"Adherence" at a family medicine clinic

"Our next patient is here for hypertension follow-up," says the resident I'm working with. "I started him on hydrochlorothiazide last visit. He probably didn't take his medication." It’s my first week at the family medicine clinic, and questions ran through my head: why may he not have adhered to his medication, what's his blood pressure today, what are his cardiovascular disease risk factors, but one that bothered me through the visit and after: why did we think that he hadn't taken his medication, and did that assumption impact his care?

How do health professionals predict whether patients are likely to “adhere” to medical advice or medications? And does the expectation itself affect the care received?

Based on socioeconomic status, race, or other social constructs, a provider may assume behavior or characteristics—such as non-adherence—about a patient. But what operates on individual levels has structural and epistemic scaffoldings. It’s important to see these individual biases as rooted in communities and histories because doing so makes clear that it’s a system that fails individuals, and not the failures of individuals. 

Perhaps the assumption of non-adherence was based on the patient's pattern of behavior, or the patterns of the underserved population the clinic serves in Stamford, CT. Indeed, Mr. LS, a Black man in his 50s, had an ASCVD risk of 10% and had been recommended to start a statin. He had requested to not start it and trial diet and exercise first, but there were multiple notes showing that he had not made diet or exercise changes in the past. It can be easy to justify resignation based on a person’s patterns of behavior in the past, and to place the blame on the individual at hand.

But individual behavior has much to do with the community which forms a person’s habitus, the different worlds we live in based on histories of inequality and subjugation particularly in that of the US: trust in institutions of power and authority such as medicine, neighborhood stratifications including food deserts and lack of access to healthcare, and a country whose equality of opportunity was also founded on the oppression of Black people. According to a 2019 study conducted by DataHaven, the income inequality of Stamford’s Fairfield County is highest out of 100 largest US metro areas: the top 5% of earners made nearly 18 times that of the bottom 20% disproportionately. Black and Latino residents, which make up the majority of the patients seen here at the Optimus clinic, have higher rates  of poverty and unemployment, 17% and 18%, respectively, compared to white residents, 5%. 

Stamford's shrinking middle class and demographic trends mirror the disparities of the country, as COVID-19 has sadly illuminated with Black Americans dying at three times the rate of white Americans as the pandemic accelerated. Just two weeks ago, shortly after the nation let out an uneasy sigh after the conviction of Derek Chauvin, 13-year-old boy Daunte Wright was shot in Minneapolis—one among the many shootings that followed. Health professionals cite the disparities in health outcomes such as a maternal mortality rate two to three times higher in Black women compared to white women. Everyday biases, stresses, and power differences faced by minority populations, including assumptions about adherence and behavior, are less visible forces underlying such measured statistics. They will take extra effort to overcome, but individual actions and responses in tandem with policy changes go hand in hand.

There are understandable reasons for resignation and assumptions for patients like Mr. LS: time constraints in a busy family medicine clinic with other patients to see and limits of reach physicians have into the social structures on top of patient care. Still, a better understanding of social and economic determinants of health can be a stepping stone to overcoming resignation. Mr. LS had taken a detailed report of his blood pressures, but he had not picked up his medications. The detailed report showed his initiative to make change; what was the barrier to picking up medications? And had he received effective counseling on diet and exercise? The expectation of lack of change likely prevented action that could have been taken, but was not, to address these questions. In practice then, the visit became a quick admonishment to pick up medications without much else—reinforcing individual rather than systemic failure unfortunately.

It was true that Mr. LS had not taken his medications, but the assumption and resulting response of resignation only contributed further to already elevated barriers to adherence. Change is not solely the burden of the individual provider, and yet, a culture of resignation—on the end of providers and patients themselves—feeds further into the cycle of disparities. I believe that the next time Mr. LS visits, we’ll be able to do more to help him, and all of us, build a society which values social recognition and the capacity to aspire.

Seasons of Reading in 2019

Middlemarch at The Strand's rare books room!

If books have seasons, then spring is democratic, summer is feminist, fall is poetic, and winter is nostalgic, at least, that was the literary calendar of my 2019. Books are also a more enjoyable way of measuring time as I take stock of the year. It’s like reminiscing on characters in a familiar village, except the village is your mind, and most of the time, its inhabitants are rather observant and chatty friends.

I’ll start with an old one who kept me company throughout the seasons: I first read George Eliot's Middlemarch five years ago, and since then it has been like a best friend who won't shy from revealing your own ridiculousness, capaciously. This time around, I saw more clearly my own misbeliefs in Lydgate’s conviction of submissive loveliness as the ideal of femininity and Dorothea’s glorification of the mind of man and his doomed "Key to All Mythologies.” I found some fates (Ladislaw’s, Mary’s) more admirable; others (Lydgate’s, Rosamund’s) more tragic.

Like the youthful idealism and somber realism that runs through Middlemarch, Jedediah Purdy's For Common Things brought a springtime restlessness that said: You are not alone in your desire for authenticity, sincerity, caring. Politics is how we make decisions together to build our world. It took me to Purdy's A Tolerable Anarchy which asks what we mean when we employ American freedom. How is freedom personal and political? How is it traditional and radical? These practical and utopian dimensions of freedom, along with the matriculation of a sweep of women and minorities in Congress, roused an energy in me that oftentimes felt misplaced against the backdrop of gentle Hudson waters and delicate cherries outside my window.

Freedom is also at the heart of This Life by Martin Hägglund: if our time in this life is limited, then it matters urgently what we choose to do with it. The limits on our time make imperative that we live in a realm of freedom, to care for the things that we love and find worth preserving. Such care, Hägglund argues, cannot be found in a vision of a Christian afterlife, but in a vision in this life, in politics and democratic socialism. Hägglund's strictly secular account informs how I think about a personal relationship with Jesus and a kind of private Christianity that speaks at the level of nation.

Our minds flicker and rest, between people and places and time, and the shifts between minds are fluid, yet unknowable and impenetrable. My summer subway reading of 2019 was Elena Ferrante’s Neapolitan Quartet. After Lila’s marriage in The Story of a New Name, I instinctively clasped the book shut and wrote in my journal that I would never lose my last name. I fumed at Nino, a man who fed off the care of women and took advantage of his multiple relationships for personal gain. Summer was heated marvel for stories that could speak so much untold truth about my and this world. I learned from Ferrante and Virginia Woolf, in To the Lighthouse and A Room of One’s Own, that to write is to co-create our stories as women. My writing took a new shape and gumption, and I wrote my first op-ed articles in 2019 with these inhabitants in mind.

The necessity of writing did not hamper its joy; it illuminated the beauty of the sounds of words. Wendell Berry was a companion and guide in this journey, as I woke in fall mornings with his A Small Porch poems and essays, where "a world of words could not describe this wordless world." Mary Oliver passed away earlier in the year, and her A Poetry Handbook walked me through the assonances and endings that gently stream, rippling over stones, smooth and strewn. In autumn, I collected words as I collected leaves, scattered into corners of my village-mind: apricity, venation, luminous; my favorite one: nefelibata, one who walks among the clouds.

We write to heal, we write to be seen, we write to make amends with a past impossible to amend, and to communicate with those who will never speak our language—those most close to us, like the Ma that Ocean Vuong addresses in On Earth We're Briefly Gorgeous. The shimmering words, lexically and grammatically, had the power to bridge distances between spaces geographical and generational--as close as two dashes side by side.

Reading the novel shortly after my trip to my heritage-land, Shanghai, I was reminded of my attempts to record and preserve the stories of my grandmothers. As I sat by Nainai on her couch, she asked, why do you ask these stories we forget and don’t speak about? It was the irony of a generation thrice removed trying to go back to roots before their roots, to understand the self—myself.

This desire to understand added a new neighbor to my village, Reading with Patrick, a memoir by Michelle Kuo, a Taiwanese-American then in her twenties who self-identifies as a contemporary Dorothea Brooke, navigating a world of heartbreaking inequality and immigrant pressures of economic security. It’s also a book about novels; about how reading, and reading with another, changes you both. It was during this season that I had been reading, also through another's eyes, classics like Tolstoy’s Anna Karenina and Flaubert’s A Sentimental Education, which opened up a city-outside-a-village, and I found my New York City merging with the porousness of minds and affect in 19th Century Russia, or with pervasive ennui and cliché through the French Revolution of 1848.

It must have been in the second-to-last week of the year when I entered again one of the final scenes of Middlemarch: Dorothea attempts to read a book of Political Economy, a detail which made little impression in my 2014 mind, but in 2019, I found startling, for the subject has been a centerpiece of my thoughts and questions. Like life and like literature, 2019 revealed a sharper sense of the mistakes of blind idealism; things change and we can’t go back, which doesn’t necessarily ebb hope, but strengthens it with realism and co-creation.

What Debussy and Sibelius Teach Us About Patriotism

Program notes written for Columbia University Medical Center Symphony Orchestra's Spring concert.

Both Debussy and Sibelius shared a tendency to decry nationalism in their music. Sibelius described his Symphony No. 2 as strictly non-programmatic. Debussy was known to be "without ideology and without convention."

But to what extent are composers, or, for that matter, any of us, impervious to the patriotic sentiments of the time? For Sibelius and Debussy, nationalism—the kind grounded in natural landscape, poetic voice, and shared commonality—permeated their music.

2018: My year—of books—in review

I was inspired to start sharing a list of what I've read from Jill Dolan, a teacher who shaped my writing and how I see the world and engage with it. I thought I'd share those reads, here. Some of them were published in 2018, and most of them are (age-)old. Perhaps some will resonate with you in your search for books to kick off the new year. (Listed in the order that I read them.)