"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.)

The "Fantastique" fantasies of Hector Berlioz

I come reeling tonight from a performance of Berlioz's Symphonie Fantastique, performed by the Columbia University Medical Center Symphony Orchestra, through which, I had the wonderful opportunity to reignite a dormant love of playing clarinet (not played since high school!). I thought I'd share, below, the program notes I was invited to write for the program, which, as it happens in the spirit of this Synapse, suitably has its own art-science (music-medicine) link!

The claims on the heart of Albert Schweitzer

"Like music a man's life means more than the sum of its parts. It is a composition with many themes and one transcendent meaning. This is a fact of all life and the life of Albert Schweitzer is not an exception but an example."

Dr. Schweitzer was organist, philosopher, theologian, and physician. After almost a decade in the other professions, he turned to medicine at age 30, against the advice of his friends and family who questioned whether "service" wasn't already found in the professions he was currently engaged in. Dr. Schweitzer was determined to serve once he turned 30, and had his eyes set on medicine. Upon receiving his medical degree, he traveled to Africa where he founded a hospital.

Age of Innocence at McCarter Theater

These flowers are less symbolic than the ones in Age of Innocence, but they sat on my windowsill in England. Of note: yellow roses.

It's hard to believe that it has been more than a month since I saw the stage adaptation of Age of Innocence and more than two months since I first read Edith Wharton's gorgeous novel. I promised myself and a couple of friends that I would share my impressions of the adaptation—directed by Douglas McGrath and performed at McCarter Theater—with special thanks to my friend Jess who had first recommended that I read the novel upon moving back to NYC (I am so glad she did!).

Age of Innocence sweeps us into the Gilded Age of the 1870s, placing us in a setting where the society has everything to do with the story. It begins as an old man exclaims, “If one had habitually breathed in the New York air there were times when anything less crystalline seemed stifling.” In the novel, we see events unfold through the eyes of our protagonist, the young Newland Archer, in real time. But in the adaptation, it is an old man—Archer as an elderly man—who reflects back upon his life and narrates. On stage, we know from the beginning that a lifetime will come to pass before our eyes. From the old man, we hear in his exclamation an exasperation with a city’s set customs that the man has lived through. But when reading that same line through the thoughts of the young Archer, we are privy to his naïve admiration for this city’s social propriety. 

On stage, the subtleties of scene embrace our senses, but miss that tool the narrator of the word has at her disposal: inner thought. So, when Archer spontaneously sends Countess Olenska, his forbidden love interest, a bouquet of “fiery” yellow roses rather than the usual pure white lilies for his fiancée, he remarks onstage, "What am I doing?!". On the page, Archer subconsciously justifies his actions—no expressed outcry, no pained expression. As readers, we are invited to speculate upon our protagonist's unexamined thoughts in our own minds, analyzing his intentions and desires. But as viewers, we can't indulge in back-and-forth speculation. For a point to come across, we must feel it—the colored cheeks, heart-quickening breathlessness, shocked expression, strained voice, and then there’s the old man—the older Archer—re-experiencing with alarm his actions alongside young Archer on the same stage. All of this makes it apparent that at that moment something is awry. None of our own flirtations with the possibilities of the page. Rather, the immediate sensory symbolisms of the moment.

The old Archer wears a white lily in his coat pocket, as does the young Archer—constancy for May. A vase of yellow roses adorns the piano, which turn bright red when Olenska enters the room—Archer’s passion for Olenska. May sits under a peach tree as she implores Archer to give her up if he loves another—ripe with innocent goodness. 

The sensory feast heightens an aura of dreaminess, of unreality—which is a theme of the story: Archer reaches for what might have been, an ideal of what could be, and savors the delight of that unreached ideal. Olenska embodies that ideal. She appears and the lighting is slanted, mystical—in the softness of moonlight, or the glow of dusk—and in one heartbreaking scene where the lovers unite but cannot be together, petals fall like snow outside the windows. The song, “Beautiful Dreamer,” haunts us throughout the play: first when Olenska and Archer sing together, again when Archer sings with May, and in the final scene when Olenska sings out her window 26 years later. The song, an auditory exemplar of dreaminess, doesn't exist in the novel yet in the adaptation it even plays a plot device: it is because of the song that May confirms that Archer loves Olenska, as he begs her to sing a song that he sang with Olenska, and the wooing words render May speechless mid-song. 

When is it not right to love? What obligations do we have to those around us, to our neighbors? How could we bear to hurt those who are good, even if it costs us our own happiness? These are the kind of moral questions at the core of the story. Olenska reflects Archer’s own sentiments back to him, “We shall hurt others less. Isn't it, after all, what you always wanted?” If Archer had to give up his respect for society and kindliness towards neighbors for his own happiness and for Olenska, the dream and love would break: “I can't love you unless I give you up,” says Olenska. Each sacrifice for the other and for those around them. 

Moral questions lend themselves better to reflection in the privacy of one’s (reading) room rather than in a theater. In this theater, we experience a vivid, beautiful, well-executed dream, but the dream suffers from a lack of trust in how real the events are: are they memories seen through rose-colored lens of an older narrator? Are they too sensual and exquisite so as to evade scrutiny of thoughts? 

Even if not in the theater, the time for analysis inevitably comes (probably in the lobby!). We have to grapple with what happens—what is dream and what is reality, and what is better, if there can be a “better”? While Archer lives in dreams and visions, that is not all. If that was all, the story would be tragic. In the ending scene, we want to snap Archer out of dream and into reality. But the reality is that Archer and Olenska stayed true to their values and themselves, their unrealized love made them better people, and this is rare and beautiful. What happened was not a romanticized reverie clouded by an elder’s reflection of youth. What happened unfolded in a real time, place, and manner. People tried to live out their lives as best they could, afforded to them by the limits of society—the story that we try to live out today as best we can.  

Being whole together: Yo-Yo Ma and Krista Tippett in conversation

An absolutely lovely discussion between Yo-Yo Ma and Krista Tippet, on On Being, "Music Happens Between the Notes," which I've excerpted below.  I listened to the podcast last month when it came out, and am so glad to revisit just as I begin to look into music and civic engagement. I'm excited by the ways that the arts can foster not just social connectedness or socio-emotional well-being, but the sense of civic participation. The state of civic participation and democracy worries me, for reasons obvious to us, not because I don't have faith in the goodness of the people, but because so much seems to rest on the people in face of forces of negative influence. Lincoln said in his first inaugural speech, "while the people maintain their virtue and vigilance, no administration,by any extreme of wickedness or folly, can very seriously injure the government in the short space of four years." I think musicians and artists and humanists share a similar kind of philosophy, to let the ideas and connections spread which bind us to do us good. I do hope it works.

Here's the except:

MR. MA: So it's not about how many people are in the hall. It's not about proving anything. It's about sharing something.

MS. TIPPETT: It's about being whole together, too, isn't it? Which includes all these things that could go wrong.

MR. MA: Absolutely. Rewind to September 11. On the morning of September 11, I was in Denver. At 9:00 my wife calls me and says turn on the television. Something bad is happening. I turn on the television. I'm supposed to go to Colorado Springs on the 11th and to Denver to play another concert on the 12th and the 13th in Phoenix, Arizona — three different orchestras. And in the wake of this horrific thing, every orchestra had to decide, do we cancel or do we play?

And what every orchestra decided was, we're going to play. We may change the program a little. We're going to actually be together and have a moment, literally, of being together. Music will be the way that we will come together, because we're asserting ourselves as a community, as a people, as a city, as whatever. And we need to be together. To this day — now, this is now, how many, 12 years later — when, if I go back to any of those places, not a single person does not remember vividly what that evening meant.

MS. TIPPETT: I think that's a wonderful image for some language you use of being a citizen artist; that this insistence that this must be at the table, arts, in music, as we define ourselves culturally and weight it as defining alongside politics and economics and the things we discuss that we sometimes seem to take more seriously.

MR. MA: Well, I think it depends how much room we have for what. And the thing is, again, what is it and why? What are we doing here? Who are we? And I often ask musicians, “Do you think of yourselves as the instrument that you play, as your identity? Or do you think of yourself as a musician? Or do you think of yourself as a human being? And what is the ratio between the three?” I think that the citizen part is somewhere towards the human part, because we're looking at how we fit in within society. And if we look at our Constitution, we have an ideal of what our nation could and should be like. So, how do we participate? I know I, for one, often feel frustrated and say, “There's so many things that are happening, and I have nothing to do with it. I'm not connected to it. Therefore, I can't care about it, because it's just a waste of time and energy, because it's all beyond me.” Now, that's kind of like giving up. It may be true.

MS. TIPPETT: And I think that's an experience so many people have, so many people who do different things in different corners.

MR. MA: But ultimately, if we are the democracy that we claim to be, it does require full participation. And that's the anomaly that I'm sort of trying to wrestle with in myself, too. As a musician, I'm thinking, OK, well what in the world can I do? Essentially it's like what my wife always says to me, “Don't just make lists. Just ask, what can I do to help?” And I think if we ask, if we even start to look, you will find lots and lots of needs.

MS. TIPPETT: Yeah. I love this language Rilke about living the questions. And I think there is something powerful about posing the question. You can't live into it unless you ask it.

MR. MA: Right. But once you ask it, you already put yourself in a position of slight vulnerability because you don't know the answer. And I think that by doing that, you can actually begin to see where the solutions may lie. At least you start to open yourself to someone else who might propose a solution that starts to lead us in a certain position. I think that's where the basis of a cultural citizen or a citizen musician comes in, because I think that as musicians, music actually very easily crosses spaces?

You go from people's earbuds, into concert halls, into living rooms, into cars; it can exist across a lot of different physical spaces and geographical spaces.

The Literary Vesicle returns!

Hey readers! Remember the "literary vesicle" of the synapse? Thought I'd bring back books to the synapse. Here are some I'm reading, and then some I'm hoping to read soon:

What is Populism? by Jan-Werner Muller
A Princeton pre-read. Muller demonstrates how populism must be differentiated from simply appealing to the popular masses. Populism is about excluding others to reinforce a "truer" notion of a (national) identity. Case examples include: yes, Trump.

A. Lincoln: A Biography by Ronald C. White Jr.
After reading Dreams from My Father by Barack Obama, I thought I'd explore the life and mind of one of Obama's greatest role models. I was also curious as to how Lincoln drew on the Bible teachings in the challenges of the Civil War, while maintaining an independence from the institutions of religion like the church.

Lincoln in the Bardo by George Saunders
In the midst of reading Lincoln's biography and stumbling upon this piece of fiction in the bookstore, based imaginatively around Lincoln's relationship with his son Willie, I decided to pick it up as a flight read. The supernatural aspects have derailed me at times at night, but that's more of a statement on my own vulnerability to supernatural thoughts than anything book-related.

Milk and Honey by Rupi Kamir
Picked up from my sister. The poetry is so easy to read that it doesn't really feel like poetry, but more like self-help or friend's tumblr for the broken-hearted and healing. Not a bad thing when you're looking for something raw.

Arrowsmith by Sinclair Lewis
When Dr. Arnold Gold passed away, a New York Times obituary noted how he was deeply impacted by this book. The story features a young aspiring doctor who tries to balance the ideals of research (for the sake of discovery and learning) with medicine (for practical outcomes). To be honest, I'm not entirely captivated by the prose and it doesn't portray medicine in a very appealing light (not a bad thing, but intriguing considering its influence on Dr. Gold). I am only 1/5 of the way through...

Evicted by Matthew Desmond

So humane and eye-opening. One of those books that reshapes not only how I think about the particular topic of poverty and eviction by transporting me to real places, but also how I think about a field—in this case, my admiration for what sociology can look like at its finest. 

On my to-read list...
The Tea Girl of Hummingbird Lane by Lisa See
Intern: A Doctor's Initiation by Sandeep Jauhar
The Empathy Exams by Leslie Jamison
Against Empathy by Paul Bloom
Do Not Say We Have Nothing by Madeleine Thein

After the March, Again

Passing Columbus Circle, by Central Park, marchin' in the rain

I wonder about marching.

“People march and feel good and think they have accomplished something,” says David Brooks in “After the Women’s March,” where he argues the Women’s March was too wide-ranging and not specific enough to demand anything. True, protests often don't lead to direct policy change. And although not the intent, they tend to further politicize and alienate those on the other side of a sharp divide. Yet those marches that simply "celebrate" sort of lose the meaning of protest.

At the Women's March, I felt the run and rush of emotions, thrill of chant and solidarity—it goes through you and through the crowd. You march with friends, with strangers, and you see you're part of something larger. It's indescribable. But did it do anything? Or were we simply, as Brooks put it, “[descending] to the language of mass therapy?”

Here’s what happened: after that march, the spirit never really left. There was a girl statue fiercely facing the Wall Street bull, “still she persisted,” “immigrants are welcome here,” “this is what America looks like,” “science, not silence”—more marches, in DC, NYC, all around the world, like (forgive a nerd moment) radical chain reactions that undergo initiation and propagation.

After the latest March for Science, scientists will increasingly find themselves reflecting on their roles in a profession that's not exactly known to be a protesting sphere. Many scientists feel they can no longer deny a responsibility to the public, to play their part in the accurate dissemination of knowledge and training of scientists. In a real sense, their livelihoods depend on it and funding, but more so, human lives and the natural world we live in depend on it. While keeping an inner thirst for investigation, scientists must confront social advocacy, although many might prefer to focus on discovery without a greater agenda.

There's a romantic purity to the idea of the scientist, and artist, engrossed in discovery or creation outside the forces of social purpose—Art for art's sake! Eureka! The artistic impulse! (which, by the way, almost became the name of this blog). So how to reconcile this purity with social responsibility? I loved musician Andrew Bird's reply in conversation with physician Atul Gawande (see this post): “When it speaks from the heart, do it. But when the responsibility comes from external pressures, from duty to speak out, it usually doesn't go well." Attend a march, and you may find afterwards a need to speak, from the heart. With fervor and solidarity, we reach out beyond ourselves, and we learn from a variety of perspectives and motives. The process of coming to terms with the experience, with the questioning, and our resulting new understandings—that’s important. These are first steps.

A post-election letter

Dear songwriters and aspiring songwriters,
If you are interested in connecting with a Trump or Hillary supporter, email me at hih.connect16@gmail.com. No musical experience necessary, just a willingness to listen and connect with an open mind and heart with someone we hope we can understand better. Details below:

Last night and today have been full of confusion and alienation for many of us. Into the early hours of the morning, we watched as it seemed we no longer knew the people of America. Paul Krugman shares the sentiment in his article "Our Unknown Country."

I think many of us are in despair over our country we love so dearly. I see from the flushed faces of friends, the posts of outrage on facebook, support groups at the medical center, and my sleepless tearful night, too. While we grieve and mourn, many of us feel an intense desire to do whatever we can to help.

The night before the election, I had an unexpected call conversation with Alan, a 68-year-old devoted Trump supporter in Alaska. Hillary's get-out-the-vote script told me to politely end the call with this Trump supporter, but I listened because he wanted to speak. I disagreed with him on most every issue, but after 30 min, I also heard about how he liked to go fishing, and how he wanted a better life.

I didn't change his mind about who to vote for in the slightest, but I developed fellow-feeling and connection with a man I would have previously thought unrelatable, and I think he felt at least somewhat similarly about me, too.

The fight towards understanding is not always palatable or easy. As I write and convince myself, it might not make sense. But sometimes the most important thing we can do is connect and heal on personal levels. For me, I know of no better medium to do so than through music.

Friends, if you are willing to try this, I ask you to email me at hih.connect16@gmail.com. You will collaboratively write a song with a Trump or Hillary supporter, and I or other musicians will guide you through the process of doing so. You do not need prior musical experience, only an open mind and heart to connect.

Our country is resilient and we will go forward. It starts with working together. We can connect with other stories and share our own—it's one small step towards healing our nation.

Email me at hih.connect16@gmail.com if you are interested in participating.

Andrew Bird and Atul Gawande on Music and Medicine

Dr. Gawande, my sister, and me at Dunkin' Donuts--jk, The New Yorker Festival!

My sister Lucy and I half-run half-skip to Gramercy Theatre in East-side downtown NYC. I check my watch as we exit the 23rd St 6 train subway—"Lucy, we're making good time: 6:55 pm!" Just 5 min before the show...

As we enter the there's this suspiciously festive red glow which reminds me of a BBC Proms moment in London's Royal Albert Hall, except it's The New Yorker Festival and I'm equally nerding out to see Dr. Atul Gawande and musician Andrew Bird in conversation. "Whoa, Lucy...I was kind of expecting a lecture hall or something..." Are you serious

Are you serious—no question mark—is the new album of Andrew Bird's. Andrew's music makes me think of the intimacy of Zoe Keating's one-woman looping cello orchestra with the energy of Joy Kills Sorrow's folksie-stringy-plucky drive. A classically-trained "true goth," as Dr. Gawande describes, Andrew casually remarks, "well, there's a reason why conservatories are called conservatories." A rebel, he wields his violin like a ukulele-turned-fiddle-turned-harmonica as he whips out what The New York Times describes his "inner operatic folkie." Lucy turns to me and whispers, "he makes me want to play the violin."

We listen as "Puma" fills the theater:

'Cause it gives rise to the rumor she's a girl and not a puma
And that light that shines is not a pearl, it's just a tumor
...
But the doctors, they told me to stay away
Due to flying neutrinos and the gamma rays, oh

"What is cancer?" Andrew ponders aloud, first as an aside; then, his eyes light up as it hits him—he's talking to a surgeon..."What IS cancer???" And in childlike curiosity, "I mean, does cancer have a reason for being there?" It was one of my favorite moments of the evening, as Dr. Gawande explains in true physician-educator style the mutations that give rise to cancer, and that the cells are trying to survive...

"Ah! So they have a will..." Andrew replies, somewhat-satisfied.

"I write about things I don't understand," says Andrew. Cancer. Fake palindromes. He also writes about "a lot of things we're not talking about as people," and sometimes his approach is from a "scientific angle that shows us what we're made of."

An audience member asks Andrew about the social responsibility of the artist. He says, "when it speaks from the heart, do it." But when the responsibility comes from external pressures, from "duty to speak out," it "usually doesn't go well."

I think music is one of the best mediums in which external motivations can start to dissolve, because art allows us to so naturally connect and start the feel that intrinsic understanding rather than the prescribed duty; the sense of what I get when I read a piece of fiction, like George Eliot's Middlemarch rather than one of those "develop kindness" books like David Brooks' The Road to Character (Rebecca Mead further makes the point).

After the talk, Lucy and I discuss over pizza and chocolate mousse cake (a delicious combination, by the way): how does the social responsibility of the artist compare to that of the physician? It's a question for us all as we ponder the boundaries of our professions, but in medicine in particular, there is the toxic notion that as long as we treat the biological disease, we're doing our job. But Dr. Gawande and many know otherwise. Gawande writes in Being Mortal,

We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive...

The chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.

I think tonight's conversation is about a sense of will. Why are we alive? It's about creating our own meaning, of crafting our own song, of breaking from classical traditions to create something richer—looping and whistling along. And the will of connecting with another, of seeing how our experiences are inherent in another's—whether between physician and musician, or any number of communities and identities. It's a testament to the power of listening and relating through music.

Our power to choose

Premiere of David Lang's "the public domain" for 1000 voices at the Lincoln Center. Lyrics: "Our power to choose"

"Where have you been? I wondered about you..." says the patient lying on the bed in front of me. Light streams in from the Hudson River, and I think how peaceful a time this is, how unchanged and natural it feels, to be seeing the searching calmness on this man's face. He has a gentle smile on.

Except that everything is not the same. It had been a week since I had seen my patient. On my last day on the wards, I told him I needed to help this world make music. And he said, "go do it."

I came back for a practical purpose--to pick up my tablet. I had stalled long enough. Part of this seemed symbolic. I'd given him my tablet so he could talk to his family; I'd entrusted a part of me to him. So maybe I stalled because telling him felt like a statement bigger than any meeting with a dean or signing of a contract.

Donned in my white coat, he asks me the usual questions--

"What do records say?" "What's happening to me?" Eyes alight.

The tablet is on the table. His phone, now fixed, is in his hand. I sit down on a chair beside him. And I have to I tell him I didn't know what was happening--I hadn't been a part of the team for the past week. I see the dejection in his face; I feel my own disappointment. And then he says,

"go do it."

I will go forward caring for others in a different way: it's uncertain, but I believe in it for us all--and if I don't, I will forever ask, what if? I have to give it a shot or live with regret. I have a deep sense of what I'm fighting for and why, and no matter what path or profession I end up in, I'll never lose that: music at the core--about connecting with humanity.

Before going, something compels me to ask him, "what makes a good doctor?" His answer:

1. Be loyal
2. Be prepared
3. Be charismatic
4. Believe in god

A doctor comes into the room. I'm about to say--"I'm just a medical student," but I catch myself.

As I look back, I smile, we smile, I'm going.

Hope and aspiration

Evening ensemble, from metmuseum.org

From Jeff Nunokawa's note today:
"One thing essays have always been about (not all of them of course, but enough of them to notice and call part of the tradition) is everyday life: things that come with everyday life (the death of a moth; the rise of the sun). Well, there’s something about everyday writing, especially the kind that aims to help keep you company while you start everyday that reminds me of the morning as it’s been handed down to me. It’s a little repetitive (to say the least, as my mother would say), but also a little hopeful. It’s some weird combination of routine and experiment: writing everyday, starting everyday. I guess what I’m trying to say is this: the faith of our mothers and our fathers you can also find in the everyday writing I’m trying to do here. That faith inheres in a hopeful feeling that goes along with and a little beyond the less than hopeful feeling that you have when you first wake up and realize you have to to get up and do the same damn thing you did yesterday and the day before. It’s the faith that believes that there’s something on the other side of our everyday trying and it’s not all dark."

And a poem my classmates and I discussed today in our Narrative Medicine session:

Aspiration
Henrietta Cordelia Ray, 1848 - 1916

We climb the slopes of life with throbbing heart,
And eager pulse, like children toward a star.
Sweet siren music cometh from afar,
To lure us on meanwhile. Responsive start
The nightingales to richer song than Art
Can ever teach. No passing shadows mar
Awhile the dewy skies; no inner jar
Of conflict bids us with our quest to part.
We see adown the distance, rainbow-arched,
What melting aisles of liquid light and bloom!
We hasten, tremulous, with lips all parched,
And eyes wide-stretched, nor dream of coming gloom.
Enough that something held almost divine
Within us ever stirs. Can we repine?

Tomorrow, I'll have my evaluation on history-taking and the physical exam ('H&P' History & Physical, in med-speak). I'll share songs written for patients and evaluate the impact of those songs. I'll write a final patient case write-up on chest pain. Next week, I'll take the Shelf Exam in Ambulatory Medicine and give a presentation on the songwriting project. Lots to study, learn, write, present! But in the spirit of Jeff's note and Henrietta Ray's poem, I shall climb the slopes of life with throbbing heart / and eager pulse, like children toward a star.

It’s the faith that believes that there’s something on the other side of our everyday trying and it’s not all dark. 

In New York you can be a new man

Hamilton proudly stands today in my favorite outdoor reading-writing spot!
(near Butler Library, Columbia University)

This is too good not to share: Hamilton at the White House! You've got to check out these video performances:
Alexander Hamilton
My Shot

When I watch these, or listen to the soundtrack on Spotify, I'm filled again with the belief that music matters because it instills us with collective feeling and belief--to take pride in the democracy we have and its true values, to remember that we are a country rooted in immigrants, spirits in opposition to the wave of exceptionalism or superiority or divisions of otherness,

to stand up for others, especially the weak, especially the vulnerable, knowing that each of us is only here because somebody, somewhere, stood up for us.
~2016 State of the Union Address

Snapshot of a moment

So many moments to remember. The 90 year old man in the ICU, head down, back hunched—I needed to hold his hand. I know it matters. Wife also hospitalized—lupus and dementia—he kept saying "oxygen." The defeatedness in his face. "Lymphoma" his first whispered words. The bright, white hospital light—too bright. There needed to be tenderness for this frail, strong man. As the resident and intern walk away, the patient turns to me, eyes bright and wide, hand still in mine, squeezing. I lean in close to listen: "I need oxygen or I get violent." The resident waits for me, at the door. O2 sat 94%, fine, but he was short of breath. Resident shrugs, "he's okay."

I wanted to stay. I wish I could do more. We are in the presence of such vulnerability, such humanness, and every little thing—touch, listen, glance, leaning—matters, I think, I hope, as I walk down the hall with the residents, back to our ward.

There have been a couple of encounters like this in the past weeks (another week gone by, already?). It's hard to stop and write and think. It's hard to collect my thoughts and process them. It's easy to let my emotions dictate myself. I wanted to write about Obama's State of the Union Address. About America the Philosophical. About e.e. cummings at Book Culture. But right now I need another kind of mental processing. I'm yearning, toiling, praying, loving.

First Day

AH, I'm part of the medical team! (Island Med Student blog)

I'm writing to capture this sense of gratitude and appreciation for today, my first day on the wards in general medicine, and my first rotation ever. This is a day to remember! I'm working as part of the team at the Bronx Veteran Affairs hospital, and I'm feeling 1) relieved, 2) grateful for the education and support I've received, and 3) optimistic and hopeful about this rotation, and this year.

A couple of thoughts:

1) I cared for Mr. M, a patient with gangrene. True, I've taken the H&P (history and physical in med-speak) multiple times before, but this time I felt like I had a much more substantial role in making a difference for him. When he wanted a salad, I could try to find one for him, and go back and check to see if he'd gotten it. And I think he appreciated having a hand to hold during the blood draw. I hope I'll get to see him tomorrow again, if he's still here (he's scheduled for a surgery). He's not my assigned patient, but I'm feeling this sense of "myness" for him. 

2) I presented Mr. M's case to my intern (1st year resident), who seemed impressed by the completeness of my presentation, and gave a lot of good pointers. I'm excited to start doing things on my own: presenting to the attending, writing progress notes, drawing blood, really helping out the team--as soon as I can! It felt validating to have prepared for the H&P, and to be able to do well on it, and I'm going to work to get it better, fluent, and memorized. 

3) Tonight, I don't have to worry about studying. Yes, it'll be learning, but I'll be reading and learning on my own accord, to learn everything I can about my patient, and it feels real and meaningful.

4) I'm grateful to my intern for spending such a great deal of time with us medical students, spending two hours going through my presentation. I will make it a point to get better and smoother. I'm still quite loss at to what to expect in terms of the daily schedule, how to use the computer system, how to write progress notes; yet the laid-back atmosphere of the team and their expectations has put me much more at ease. Still, I want to take charge of my own learning and challenge myself so I can help the team and patients the best I can.

To communicate, present, learn, connect--art really is at the heart of medicine. 

Hello 2016, hello again!

"The Doctor" by Luke Fildes (Wikipedia)

It's been so long since I've written that I'm quite at a loss at how to start. So much has happened in the interim: I finished my Bachelor's in Psychology, went on to do my Master's in Music Studies, and am now in medical school, year two! With the transitions and medical school, this blog fell way to the side, for which I am making amends starting...now!

Where to start? I still can't quite grasp that I started this blog in June of 2010—I remember it was a summer day in Beijing between my freshman and sophomore year; I was interning in the marketing department of a seed company, and I had an impulse (it may have been too muggy to move much and too polluted to go outdoors), which resulted in The Birth of the Artistic Synapse. There, I decided "synapse" was an apt metaphor for connections, though at the time I hadn't known to what manner and extent those connections would play out.

This blog became about connections between ideas, thoughts across disciplines. Especially in music and psychology, and more generally in beauty and artistic perspectives toward unconventional subjects and objects, and in the world of living. It also became about connections to myself: what I want, what I love, and, why I am going into medicine (The Art of Medicine). It does me good to read that post again today, as embark on my very first clinical rotation next week in internal medicine.

But most importantly, this blog has made connections with others. Strangely enough, one reason it has been so hard for me to write again is the paradoxical knowledge that comes with readership: I am less at ease writing when I know others are reading; yet all the more reason to do so! You, readers, have delighted with me in neuro-analyzing Mona Lisa's smile, relating the works of Escher and Chopin to String Theory, and (mis)applying the Heseinberg Uncertainty Principle to love. You've even stuck around for infatuations with Organic Chemistry (a product of orgo-withdrawal). 

One message from a reader in particular struck me dearly, and left an impression. I think I was in my neurology block, when I received in a message in my inbox asking if I still wrote, especially now about life as a medical student, and referenced this blog in his new blog project: poeticlust.com. I'm touched I played even a slight role in someone else's blogging endeavor, and I'm writing this post, starting anew, with his words and encouragement in mind. He quotes Carl Sagan: “writing is perhaps the greatest of human inventions, binding together people who never knew each other.”

I think of how other blogs speak to me—Loose Signatures, The Feminist Spectator, Live Thoughts—whether a delightful thought, an unexplored topic, or a relatable personal experience, and I see how blogging matters—over time thoughts are better formed, emotions better understood, actions better intended.

Looking through my old posts, I do think my writing has helped me become a better version of myself. As I read, I am reminded of the wonder and delight present even in the face of tedious memorization so often necessary in medical school—I'd been there before, after all. And as I go forward, I think there is no better time than now, as I care for patients, in bringing out the best of medicine: the beauty of human life and connection. It's time that I write again, because I want to capture and preserve these moments; I want to always remember the artistry in our profession, and writing helps me do that. It helps me be a better self, and maybe, even, help others do the same.

I came across a post from exactly three years ago on this first of the year with the thought, "Our journey is right here, right now, and to discover we'll just have to keep our eyes open, new, and shining." There's nothing like the past to help us go forward, to help us learn what makes us tick and make the most of our learning. It's even better when shared with others. I'm excited to bring in the new year with you! It's going to be a good, growing 2016.

When a medical student goes to Alcoholics Anonymous

"My name is Erica and I'm an alcoholic"

is not something I could imagine myself easily sharing, much less in front of rows--at least ten rows filled--within the confines of the St. Aloysius Catholic Church, much less to follow that statement with a personal speech interjected with casual fluency interspersed with shouts from the crowd. Yet it is what I witnessed alcoholics do this Saturday evening. As a medical student non-alcoholic observing the proceedings of an Alcoholics Anonymous meeting, I was an outsider even before I stepped in. Crossing across the Harlem streets between Frederick Douglass St and 132nd St, I paused before the church with some uncertainty, before a man asked, 'Where you going, sweetie?" and as we both approached the entrance, I replied with awkward cheer, "here!"

At the entrance

Certainly he was not the first person to raise an eyebrow at my entrance--I, an Asian American twentysomething carrying my backpack, felt quite conspicuous in the midst of the middle-aged mostly black crowd. Thinking back to my visit to the Frick Collection earlier in the day, I started to reflect that my feeling of awkwardness was something these people experienced daily in entering the kind of 'white spaces' which have unconsciously become so natural for me. 

Despite feeling rather out-of-place, I also felt a great sense of camaraderie in the crowd--so that rather than feeling like an uninvited stranger at an official meeting, I felt like a new acquaintance joining a close-knit group of friends, whose inside jokes went over my head. And rather than a therapy session in which I imagined myself as a wallflower, I found myself smiling and nodding along with the shared stories like a (somewhat-clueless) audience member at a comedy show.

For their stories were reminiscent of those from The Moth radio hour where members of the public share gripping personal tales with a receptive audience--they were fun, casual, personal; they elicited laughter and cheers from the crowd; they were told with flair and comedic effect. A man with a blazer and T-shirt went up in front of the crowd, half-grunting half-laughing, "I am certified NUTS!" (laughter from the crowd) "I know I'm crazy," and, referring to his alcoholism, "I know I gotta get out." He goes on, "Alcohol removes," and with dramatic pointing, "Table.... Leg... (laughter). Brain... Kidney... Liver." And a woman with camouflage cap and shirt announces in clear, stately tones, "If it weren't for AA, I wouldn't be here today." 

The last speaker was celebrating her 14th Anniversary--that is to say, it was her 14th year as part of AA, and celebrated with candles and cake. She spoke with flair, spunk: "I was loud. I'm still loud. " And then, sincerely, "My baby teaches me to be better. You all teach me to be better." And, "Others help us see what we don't see in ourselves." As I approached her after the session, along with many others who expressed their congratulations, she turned to me with a bright smile and extended arms--"Are you new?"

I left with the feeling I get when I attend mass at a church and religion I don't "belong to," and why I attend in the first place: that the world is a better place, and can become a better place. That despite our differences, we all seek to be better. And that matters, for alcoholics and for me. 

Psychologists use smartphones to measure ethics

What would you do if you could divert a train to save five men but kill one man as a result? Would you do so? What if you had to push that man in front of the train to save the others?

Psychologists often use these kinds of “trolley problems” on test subjects using desk computers in their laboratories to study our moral reasoning. But recently a study published in the journal Science went beyond hypothetical questions into real life. Psychologists now have a sophisticated lab tool for examining morality not just in the lab, but in everyday life: the smartphone.

In the study, 1252 participants of varying ages, ethnicities, and educational levels from the US and Canada texted—in their homes, in the streets, wherever they happened to be. At five random points each day, they would receive a survey by text message, and they would briefly describe the moral or immoral acts they had committed, been the target of, witnessed, or learned about (e.g., through gossip, news, and the internet) within the last hour. From the texts, the researchers were able to measure the frequency and content of moral and immoral acts.

They found that people who were non-religious committed about as many moral acts as those who were religious. And liberals reported more moral acts of fairness, liberty and honesty, while conservatives reported more moral acts of loyalty, authority, and purity. Committing a moral act was associated with a greater sense of purpose, and being the target of a moral act was associated with higher levels of happiness.

Overall, moral acts were reported just as often as immoral acts, but there were some interesting imbalances. Acts committed by the self or received from others were more than twice as likely to be moral than immoral. The opposite case emerged for learned-about acts: they were more than twice as likely to be immoral. The use of smartphones allowed researchers to examine interactions in real-life time, which previously had not been possible in the laboratory. This allowed them to examine how one moral act determined the occurrence of another throughout the day.

Their findings provided evidence for a kind of moral slacking that psychologists call “self-licensing”: people who commit a moral act early in the day are less likely to do so later on, and more likely to commit an immoral act. But there was also evidence for what psychologists call “moral contagion”: people who receive a moral act are more likely to commit a moral act themselves later that day. Self-licensing and moral contagion are amenable to social intervention. So we may be able to alter moral behavior by intervening in the moral course of people’s days.

Researchers foresee the ability to use the smartphone not only for data collection, but to provide interventions to increase self-discipline. According to the original paper, “Given these different mechanisms, it seems important to find out more about how the principles of moral contagion can be used in public policy interventions, and how moral slacking may be prevented.” The study is one of the first of its kind to study ethics outside of the laboratory. More studies will need to be done, but this one has made striking entrance into the real world.

It collected an impressive number of 13,240 responses, substantially more than most psychology studies. The larger the number of responses, the better that sample represents the general population of interest. This allows for robust results and generalization across large populations. But since participants were sampled exclusively from the West (US and Canada), researchers weren’t able to examine how cultures differ in their prioritization of moral values across cultures – a subject of great interest to moral scientists.

Still, the study provides evidence that controlled but artificial laboratory findings also apply to people’s everyday moral experiences. Although the findings are tentative, they provide important areas for further research, and new methods to do so in real-time, everyday situations. “I think of this as a first look of how morality plays out in real life,” says Dr. Brian Nosek, a psychologist at the University of Virginia. “The first telescopes didn’t tell us everything about the galaxy, but they gave us a tantalizing sense of what’s out there.”