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Friday, January 7, 2022

Rotations through 2021

I wrote these reflections through the past clinical year as part of a series of posts shared with classmates. We would respond to a prompt dealing with the patient-physician relationship or a public health topic, and we would discuss together near the end of each rotation. These sessions were one of the highlights of the year because many of us in the group became close friends--a kind of closeness that comes with sharing and supporting each other through what can be an odd and beautiful and shocking place. It can be hard to preserve that naive response to navigating patient care and the healthcare system. Here are mine, shaped and made richer by my classmates', and edited with ellipses and removed names to remove identifying information.

Medicine, 2/26/21 seemed to me, and more so in hindsight, that attributing Ms. T's oxygen requirement as from anxiety rather than progression of disease was not just a circumstantial oversight. Particularly in women and women of color, pain is more often brushed off as psychological rather than as reflecting clinical course. I thought of all the times I had gone into her room to play music while helping her wean off oxygen, and the gnawing realization that I was complicit in the biases. She's now in the MICU and no longer intubated, and we're hoping for a course of recovery onward. 

Medicine, 3/21/21

When I had first met Ms. T, she was on the general medicine unit (my first service and patient at the hospital) and we had thought she was recovering. Our team thought that we would try to address the longstanding iatrogenic issues she had which had put her at greater risk for infection and respiratory compromise...

Two months later, I am nearing the end of my rotation, and she is nearing the end of her hospital stay. She is out of the ICU and on the floors... she is breathing well on room air after a course of steroids; she is ready to be discharged to rehab within the week! It was joyous to see her in her recovered state after her long, bumpy course, and to see that she is able to walk around and even ask to play on the piano! To think that at first, we were thinking her longstanding issues were unsolvable to seeing such large progress all done while in this inpatient course is a lesson on the importance of addressing and keeping faith in the possibility of holistic recovery.

Pediatrics, 6/25/21

...L was known to the team and most all providers on the unit, as she has a chronic medical condition and frequent hospital admissions. She became beloved to me, and I believe in her. But that belief was tested at times, from pressures from the team, L and mother, and myself.

L is the expert on her condition, and it's clear she knows herself well...When I go back to the team, I advocate for L's desire to have a procedure she typically gets done outpatient done while she was in the hospital, but I can tell there is uncertainty about keeping her longer in the hospital, and the desire for a minimalist approach. I make her case. The attending physician and senior resident look at me and shrug, "let's do it."

...Later that afternoon, I talk to L. She asks me to sit with her on her bed. We talk...I go to the nurse, who tells me that the charge nurse will not like the sound of her requests for more supplies. I go to the charge nurse, and she is fuming: "L and her mother are draining this hospital system...--they need to leave this hospital!" as she hands me boxes of supplies.

For the first time, I start doubting L. That evening, I am conflicted. On top of my advocacy on behalf of L which seemed to cause more mess for the team, I am dealing with my own thoughts and feelings of starting to doubt her. I think it is terrible that I may have to restrain myself in my trust...

...L knows herself and she advocates for herself and others. In the end, all of her intuitions about what she needed: the procedure, her clinical improvement, her concerns--played out to be true from the way her clinical course unfolded. But even if these outcomes didn't play out true to L's word, I trust L because she and I trust each other. I think that trust can co-exist with the conflict from team and self and patient and family. As I stay with her my last day, I recall walking out of her room. "I love you," she says, playfully. "I love you, too."

Psychiatry, 7/12/21

"The bad voice told me to tell you, 'No'." J said. At long last, he brought his gaze up to meet mine. I had been asking J, the teen I had met the day before, about whether the voice he heard in his head, which he called the "bad" voice, tended to speak to separate him from people who cared for him....I knew that something felt not right: he had replied so quickly, and his eyes immediately left mine. We just sat, the two of us in the interview room, in silence for what felt like minutes. When he at last revealed that he had "lied" to me as well, the intensity in the room remained, but the tenor changed. There was an unexpected intimacy, a trust that felt like it was suspended in the air. "And yet you're telling me this now. Why?" Silence, again. Sometimes I don't know if what I say is the right thing to say for my patient. I'm not sure how to respond to the feeling of undeservedness I have when a patient shares their diary, or their past relationships, or the voices in their heads. But I'm learning that the emotions latent in silence allow for the sacredness of words to surface, and a space for trust and discovery.

Neurology, 9/15/21

Ms. S is a gentle and calm elderly woman, she has blue eyes which seem to smile at us, and despite her tremors there is a grace to her presence...Ms. S, who has been quiet throughout, speaks up immediately: "I would rather die than have the procedures." To my shock, the attending proceeds to use this sensitive statement for the physical exam of cranial nerves: "Could you bring down your mask and repeat what you said?" 

"I would rather die than have the procedures."

"Keep an open mind!" replies the attending, before getting on with the next part of the exam.

It was an uncomfortable moment for the statement to have been used for an instrumental purpose of the exam, and then brushed off in reply. It was a lack of truly listening and acknowledging concerns. Realism was due here: "I know, this sucks." Ms. S was going to need to continue to rely on others for the rest of her life. Hope was needed: "We are with you and want to do what we can for what matters for you." These past weeks, in outpatient and in stroke service, I've come to discover that the beauty and tragedy of neurology is that it is so linked to what makes us human, what it means to be well and flourishing with the people, activities, and values that matter most.

Surgery, 11/3/21

Last week, a patient that I followed died in the OR. The decision to take him to the OR was unexpected and not made in discussion with the team. That morning, I had spent almost an hour talking to him...But all factors seemed to coalesce so that "efficiency" won out over "empathy"...Most of all, as a team we failed in understanding the patient throughout and up to right before the surgery; a failure in communication cost a person's life. I was angry, conflicted, and the what if's ran through my head. I know that we all acted in good faith, but it was a lesson in how a lack of understanding and patience had dire consequences, and in learning as a team to not let it happen again.

Ob/Gyn, 12/9/21

Mrs. F had missed her last appointment and now was arriving to clinic for her 6 week postpartum visit. As we were asking her about her symptoms and baby with the Spanish interpreter, I noticed that her affect was flat and she barely made eye contact...Once I had a quiet moment with the resident, I asked what she had thought about her affect. "It was weird," she replied. But still, despite noticing something was off, missed were those questions about psychosocial support: What social support did she have? How did she feel about her pregnancy? How was bonding with the baby? How was her mood?

Up to 80% of women experience postpartum blues after pregnancy; hormonal changes continue to affect the body. Around 15% experience of those postpartum depression, something F was exhibiting signs of that we should have further evaluated. I wonder how much of the blues/depression is also a product of the prospect that women face the burden of childcare, and especially in the US where women serve as a social safety net. Those same disparities that contribute to maternal morbidity outcomes in pregnancy complications also contribute to a disparity here: those with more means are able to outsource child care to centers or hiring others.

It will be shifts in norms counteracting the image of the working and caregiving mom along with policies: universal access to affordable childcare, reductions in intensive work and parenting pressures, and ensuring that all families have access to the resources they need--to address some of these more hidden disparities in well-being on an individual and societal level.

Sunday, May 2, 2021

"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.

Tuesday, December 31, 2019

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.

Monday, April 15, 2019

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.