off-putting. We’re not used to seeing these weird shapes or short lines. Where does the emphasis fall? If you can go hear a poet read, let the poet voice it for you and then you can start to experience it more on the page yourself.

Don’t be afraid of it. Because our time is limited as well, we can read a poem in a relatively short period of time. You can even write one in a relatively short period of time. Or you can, at the very least, get a draft in. So it kind of fits into the spaces of our very busy lives in a way that an 800-page novel doesn’t.

Oh yes, are you referencing to the giant stack of books next to my bed that is always waiting for me?

Ahh, the iconic stack. That can be demoralizing it itself, can’t it? There are some poets, especially some contemporary poets, who are writing very deliberately to be vexing, to be disrupting, to challenge structure. Maybe don’t start with those poets. Maybe as you get into poetry more, try reading those poets. They’re doing some really interesting and cool things, but starting there can feel more daunting. They are trying to challenge us in how we receive language and what language does.

Who would you recommend? And who are you currently reading?

I’m actually going back and reading [Walt] Whitman now. I have a colleague who is doing a series on PBS about Poetry in America and she’s doing an episode on Whitman. We were talking about him recently. He actually worked as a volunteer nurse during the Civil War tending to wounded soldiers and one of my favorite poems of his is called “The Wound Dresser.”

For contemporary poets, there are so many who have addressed the idea of illness in ways that I find so compelling and relevant for medical students and residents. Marilyn Hacker has written about her experience with breast cancer. I think her poems are intensely musical. They are formal and correspond to the idea that most people have about what poetry is. It will feel perhaps more familiar to people who don’t have as wide a familiarity with poems. They are very narrative and tells stories.

Mark Doty has written about HIV/AIDS and has a very accessible form. It restores your faith in the possibility of there being beauty in the world when you read his poetry. The poems are just so beautiful and so moving. When we spend a lot of time in the grim hospital world, I think it’s nice to see beauty.

Freudian Slippers

I am standing in front of a heavy brown door with a small window at eye level. Unlike a prison door, or the doors continuing down the hospital hallway, this door has a New Yorker Comic taped to the frame. The comic shows a Dr. Frankenstein image, a monster on a table, a humpbacked assistant, and a request from the doctor, “Bring me a stem cell.” Already I like the person on the other side of the door.

As a nurse administrator, I try to visit patients on our Bone Marrow Transplant unit once a week. As I round with the unit manager, I take my time getting to know patients, families and staff a little better. It’s my favorite part of the week. Double booked meetings and an overflowing inbox, can only be balanced by time on the front lines.

I peak through the shades in the small window and see a tidy room with a hairless patient sitting in a chair next to the bed. I have often thought about the hairlessness of the patients I visit. It is more than just being bald. The mixture of vulnerability, determination and courage that can radiate from a cancer patient is amplified without a layer of hair. It can be a very powerful image.

Knocking on the door and asking permission to enter, I first notice the slippers. I am used to seeing teddy bears, sports themed, or simply brightly colored slippers to keep feet warm, anything to brighten a day and define a personality. These slippers have crazy white hair, glasses, and a big nose, immediately recognizable as Sigmund Freud.

Over the years, I have perfected the art of walking into a room, cold, without a clinical reason to be there. As I introduce myself, I look for a way to connect with the patient or family member in the room, pictures, quilts, or an obvious sign of distress. Today I choose the slippers and ask of their significance.

As I had hoped, this produces an immediate smile. It takes energy to smile when you are fighting for your life. I’ve heard that old adage about taking more muscles to frown than smile, I would like to see the data on that research. I suspect the psychological energy needed is not factored into the equation. It is exhausting being a transplant patient and I don’t take smiles for granted.

Along with the smile comes the answer, they are “Freudian slippers.” I return the smile and try to come up with a “Freudian slip”, but my mind is not quick enough, and I have to settle for simple conversation. I learn about the website where the slippers were acquired by a friend, there is also a dedicated husband bringing in food every day, and that life could be worse, she has her support team.

Tied to the bed is a Mylar “Happy Birthday” balloon given to all transplant patients the day they receive their stem cells. It has lost some air and is a little wrinkled, but very much afloat. This tells me it’s been at least a week since the staff sang our “Happy Birthday” song and life has gotten more difficult. Very soon a miracle will take place and her stem cells will engraft and give birth to new blood cells. For now, mouth sores, diarrhea, and opportunistic infections are all knocking at her door.

I ask my usual questions, “are we treating her well, are we paying attention to those little things that make a big difference, and most important of all, does she feel safe here.” Patients are vulnerable physically and emotionally, it is overwhelming to think of all the potential “bad things” that can happen following a transplant. I seek the truth, but we are human and, as a rule, patients hesitate to complain. Today she is simply exhausted and appreciative of the nursing care.

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Over the weeks of visiting, the slippers, along with her resilience prevail through the bumpy road of this therapy. I never think of a comment to slip into the conversation that would go with the slippers. Honest communication is required even when humor is appreciated. She does well after transplant and eventually is discharged to home. We both move on with our lives.

Years later, I participate in a writer’s workshop and when asked to write about an experience at the hospital I remember the Freudian slippers. I still can’t think of a clever “slip of the tongue”, but enjoy the opportunity to reflect and share an experience. I also wonder if those slippers are sitting in the back of a closet somewhere.

Not long after the workshop, I went on a neighborhood website to advertise a canoe I wanted to sell. Almost immediately I am contacted by several people. One name sounds familiar and I reach out to give her more details. She and her husband would like to see the canoe, they only live a couple blocks away and walk over that afternoon. She has already connected my name with the hospital and when I see her, I make the connection as well. We laugh and make comments about the size of the world.

Strong and healthy, I can’t help but appreciate her new lease on life, with plenty of hair and normal blood cells. I wish I saw more patients after they have recovered from their transplant.

To make the world seem even smaller, I am hosting a medical student from India and we hear that my former patient and her husband lived in India for many years. My medical student is homesick for Indian food and is successful in receiving an invitation for the two of us to join them for dinner and some authentic Indian food.

At dinner, I let it slip that I have written a short essay about the Freudian slippers and I had finished it by saying that I envisioned them at the back of a closet, all dusty, and ignored. After dinner, she takes me to her room and into her closet to reveal the slippers sitting in the very back. Enjoying the moment, I take a picture to prove they are real. She also points out a framed original New Yorker Comic strip above her bed and tells us the story of how she found it.

As the medical student and I walk up the hill to home, we discuss what she knows of leukemia and she says, “It’s too bad other patients don’t tolerate “transformation” as well as our hostess did.” What can I say, but smile and agree.

Silenced

I gowned up in the doorway, studying her. She quietly stood at the head of Carlos’ bed, alone. One light in the room that was shining over his bed and bouncing off her face. Dark bags under her eyes. A worried, yet equally pained look on her face. A slightly distended postpartum abdomen, as she had just delivered Carlos via C-section 6 days prior.

I walked in, and on asking how everything had been overnight since admission, quickly realized she spoke only Spanish. I did not speak Spanish….though I guess I could understand it. Or use my French to deduce what she was saying. As it was 6am, and I couldn’t get a translator to come in fast enough for me to comfortably see my other patients and get my notes done before rounds, I decided I’d point and use French words in order to try my best to communicate with her while I did a quick physical exam on Carlos.

Once I knew he was stable, and could safely assume that nothing had changed overnight, I walked toward the door, motioning toward the clock on the wall that I would be back with the team later. Around “diez” o’clock. That was 10, right? I repeated “diez,” as she silently nodded her head, and walked out.

As I sat there during my half hour of free time after prepping my notes, I thought about this mom and her son. What kind of care was I providing them with?  I couldn’t be bothered to get a translator because I theoretically couldn’t comfortably finish pre-rounding in time. I hadn’t even bothered to learn her name, so how did I even really know what was going on?

On rounds, I ensured that we got a translator. Not an iPad translator, but someone who could physically sit with us. Someone who could help her explain her story, her desires, her concerns. Someone who could ask her name.

Her name was Alma. She looked like a Alma. Carlos was Alma’s first child, and she was concerned. She was concerned that he wasn’t breastfeeding, and would only drink formula. She was concerned that this rash could be a serious infection from a peripheral IV that had been placed in his scalp in the NICU. She had questions about the medications we were giving him, about his vitals, about the plan, about how much this would cost. She did not have insurance. She was worried that she would not be able to provide him with the care he needed, both financially and physically.

I reassured her that we’d find a way to pay for the care Carlos was receiving, and that she need not worry about it. However, I probed her about the inability to physically care for him. She brushed it off, thanking us for answering her questions and saying that she’d have the nurses call us if she needed anything else. As we got up to leave, I heard her whispering to the translator, and I turned around after hearing the word “dolor.” Having originally grouped the pained look that I had noticed that morning with her worry surrounding Carlos, I did not expect to hear what came out of the translator’s mouth. Alma’s pain medications after her C-section had been sent to the wrong pharmacy, and she had been controlling her pain with Advil and ice for 6 days.

Alma had become used to remaining silent. We, as healthcare providers, had trained her to pick and choose what concerns of hers were worth our time. We would approach her with pointing, with pre-translated inquiries, with one word questions such as “dolor?,”. Never thinking to acknowledge her as a person, let alone ask her name. By silencing her concerns as a caregiver, her concerns as a matriarch, were we silencing her as a person?

 

One of Those Days

Suddenly, I wake up

But not the usual way

No alarm or sunlight to guide me

It’s dark and I’m writhing in pain

 

“Uh oh”, I say

It’s that time again

I look around, “Oh shoot –there’s a stain”

It’s okay—nothing I can’t wash away

 

I better get up and take some pain meds today

Or I won’t be able to sit in class again

“Stomach” hurts, back aches, bad posture all day

I’ll be going through the motions in secret pain

Hopefully…these meds work today

 

One hour goes by

I feel the same

Three hours go by

Uterus is to blame

 

I take another dose

I know I’m not supposed to

I should wait another hour,

But how am I supposed to?

 

My “stomach” is relentless

I really can’t get past this

I need these meds to work this time

So I won’t skip today’s classes

 

I’m lying on the couch

Contorted in position

Waiting, breathing, hoping

That these meds make a decision

 

Suddenly, I wake up

My regular, usual way

Groggy and wanting more sleep

I look around—so bright outside

I think the pain went away!

 

I can’t believe it’s been half a day…

I’m almost out of time, the bus is on its way

At least I won’t be missing class today

Why Medicine?

For a long time when asked “Why medicine?”, I responded, “Why the moon?”

This answer references John F. Kennedy’s address at Rice University in 1962. There he presented America’s goal to go to the moon as a worthy pursuit, “not because [it was] easy but because [it was] hard.” I told others and myself the reason I wanted to practice medicine was, as Kennedy put it, “because [this] goal will serve to organize and measure the best of [my] energies and skills.” To me medicine offered an outlet to reach my potential. It wasn’t until my second year of medical school that I questioned my motivations.

On November 18th, 2017, my son, Stein, entered the world. His course would prove to be anything but easy. Stein was born cyanotic; code blue was called soon after his delivery leading to the medical team frantically working to revive him. As I watched his vital signs insidiously drop, I realized that I may never get to know him. It was hard to believe that only hours before I had felt a profound joy in anticipation of his arrival; this joy now was replaced with immense despair. I wept as I wrestled with the idea of losing him. I will never forget the relief that I felt after Stein was stabilized.

Due to the complications surrounding Stein’s birth he earned a stay in the NICU. During his stay, he coded an additional two times. The medical team was once again there to bring him back from death. After all of Stein’s medical issues were resolved, he was discharged from the hospital on Christmas Eve. My wife and I recognized this as a small miracle; we were able to spend his first Christmas as a family in our home.

Unfortunately, Stein’s medical journey did not end with his discharge on Christmas Eve. On Christmas day, I noticed that Stein’s breathing had become labored. The following day we took Stein to his pediatrician, where he was diagnosed with RSV. He was admitted to the ICU at Primary Children’s Hospital where he rapidly decompensated, requiring the support of a ventilator. Over a seven-day period Stein required more support than a standard ventilator could provide; he was dying. The decision was made to add additional support in the form of ECMO (an artificial lung).

With some hiccups, ECMO proved to be the silver bullet that gave Stein’s little lungs time to heal. After ten long days on ECMO support the instrumentation was surgically removed and Stein began to breathe again. He had beaten the odds. He survived.

Why medicine? If asked prior to November 18th, 2017 I would have answered, “Why the moon?” I have come to understand that medicine is much more than a venue for me to direct my energies and skills. Why medicine? Because medicine grants a setting to save lives. To provide second and third chances. Medicine has allowed me to keep my family. Medicine will allow me to help others keep theirs.  Without medicine my son would not be here today. Without medicine his story would have been written in an hour. Medicine presented him a second and third chance to live. My life will forever be indebted to medicine.

What’s The Difference?

Grey and Blurry

It’s cold.

The air is quiet in here – it must be snowing outside. It’s too dark to see but the silence is enough to tell. I roll over and hit the middle button of my phone. The screen blares at me, it’s too bright. I blink away the blurriness, 3:12 AM. This is my middle-of-the-night phone check that reminds me how much I hate sleep.

I guess this bed doesn’t help. Honestly, most people would hate sleeping if it included a twin bed, a yellow blanket that’s as old as I am, and a broken neck. Ok, not broken-broken, but close enough. I could really use a better bed.

I’ll try to get to sleep again. I saw that it is snowing, the glare from my phone confirmed my guess. It needs to be warmer down here. But I guess cold, alone, sleeping in my parent’s basement as a 44-year-old man is just about a perfect picture of where this downward spiral has brought me.

 

White Walls

The nurse tells me it will just be a few more minutes. I tell her thanks and I  feel the exam bench and the crinkly white paper underneath me. I reach into my jacket pocket and my x-rays greet me when I open my phone. I’ve been carrying the picture of them around, checking them during the bad times, just to see the reason why my neck and left arm are exploding.

The x-rays tell the same story I’ve heard from four different doctors now, “Your neck sucks”. Ok, the doctors are a bit more professional in their delivery but they have all said that something is wrong. It’s, “degenerative disc disease”. No, “arthritis”. Actually, its, “the car crash from High School” (during which I gracefully headbutted the windshield), or it’s my favorite diagnosis “just the stress you’ve been carrying” for the last three years.

The real pain started about a year ago. My neck throbbed sporadically before that but starting a year ago both my arms started to tingle and my fingers went totally numb at times. I couldn’t turn my neck to the left and the pain was like a slow burn with the occasional Zeus-like lightning bolt shot down my neck and arm.

I don’t know how it started. Honestly, I don’t really care at this point. I just need some help. I need to get better. I mean, my job is fine. It doesn’t keep me from doing what I need to, it just drives me crazy. I have two good kids but I know that my pain has kept me from spending the time or giving the love I would like to them.

The doctor is here, I can hear her outside. I lock my phone and look up at the white wall and feel a wave of something. Apprehension? I guess. I really don’t want to hear the same, “let’s wait and see” plan.

Three quick knocks on the door and now she’s in the room. She presents herself as Dr. Kamul and she’s one of the hospital’s spine surgeons. We talk about the physical therapy I’ve done, the massages and the ibuprofen. I don’t mention the occasional hydrocodone (which I get from my friend Mitch) that I take when the pain is too much.

She nods as I explain my symptoms and says the next step is surgery. I think, “Oh God, yes” but outwardly I say, “sounds good”. I don’t know what the normal reaction to surgery is but, in my case, I feel a weight come off my chest. The forums and articles online say that surgery to fix a herniated cervical disc is the best treatment. So, put me under and cut me open! I agree to come in the following Thursday and promise not to eat after midnight. I jokingly ask if 11:59 is OK and Dr. Kamul says “Sure, just no going back for seconds” while smiling. I trust her and I am ready to ditch this pain.

 

Cone of Shame

Bed-time. I approach my twin bed and say, “hello old friend”. Not to the bed, I hate that thing. But, next to the bed lay the pain pills I was prescribed. They are the only thing that takes the edge off of what I still feel.

The surgery went well. I’m two-weeks removed from the operation and Dr. Kamul said they were able to fix the disc and I should be pain-free in a few more weeks. Pain-free is quite a promise because right now I still feel it. I took some weeks off from work and my parents have been helping me out with the recovery but something still isn’t quite right. My kids came and visited me here at their house once but I wish we would spend more time together.

I change my bandage try to turn my neck. Ouch. About two more weeks and I will start physical therapy. I kind of feel like my dog when she got spayed and had to wear the white cone around her neck to prevent any improper genital inspection. My neck bandage hasn’t been to prevent genital inspection, per se, but my dog has looked at me with more sympathy than usual lately.

The pain pills have been helping. I am supposed to take less but they haven’t been working as well I guess. The hydrocodone I was taking before the surgery has helped and Mitch, the guy I get them from, brought over some dinner and pills a few days ago. I’ll take less this next week after I start feeling better.

 

Therapy Session

Julie, the therapist, is great. I would call her Dr. Andrews but she insists on Julie. So, Julie it is. I started seeing her with my wife (now ex) two years ago. The couples therapy didn’t work out so well but Julie has been great. Today we start by talking about my kids and how I am dealing with the divorce. You know, therapist small talk.

Then we get into how surgery recovery is going and she says she is worried about me. I tell her I’m fine but she insists that I talk about the pill use. I really don’t know. It’s just the only thing that helps. She comments that it seems that the pills are being used not for physical pain but also for emotional distress. Maybe. I mean, life has been pretty shitty the last few years, so yeah. Maybe. I know I am taking too many pills – but they help.

 

Clubhouse

I take my oldest kid to the golf course where Mitch works. We come here a few times a week now. Mitch’s boyfriend is a doctor and supplies him with the pills that I, and a bunch of others, come get at the clubhouse.

I don’t like coming here but it’s good for my kid to get free golf. I’ve been taking the same amount of hydrocodone and occasionally I take an occasion oxycodone. I am supposed to be weaning off of them (for a few months now, I guess) but stopping makes me anxious and nauseous. And, who cares. I mean, I have my kids and my job but what else?

 

The Car Ride

Since the therapy session with Julie a while ago, I have thought more and more about where I’m at. I am addicted. Julie told me to be upfront with my kid about it. Admit it. That sounded like a pretty horrible idea at the time but something has got to change. If I keep going I’ll be like my sister, in-and-out of rehab every few months. I don’t want that.

The last year since the surgery has been rough. I haven’t gotten my feet under me yet. I am trying to find my own place again and move out of my parent’s house finally. The pills have been a constant from before the operation, I wish I would have never started with them. It’s just hard. Stopping sounds like hell at this point and pain is pain. Pain from a life that hasn’t turned out how I wanted or from someone slicing into your neck. It doesn’t feel different, really.

I’m parked outside my kid’s mom’s house — I’m going to take the older one to dinner. I sigh. What a life to have to admit to your kid that you’ve got a pill problem. He’s walking to the car now. One last deep breath and here we go…

Balance

It’s funny how sometimes life can catch up with you. Usually when you least expect it. Not really funny, but you try to laugh so that the amalgam of emotions doesn’t swell up and drag youdown into it, the sense of being overwhelmed and feeling inadequate, but also feeling like you are up to the task and can and should do it, and you’re worrying about your spouse and your future and the possibility of children and the professor asks you a question about which disorder the patient has and you’re not sure because you meant to study those last night but then you got a flat tire on the way home and it took so much longer to fix it than it should have, your wife was waiting for you when you got home and she had just had a terrible day, you could see it in her eyes, and when you said hello and gave her a hug she just broke down into tears, big alligator tears and sobs, and you talked to her about her day and held her and helped her, all the while realizing that you would never get to those disorders because it’s too late to start now, if you do that you won’t get any sleep at all and you haven’t slept for the last four nights so that wouldn’t be good, you probably wouldn’t even be able to stay awake through that quiz tomorrow, much less get anything out of it, so you decide to go to bed so you can do better tomorrow and you try to console yourself by telling yourself that it’s okay to take time for your relationship and that it’s important and that you don’t want to get divorced so you had better give your relationship time because so many doctors get divorced and you don’t want to go through that, no, not again, and so you go to bed so that you can do better tomorrow but you’re so worried about doing better tomorrow that you don’t actually sleep and so tomorrow comes and you’re just as tired as you were afraid that you would be and you’re trying to stay awake in the group discussion, only someone was asked a question, oh no that was you that was asked the question, maybe it’s a question on one of the things that you were able to cover before you left to go home last night, oh no, it’s on those disorders that you didn’t get to and how long can you wait to think through this before you give an answer, oh no it’s already been too long, everyone is looking at you and they probably know the answer, in fact you can see it in their eyes and you know that they must know and must know that you don’t know and it’s been far too long and your professor is staring at you and you have to answer and it’s been too long but you still don’t know but you have to answer so you say, “Umm… C.” “No, Mr. Smith. C is not the correct answer. Does someone else know the answer? Ahh yes. That is correct. You see Mr. Smith, this one is obvious if you had just caught the second line there glaring out at you from the question stem. Yes, very obvious. It was covered in the disorder readings you should have done last night.”

A fictional short story inspired by life events. This piece represents some of the challenges involved in adjusting to medical school and striving to maintain a balance between a career and the rest of life.