hiatus

Hemodynamics is on hiatus. Thanks for stopping by, though, and I am sure it will start back up at some point, in some form. In the meantime I share links and T-cell news at tcells.tumblr.com.

why I walked

I admit I only signed up for the AIDS Walk because L, the HIV social worker in my clinic, was the captain of the team and intercepted me on the way to the hospital cafeteria with her strategically placed table.

And when I got to the walk this morning, many of our "Team Members" had evidently contented themselves with having raised a little bit or a lot of money--most didn't show up to our team meeting spot on the rainy morning of the actual walk. That's fine, really; our hospital employee team was a "Gold Team", and as a medicine resident from a rival hospital sheepishly noted, our hospital's team raised more money than that other bigger hospital's team did. Really, everyone who shows up and takes a tote bag and water and granola bars is probably just costing the AIDS Action Committee money--so maybe it's a favor to raise money and then bag the walk--there's even a category called "virtual walkers" to describe this strategy.

Still, it seemed like I was supposed to be there, so I went.

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By mile 2 or 3 I'd separated from my fellow employees and could have easily hopped the T and gone home. Our hospital had done its bit--a community relations person had waved our sign around, we'd raised our money--and now it was time for the teams of the corporate sponsors, college charity groups, and AIDS non-profits and government agencies to finish the walk. Or so I thought for a moment. And then I started really making note of a small but persistent group of teams, each with their team t-shirts, made to memorialize a family member.

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It was the 25th annual AIDS walk in Boston--they've been doing these things since 1985. A long time. Walking on my own, I was speeding up to get back to the finish line. I thought some about the morning teaching session I need to do on Wednesday--I think I'm going to do it about a patient of mine with AIDS.

As I walked, I noticed that the AIDS Walk had put up these little signs noting each year of the walk and events in AIDS history. I started doing AIDS work and volunteering in 1991, when I arrived in San Francisco. It was the red ribbon/Magic Johnson year, the signs reminded me--the year that AIDS most clearly became a part of mainstream culture. Sometimes I can be hard on myself about why it was I started then, when it was easier, and not in 1988, after I found out that my student government teacher had died, or in high school, in the mid-eighties, when passing out condoms would have been a radical act. (To ease up slightly on myself, it's true that I hadn't yet really had sex myself, so the gesture would have been a complicated one.) But then the next panel reminded me: that next year, 1992, was the year that AIDS became the biggest cause of death for young men in the United States. And in 1992, it only seemed like it was going to get worse.





1991-2010: I've been somehow involved in AIDS work almost all of those years, with a few small breaks for parts of my medical training. More than half the epidemic--in fact, now, about two-thirds of it, minus the very worst years. Next year will be 20 years, out of 30. I don't know what to say about that exactly. I could have stopped in 1997, since from 1991 to 1996 I said I would stop doing AIDS work and start doing something else "when the crisis is over" and when I said crisis I meant the kind of mass death that ended in San Francisco with highly active antiretroviral therapy.

But I didn't stop, though most of my friends who were also there for the crisis did. I'm still not sure why I didn't go do something else. For a brief moment in 1997, I almost went to work for an ad agency but I got another AIDS job instead, and I was relieved and knew I'd made the right choice. During a year in a lab, I found that I was depressed until I started volunteering for a needle exchange program.

No one I was super close to died or even got sick. There wasn't some big cathartic event, other than living in San Francisco in the early 1990s, that kept me going. I just kept thinking about AIDS because I kept thinking about AIDS, even though there would have been a lot of other alternative paths for me in which I probably could have done greater good for a greater number of people. So it's not like I'm claiming a moral high ground. I'm just observing the persistence of a theme. It is what it is.

Given that I have kept doing this work, kept connecting myself to this epidemic, I'm glad I got out in the drizzle and walked. Not for my hospital. And only partly because of the AIDS Action Committee--since the money raised was raised whether or not I walked, and they probably could have given my tote bag to encourage one of their nutrition clients to go to the farmer's market or something.

Mainly, I was glad to walk because those little clusters of families with their team t-shirts deserve to have lots of people around them when they gather together to remember someone now gone. It also gave me a couple of hours to think about how long this epidemic has kept pulling me back towards it, for reasons I don't entirely understand.

If you want to give some money to the AIDS Action Committee--they're good people. I know them personally because they're getting food and other services for one of my patients who's really sick, and a few years ago they got me down to the statehouse to help lobby for their (successful) effort to decriminalize syringes and make clean needles available in pharmacies in our state. They do a lot of other great stuff too. Here's the link to my AIDS Walk fundraising page.

And: thanks so much to that small but sweet group of friends and family who donated--it means a lot to me. It's true that because of your donations, I qualified for a tote bag; but more importantly, my patient will get some food. And trust me: he needs it.

1996: what color was my parachute?

I was looking through old files for something else, and found this. Since you're reading this blog, you know what finally happened. Math was hard, but I stopped letting that stop me. I bought an algebra book, re-learned algebra and trigonometry, took science classes, went to medical school. Apparently What Color Is Your Parachute? knew what it was talking about. Maybe.

Also I had kind of forgotten how into REM I was back then.


Whenever someone asks me what I’m up to these days, I say, “Oh, trying to figure out what I’m doing with my life.” Then they chuckle. Heh heh. They’ve been there.

But were they ever really as desperate as I am now? Because I’ve turned not once, but twice to What Color Is Your Parachute? It’s maybe the most famous self-help book ever--so I must be in bad shape, right? The concept of the book is that if you follow its instructions, you’ll not only find just some job, but you’ll figure out exactly what your ideal job is and then get it. I’m a product of the culture that this book helped to create--it was first published a year after I was born. Maybe that’s why I hold on to the belief that it is actually possible to find an ideal job, a true calling, even outside of “Lottery Winner.”

A while ago, I was housesitting in a house so beautiful that I went out and bought twenty lottery tickets so maybe I could buy a house just like it. At least one of the beautiful house’s owners had read an early edition of What Color Is Your Parachute? which they still had laying around, marked up with notes. So, after my lottery tickets yielded no results, I sluffed my way through a few of the book’s career exercises. I came up with a plan, which was a pretty good plan except that it depended on some people who didn’t agree with it. After that, I managed to ignore my career woes for a while. Actually, I was sort of ignoring my career, period. My new boss, the smarty-pants bastard, eventually sat me down and told me that I’d better start shaping up. Which reminded me--oh yeah!--I still hadn’t figured out what I was doing with my life.

So--back to Parachute. This time I started in on informational interviews. A series of what-do-you-dos and how-do-you-like-its yielded a great deal of interesting information, not least of which was that if you sit people down and ask them about themselves, some of them don’t really want you to leave. Maybe ever. A couple of people told me I should be a doctor. Sounded cool, but difficult. I’m like that talking Barbie--math is hard. Plan B was a little more accessible: account planner at an ad firm. Until I realized that having Plan A as “Be a doctor” and Plan B as “Be an account planner” was a little too much like talking Barbie. I still really hadn’t figured it out.

So, back to the book. I started doing all the exercises, not just the few I didn’t find depressing. While I was writing a list of everything that I had ever learned, I was listening to an REM song and it occured to me that part of what bothers me most about submitting to the indignity of this kind of exercise is the overwhelming sense that most of my heroes never really did this. When REM were a bunch of students in Athens, GA, they just started playing music because they loved playing music, and then they started putting out singles and albums and videos, until they became the huge phenomenon they are today. I just can’t see that there would have been any career self-help books in the process.

From when I was fifteen to when I was twenty-four or so, I had a calling. I wanted to be a movie director and I wanted to make frequent interview appearances in oversized magazines and late night talk shows. But let’s not speak of those mistaken notions now. Let’s focus on the future: I need a new plan. I know that What Color Is Your Parachute? should help me find some reasonably satisfying direction, but I yearn for something more: a new calling, a new certainty that what I want is what I will be best at and enjoy the most and give the most to the world by doing. And also that it will be infinitely glamourous and make me famous and loved.

The problem is that this book, this Parachute is designed to move you away from obvious answers and convince you that, for instance, everything you like about being a movie director is actually fulfilled by being a freeway engineer. The idea is, obvious answers aren’t always the best answers. Sometimes you’d actually be happier designing freeways or selling plastics. But in the direction of obvious answers also lies the allure of glamour--of what everyone wants, or thinks they want. Diving with sincerity into a career self-help book is a sure sign that you’re giving up glamour. An important step, no doubt, but also, inevitably, a sort of depressing one. This isn’t going to be about your calling, the moment in Athens, Georgia where everyone realized you really had something. This is about settling down and going to work.

the future of the future

Wikimedia commons photo: Samuel Delany. NASA photo: Charles Bolden in 1992


Yesterday, I was registering the fact that President Obama has appointed Charles Bolden, an African American astronaut, to run NASA. I googled him, thinking about how it's not that incredible anymore to have black people go up in space, and that therefore it doesn't seem incredible that there's a black astronaut in charge of NASA. And then one article, which included various people gushing about Bolden, included a comment from his astronaut buddy Franklin Chang-Diaz, whose daughter is a Massachusetts politician with the same last name.

I don't want to dwell on the point, but "Franklin Chang-Diaz" used to not be an astronaut kind of name, nor a Boston politician name either. In fact, it is hard to know which would have seemed more improbable in 1950, or 1960, or even 1970.

I don't want to be the white guy who looks on in wondrous rapture about little victories of diversity as a way of ignoring inequality and discrimination. So let me pause and register that the world is still what it is; inequality still is the rule, not the exception. At the same time, the world is different than it used to be.

NASA made a decision, when it started the shuttle program, to change what astronauts looked like. Now, many years later, there are a fair number of black astronauts, women astronauts, astronauts from different parts of the world. Some of them are rising through the ranks. There are still plenty of white guy astronauts and white guys slapping each other five in Mission Control--the world hasn't changed so much--but it's different than Apollo.

This got me thinking about science fiction. I've mostly left the genre behind in my own reading over the last few years. My friend S. knows it better and is able to write about it more seriously. Still, from the reading I did in years past, I can say there are a few different versions of the society of space in science fiction. One of those versions comes from an often quietly utopian impulse, which involves more small-bore problems of dealing with difference, or of trying to make a better society, or of living in a different way than we now imagine. It does not describe utopias, but its broad imagination, its sense of possibility, is a form of utopianism. It is a way of saying, anything is possible. This genre uses science fiction as a way of stretching our imaginations about what could be. Some of the practitioners of this kind of science fiction, people like Octavia Butler or Samuel Delany, were African American, and the humans who inhabited their worlds were often of many colors, not to mention genders and sexual orientations. In fact, not at the time, but retrospectively, some people call them pioneers of Afrofuturism.

There is no immediate relationship between Samuel Delany, a gay man with a big unruly beard who now teaches creative writing at Temple, and Charles Bolden, a former Marine and astronaut, who will now run NASA. They are both black men who are interested in outer space, but then, so was Sun Ra. I can't really imagine Borden and Delany at the same event. And though there must be someone who knows them both, I don't think they travel in overlapping circles. They have outer space in common, sort of (though Samuel Delany does not even depend on that trope). But one of them is interested in imagining different planets as metaphors for different ways of living. The other is interested in specific real different planets as places we might drive a space ship to. Delany is wildly progressive; Bolden is not, at all.

When NASA chose its astronaut corps for the shuttle program, it did so for political reasons that were very much of the here and now. NASA understood then and understands now that its work can either seem like an inspiration, a bold project of building human capacity, a project on behalf of nothing smaller than humanity itself; or, alternatively, a wasteful boondoggle and gadget racket that has nothing to do with anyone's concrete problems. Choosing a diverse astronaut corps helped keep NASA looking like it was staying on the right side of that line. That has nothing to do with anything as edgy or visionary as Samuel Delany. Yet, if you would have written a science fiction story, in 1969, that imagined a black president and NASA chief, you would have placed yourself firmly in the left wing of the genre.


There are all sorts of possibilities come true lately, which I've been noticing simultaneously. Less lofty but maybe more spectacular: in my pocket, my iPhone seems more spectacular than a lot of gadgets I read about in science fiction books when I was a kid, exactly because it is an everyday device. Without any mythic resonance, an improbable-seeming thing I carry in my pocket, the iPhone is not a super phaser or a scanning diagnostic tool that instantly does my medical work for me. It's just a phone, a newspaper, a street map of the developed world, a global positioning device (the very existence of which is improbable, much less that it is in my pocket), a massive encyclopedia written by a global collective, a camera, some video games, a music player, a way to write people brief letters or read letters from others, and other things as well. And I put it in my pocket and carry it around! Every so often, we do make note of how incredible this seems. Perhaps I'm just getting older, and remember more and more time, more and more of my own history, that took place before we could take such things for granted.



Whether for the head of NASA, or my iPhone, the future is harder to accurately imagine than it first seems, and not just because you thought the phone/clock/navigational device would be a Dick Tracy-style watch and not some pocket version of the monoliths from 2001: A Space Odyssey. Once the future arrives it seems ordinary. To imagine the future puts a wondrous glow on it.

The future is not simply a time like other times; it is a time when anything is possible and therefore it is a time made up of a larger-than-appropriate proportion of our hopes and fears. When we find ourselves in the time that used to be the future, there is no such resonance. Some things are newly possible, others not possible anymore, and we simply find ourselves in a new set of circumstances. We fear and hope for new things. AT&T sends a bill for the iPhone minutes. The future is no longer the future.

But there is something about this year, and I know I'm not the only person to feel this way, that feels a bit more like science fiction than most years. The dull apocalyptic dread of the American economic empire in collapse; a black president with a Muslim name; iPhones in our pockets; gay marriage through all of New England but not in California or New York; a black astronaut in charge of NASA. Some Puerto Rican lady gets appointed to the Supreme Court and it is the exact person that the press has been predicting all along, which makes her appointment seem like an almost unadventurous boring political move by our president, who--we're almost used to it now--is a black man named Barack Obama. (Afrofuturism, indeed.) We take the internet for granted but we're still figuring out how to use it; we're also now used to things like dance music made entirely by computer programming; and we forget how extraordinary it is that in so many ways, from dumb television to crucial navigation, we depend on satellites orbiting the earth.


It's not future shock I feel; just a sense that the present is improbable, and thus, that the future must be even more so, for better, for worse, or, simply, for different. Really different. All possibilities remain possible. We are in a time that feels like the future even as it arrives. This year, more than most years, I find myself in the future, still catching up.

Why I write: props to a zine and a blog

photo: punk zines as depicted by Wikimedia Commons


Blogging is a wierd exercise. A while ago, a noted figure in healthcare blogging came to talk to my hospital; he and I know each other through our blogs and I introduced myself before the talk. During the talk I got a page from a nurse, and had to go out of the room to answer a call about a patient. Apparently in the meantime someone asked the speaker about his blog and he said something about how blogging is partly an inherently narcissistic act, and then looked over in my direction and said, "What do you think Joe?" A friend of mine said, pointing to my empty chair, "Oh, he's not here, he's outside looking at himself in the mirror."

A funny line, but if I liked myself that much, I wouldn't need a blog.

Given that most blogs, including this one, don't have that many readers, and at least in my blog's case, are more commonly found by people stumbling through Google Image searches than by actual devoted readers, blogging can really be only part narcissism. Or maybe it's just narcissism combined with masochism. I don't think either description is right, though. I think all writing requires pure and unproven faith that someone else will be interested in what the writer has to say. And in terms of its relationship to an audience, I think writing is more an exercise in hoping that you're not alone in thinking what you think--that others will read it and relate to it, and maybe even find that it says what they were looking for words to say. Good writing can't spend much time trying to convince readers that the author is fabulous.

Before blogs, there were zines, and I was a fan of zines too. Before some set of people thought it was a good idea to post their writing on the internet, an overlapping set of people thought it was a good idea to type or write a bunch of stuff and take it to some copier and staple it into a little booklet and sell it at some grungy video store or bookstore. I was one of those people too; my writing grew and flourished in my little zine, each issue carefully worked over, slowly, slowly, in between other things.

On that note, two shouts out, one to a blog and another to a zine.

The zine: Doris. Cindy, the author of Doris, has been doing this for a long time, since before blogs. I used to buy her zine when she bound it with red duct tape; now she actually has slightly less DIY-looking binding but she's still got the cut-and-paste, typed and handwritten, no PageMaker punk rock style. She's also doing more writing to support survivors of abuse, including a handbook/comic to support survivors complete with a version in Spanish. She actually now has a blog, but not to replicate the zine's contents--just to let people know about her projects, appearances, etc, from which I find that she's got enough of a fan base to be going on tour to do readings. I think since I've started reading her work she's become a little bit of a celebrity within the punk rock world but since I am mostly part of the hospital world, how would I know? All I know is that every time I manage to find her work I find out that she's been working hard on writing as honestly as possible, struggling but pushing forward. Find her zine in your nearby indie/punk/poetry bookstore or via her website. She also has a book with the contents of some of her earlier zines. Since I started my own medical training years ago, Cindy seems to have at the same time been working on a kind of medical training of her own, but more in the self-empowerment, up-from-the-ground-roots, skeptical-of-medical-power school of thought. I would like to think I was more a part of that world than I am, but my own internal contradictions are the topic of another post. For now I'd just like to give props to Cindy for keeping on keeping on.

The blog: one of my few actual devoted readers who is not my mom is Chris from Last Chance Texaco. Chris can be found entirely on the web, on his own blog, so less description is needed--just go read his stuff. He's still in Boise, still struggling with being in recovery, still trying to make sense of his own role in his own mistakes, still trying not to make the same mistakes again. He also posts about random other stuff, including gym shorts from the 70s, or dumb TV; the periodic light touches make the heavy stuff more compelling. In many ways, Chris's blog is something between writing for other people--he appreciates having readers--and just writing for himself, to mark each day, to mark his struggles, and perhaps to hold himself accountable by documenting those struggles.

Meanwhile, I'm now a junior resident. Apparently that means I'll have more time, and more space in my head that I can call my own. I hope my own writing will benefit, and that you'll be hearing more from me this year. I know that my writing has always been best when I share the impulse of people who write whether or not anyone reads their writing--people like Cindy and Chris who build their audiences through the constant work of documenting their own self-exploration and movement through the world. Though I actually hope to publish more this year in other people's publications or broadcasts--I am at least narcissistic enough to want a broader audience for my writing than Chris, my mom, my honey, and people who do Google Image searches--I want to always remember that my writing is most true and worthwhile when it is written by someone who is a zinester, a blogger, a guy who writes because writing is worth doing.

At hospital computers, anonymous toilers Google their inner states

Statcounter.com allows me to track what recent search terms people have used to find this site. A few people are clearly looking for this site specifically; most stumble on it with Google searches that lead them here--maybe the same way you ended up here.

Here's my favorite Google search phrase that led someone here, from a hospital-based server far far away:

"i'm a medical resident and i feel stupid"

This phrase put into Google's search box led the searcher to this blog. And all I can say is, brother or sister doctor-in-training, I feel you.

Keep searching.

Pop non-stop

video: Rihanna performing for the Nobel Peace Prize ceremony. (?!) Below, Madonna's "Hung Up" and the trailer for Rize.

I'm listening to Rihanna's "SOS" with that mash-up-style "Tainted Love" sample, and her "Don't Stop The Music" which includes a little synthesizer riff that echoes another woebegone 80s hit "I Wear My Sunglasses at Night". And while appreciating the latest in trashy but quite satisfying pure pop, I finally remembered to download the single "Hung Up" from Madonna's last album, even as her new album is about to come out. It's got a bore-into-your-body catchiness, with its roots sunk deeply into the dance floor. Absurd though Madonna may be in many ways, you have to give her credit: she knows how to make a pop song.

Let me say for the record that in college I wrote a fairly serious 35 page paper about the semiotics of dance in Madonna's videos. To put this in historical context, this was during the same semester that a group of women students at my college put on an equally serious forum and discussion entitled "Is Madonna a Feminist?" (Though I think it has always been clear that the answer to that question must be given in three parts: yes, no, and who cares?)

Madonna is a genius of pop music, whose calculating intelligence about the genre has allowed her to outlast just about every other pop star of her original era. She is no longer the center of pop music, and she will never be the startling new thing. Now that she is the age of the mothers of the most ardent pop music consumers (teenage girls), her place in the pop world is as a commenter as much as a practitioner.

This music video is one example: it's a little visual review essay about the dance trends of the time it was made. Those trends, and the kids who create them, are juxtaposed against Madonna wearing the kind of clothes and haircut she likely wore when she was their age.

Madonna, like anyone serious about pop music, knows that pop music and dance are always being born and reborn again and again in poor neighborhoods and gay clubs. So, at the end of this video, you have a group of kids from South Central LA taking a taxicab which ends up at a club in London. In reality, the only link between Madonna's world in London and these kids is probably a DVD of the documentary Rize, about krumping. But I don't think Madonna is asking us to believe that she is from the South Central LA world of krumping, or even that she understands it. Just that she celebrates it, along with Dance Dance Revolution (the dance video game seen at the end), the French acrobatic street stunts of parkour, and some kind of crazy disco dance with a fish in an Asian restaurant which for all I know represents some other kind of trend.

Now that this video has become dated, its underlying idea is actually more clear. It's about the enthusiasms of youth, which always date themselves in their details, but are also timeless in their general outlines: combinations of dance, desire, doubt, determination. It's about a woman who's now much older, remembering that time and that way of living, the time in her life when she was driven to make her mark but had not yet made it. Dance songs then were about "You don't appreciate me so I'm going to go on without you" (Gloria Gaynor was playing on the club speakers singing "I Will Survive" when Madonna came to New York) and this dance anthem is yet another variation on that eternal club anthem theme.

As for me, I remember the nerdy earnestness of the teenage record store guy who spent hours listening over and over again to a jazz record and then more hours listening over and over again to a 12" club remix of a pop song; then goes to a college and writes a paper about Madonna; goes to San Francisco and gets caught up in AIDS with the same nerdy earnestness; and then becomes a doctor, which in fact is the ultimate culmination of nerdy earnestness. Which I think makes this post the equivalent of Madonna's pink late-disco-era leotard, my memory of who I was when I was young.

Meta-analyses and pollster.com

The race for Minnesota's US Senate seat, US data on hypothetical McCain-Obama matchup for the general presidential election, and Pennsylvania Democratic primary polling, as shown by Pollster.com

I have a new addiction.

Pollster.com is the website political junkies have been jonesing for even before we knew what it was. It clusters the results of polls that ask the same question--like, Who are you going to vote for? or, Do you think the country is on the right track? Then it puts them together into a single graph with a unifying trend line. It's imperfect--I can't satisfy myself that the trend line weights for sample size--but it's a lot better than reading the polls one by one.

The medicine parallel is in what we call meta-analyses--when we try to figure out a medical question by combining a number of studies that try to answer that question. Even if a bunch of smaller studies contradict each other, the idea is that by combining a number of studies you get the effect of having one huge study, and in this kind of data (with simple results like "worked better" vs "worked the same"), sample size is all. Thus, if you can create a meta-analysis that has the effect of creating one very large set of data, the answer those data give may be more reliable.

Like any kind of statistics, the problems get more complex as you try to get around the simplest problems. For instance, even when you weight for sample size, you can't throw less-reliable studies and more-reliable studies together and act like they're equivalent--so an ideal meta-analysis gives the data from more reliable studies more weight in the final result. But judging quality, and the appropriate weight given to difference between studies, begins to become a bit more subjective the more you try to fine-tune this problem. (What is quality? And how much weight does which measure of quality get?)

Pollster.com doesn't seem to do any weighting for sample size or other aspects of reliability, but even their relatively straightforward trend line is better than a lot of nonsense political handicapping you hear on TV politics talk shows. By giving more raw data and by combining large sets of data, these graphs and datasets allow you to begin cutting through some of the worst excesses of data-mining by stupid or biased pundits. In other words, you can be your own pundit.

I am aware, of course, that one of the ways that I manage to avoid coherent political action is by being a political junkie--an observer rather than a participant. Another thing that I need to change a little bit in the coming years.

PS:
Wikipedia on meta-analysis
Pollster.com on their trend-line method

Dockworkers, doctors, and democracy

Photo from the Sydney Morning Herald: the Chinese ship, and South African church members protesting its cargo.

The dockworkers of Durban, South Africa, did what their government wouldn't: stopped a shipment of arms from China to Zimbabwe, including 3 million rounds of ammunition for AK-47s, rocket-propelled grenades, and mortar rounds. The arms would help the doddering dictator Robert Mugabe try to hold on to power, after an election that appears to have not gone well for him.

The Durban dockworkers refused to unload the arms. Then an Anglican archbishop filed a motion in court to stop the shipment. When the court affirmed the motion, the Chinese ship pulled up anchor and headed for Mozambique--or was it Angola?

Whichever port it heads towards next, the Chinese ship will likely eventually find a port, and a road to deliver its bullets. Nonetheless, the collaboration between the church and the unions exposes the banal exchanges of money, bullets and bureaucratic documents which move violence around the world. Mugabe sends money (though surely not in his own currency, which he has made worthless). The Chinese send bullets. The South African government signs the papers which allow the bullets to move from its ports to landlocked Zimbabwe. Stopping the bullets for a few days or weeks may or may not influence the outcome of the struggle in Zimbabwe, but it does help highlight who may share responsibility for the violence of that struggle.

The collaboration recalls some of the proudest moments of the fight against apartheid in South Africa, when the church and the unions led the struggle in the streets while much of the African National Congress leadership was in exile or prison. It also reminded me of a moment closer to home, when dockworkers in Oakland, California, refused to unload a South African ship's cargo as a protest against apartheid. At that time, they were supporting the work of the African National Congress as well as the Congress of South African Trade Unions in their collective struggle for justice and democracy.

This time, though, the unions and officials of the African National Congress were on two different sides of the question. COSATU members refused to unload the Chinese ship, while African National Congress government officials had already cleared the cargo to cross South Africa on the way to Zimbabwe, and the president of South Africa continues to coddle Mugabe.

The dockworkers' refusal to unload the cargo illustrates a broader political principle. In Zimbabwe, the ruling party was able to assert its primacy above all other political organizations. In South Africa, even those who have been fiercely proud members of the African National Congress also remained part of other organizations, like churches and unions, and these organizations remain an active and vital part of the political landscape. (In fact, they've helped change the leadership of the ANC, and President Mbeki's faction appears to be on the way out.)

When people in South Africa split their loyalties--voting for the ANC, but marching in a COSATU or Treatment Action Campaign march, and supporting an Anglican archbishop who speaks truth to power--their nation's politics, their own interests, and the well-being of the entire region are better served.

Thinking about the dockworkers' choice, it seems to me that in this election season, we should choose our candidate wisely, and then join an organization that also reflects our values but stands ready to oppose our chosen candidate. This is how we create the checks-and-balances of true democracy--not just by courts and legislatures, but by votes and protests, and by support and opposition by issue rather than by allegiance. Democracy is formal and informal; it involves the dockworkers refusing to unload the cargo, and the Anglican church going to court to stop it, and an independent judicial system willing to fairly judge the motion.

I've often been disappointed with myself during my medical training that I have not as been politically active as I think I should be. The dockworkers are a reminder of why a vote is not enough. My excuse this year is internship, which is my excuse for a lot of things; but that excuse will be over at the end of June. And then I will need to think about what I can do to make the world a better place, and to do my small part in exposing its violence.

Doctors sometimes convince ourselves that we are taking our own stands for what is right when we refuse to order a useless study, or fight for a medicine that an insurance company seeks to deny. But these actions are the quiet battles that take place inside the industrial process of healthcare delivery. Unlike the dockworkers, we actually conceal the violence of the system when we make private phone calls to soften its blows. Sometimes we should be ready to choose our times when we simply refuse to unload the ship.

I don't know which times these would be. The work of doctors and dockworkers is very different. Our struggles are rarely as clear-cut as stopping a shipment of arms to someone who will use them to kill civilians and suppress democracy. And a leader of a grassroots healthcare workers' movement could not in good conscience make this classic dockworkers "just try to fight us" threat:

Randall Howard, general secretary of the South African Transport and Allied Workers Union, said the dock workers had no intentions of allowing the Chinese cargo to be unloaded. "If they bring in replacement labor to do the work, our members will not stand and look at them and smile," he said.

Still, if the nature of who we are and what we stand for forbids busting heads for political gain, we can do more than vote and make quiet phone calls. What this will be for me, I'm not sure. But I'm in a mood for change, and I'm pretty sure that Obama won't be enough.

Your glamour was their genius

photo of ACT UP Chicago demonstration from wockner.blogspot.com/

An essay I wrote a while ago, that grew out of my ongoing project in AIDS history:

I have to admit that despite a lifelong professed hatred of musicals, I went to the movie version of Rent when it came out, and I started getting a little teary almost as soon as it started. Rent shows earnest people with AIDS singing about their lives until interrupted by beepers reminding them to take their next dose of AZT; it shows a support group of people with AIDS sharing their fears and finding community. Plus there’s an almost unforgivably sentimental but nonetheless lovely song about measuring the quality of one’s time in the world by the love you find in it. Sometimes I am a sentimental person, and Rent’s sentimentality hits me right where I live.

Rent seemed at first to be an unlikely candidate for mainstream success; half of its characters are HIV-positive, half are gay or lesbian, and two are heroin addicts. But that’s how some of the biggest hits are made. To understand Rent now, we have to remember what preceded it.

Fear and hate of people with AIDS are still widespread in our society, but those feelings were so common, so intense and so irrational in the nineteen-eighties that the counter-reaction eventually created a strange kind of glamour. AIDS acquired a glamour of stigma, like the glamour of Billie Holiday or drag queens. As the glamour gained momentum, politicians who voted for money for AIDS, or scientists who did AIDS research, or celebrities who wore red ribbons all got to benefit from the glamour, without having to suffer from the stigma. To stand up for the stigmatized is to cloak one’s self with the righteousness of the underdog and the aura of the enlightened.

But if we view AIDS simply through the glamour of stigma, we miss essential parts of the story. The lesbian writer and activist Sarah Schulman has written about the way that Rent combines parts of the opera La Boheme with elements of a novel of hers, People in Trouble, for important parts of its plot. But as she herself argues, whether you view Rent’s similarities to her novel as theft, honest borrowing, or coincidence, the bigger problem with Rent is the part of the story it does not tell.

You can find Schulman’s side of the story by reading her novel or in her essay critiquing Rent’s approach to AIDS and gay and lesbian lives in her book Stagestruck. But I think her point is actually made most forcefully by another project of hers that has nothing to do with Rent: an extensive set of interviews, found at www.actuporalhistory.org, with members of the AIDS activist group ACT UP.

The interviews make clear that in real life, it would have been essentially impossible for the characters of Rent to avoid ACT UP. In the time and neighborhood where the story takes place, ACT UP’s posters and protests were everywhere. Mimi might well have traded in her used needles for new ones at a needle exchange set up by ACT UP activists. Activists wearing ACT UP t-shirts would have been at the eviction protest staged by Maureen, passing out flyers for their next protest. And the people in the AIDS support group might have worried about losing their dignity, as they do in Rent, but they also would have traded ACT UP activists’ insider tips about clinical trials and experimental drugs.

One part of ACT UP’s legacy comes from building collective expertise that allowed activists to sit across the table from scientists and bureaucrats and demand new approaches to health policy and scientific research. But another part of ACT UP’s brilliance could be found in their demonstrations. Some were huge and carefully orchestrated, as when they took over the headquarters of the Food and Drug Administration. Others were smaller, including political funerals in which activists carried coffins out into the streets, blocking traffic while they marched with the bodies of their dead friends, protesting against a government and a healthcare system that seemed not to care about their deaths. At the time, that sort of thing made a lot of people furious, and all sorts of people hated ACT UP for their in-your-face stridency.

But with more than a decade gone by, it’s now clear that the provocations of ACT UP and other AIDS activists worked. They changed the science, politics and culture of AIDS. It was after ACT UP that scientists started listening to activists, and after ACT UP that federal lawmakers passed legislation to fund comprehensive AIDS care.

Let us not distort history by thinking that Hollywood led the way to tolerance. It was only after the scientists and politicians had already signed on that celebrities started wearing red ribbons. Even then, though, the red ribbons carried a little of the electricity of being on the right side of a struggle.

AIDS activists had succeeded by transforming the stigma that marked them into a weapon of power and social change. A few years later, based on the energy they had created by angrily drawing a line between right and wrong, Rent became a runaway hit. Viewed in the light of this history, Rent is a musical about the glamour of stigma. The ACT UP oral histories document the genius of the stigmatized.

Dreams

Many large mammals seem to dream. Photo from www.tanzaniaparks.com

Earlier this week I dreamed that someone from my residency program--it wasn't anyone I know in real life--plunked down a piece of paper in front of me with a dollar amount. (About two month's pay.)

"We'll give you this much to buy you out of your contract," the person said. They didn't want me to be an intern anymore and were going to pay me to stop working for them.

In reality, I would never be confronted with that kind of choice; I'd be fired or I wouldn't. But the dream made the prospect of being fired even more dreadful: I had to choose to be fired, and take the money; or refuse to be fired but not get the money while knowing that my bosses wanted to fire me anyway. I realized this in the dream, and began thinking, "This is terrible--they're going to stop me from being a doctor, they don't think I can be a doctor, but I've worked so hard to be one, I want so badly to be one"; and then I woke up suddenly with a terrible feeling. I quickly realized that I'd been dreaming.

"I'm doing fine," I thought to myself, in the dark of early morning, Ms. Dr. Hemodynamics and the Hemodynamic Cat sleeping soundly in the bed as I woke up and looked around at the real world. "That's not what's happening." Or rather, it wasn't what was happening in my actual life, where my bosses do not seem displeased with me. But clearly some portion of it was happening in my emotional life, my submerged world of fears.

Later that week, I led a presentation about a particular case, designed to start a discussion among interns, residents, faculty and guest experts about how to think about a patient's problem, and the issues it brought up. I did some work I didn't absolutely have to do on the presentation, and I hope it showed. Anyway, two faculty members told me I'd done a good job.

In the most literal sense, I have never dreamed of such a thing. I have imagined it or hoped for it in the daytime, and I have experienced it before. But I don't remember ever waking up from a dream in which one of my bosses or my teachers had just told me I'd done a good job, even though that happens much more often than someone firing me. Maybe I have those kinds of dreams. Maybe I just don't wake up from them with that startled dread that makes me remember a dream. Or maybe fear requires more overnight processing than hope or optimism do.

Freud said dreams represent narratives of wish fulfillment. I don't buy it, or not exactly. I read The Interpretation of Dreams in a film class when I was seventeen, and in retrospect I think it may remain more important for filmmakers than it does for clinicians.

I don't think I want to be fired from my job, or bought out of my contract. And I'm not prepared to do the interpretive backflips Freud and his followers required to turn that common kind of dream into a narrative of some kind of unconscious wish. It's a dream about a fear, which in the organization of the mammalian brain has got to be at least as powerful as a wish. If the brain is going to spend a lot of processing power on learning, fear is probably a better way of organizing learning for survival than wishing.

I'm a person of my era, not Freud's, and in my simple-minded way of thinking about dreams, I think of dreams as the brain reprocessing the material of the day--the intellectual material and the emotional material too. Whether they are wishes or fears, they get processed.*

Maybe the common ancestor of people and chimps slept in a forest, dreaming about her fellow apes turning on her for stealing fruit she didn't steal, horrified as they advanced towards her, shocked by this unreasonable turn of events; then, I hope, waking to find herself among peaceful family members. Now my great ape brain dreams about my bosses telling me I'd better fire myself from my job. If my dream has its ancestral predecessor, both of us apes--the ancestor great-great-great-grandmother ape and me--would be dreaming ourselves a deep social lesson, processed and then wired through many redundant circuits, which says, "Don't anger the apes around you."

For me, at least since junior high school and probably before, countless dreams have reinforced variations on this theme. Whatever imagined events these dreams are processing, their emotions and narratives surely help me be a more or less polite and socially appropriate person during waking hours. And that kind of dream creates such a powerful dread on waking that it is hard not to imagine that its mechanism must be deep and ancestral, dating back to that great-grandmother ape dreaming many millennia ago.

***

For practically every patient I admit to the hospital, I put in an order for "vital signs per routine"--which means they get woken up at night and early in the morning. People in the hospital also get woken up by their roommates, or their roommates' televisions; or worst and often most disturbingly of all, by other patients, delirious, their hallucinations representing a waking state of dreaming, or a dreaming state of waking, screaming "HELP ME!" or "GET AWAY FROM ME!" or "DON'T TOUCH MY PENIS!" across the hall again and again.

Once in a while you meet someone who can sleep through it all even without a lot of sedative on board. With one recent patient like this, I came to think that he'd spent enough time in hospitals that he'd figured out how to sleep while in a hospital room, including what had clearly become a nearly instinctive ability to fend off medical interns in the morning and keep sleeping despite their questions, pokings, and proddings. (This is not an easy task.)

Alone among my patients, this man was likely having dreams, full dreams, rich dreams. Did they make him better? Did they help him figure things out? I'll never know. I just hope that if I appeared in his dreams, I was never one of the apes who was hurting him.

<<>>

*Considerably less simple-minded descriptions of this kind of processing can be found in this article in Science for those who have access to it through local or academic libraries.

Fear is the mindkiller, part 3

My slogan for internship: "I will not fear. Fear is the mindkiller"--from Dune. But there seems to be no getting around fear.

***

I've been feeling burdened lately. I had the day off on Monday, and I was at a grocery store in a wealthy neighborhood getting myself the best coffee in town. I was there because I felt that with everything I'd been through in the previous week, I deserved a treat.

A young mom wearing some outfit that a skinny person would wear to yoga (the pants were tight and stretchy, not loose and concealing) had run into someone she knew. "Oh, I'm a little stressed right now," she said. "The kids are starting sports, and they're in school now, so lots going on, it's been a little bit overwhelming."

I wanted to turn to her and say, "Are you f***ing kidding me? Seriously. You're at the gourmet store buying $20 a pound cheese and hanging out with your kids, and what you have to say for yourself is you're stressed?"

Then I reminded myself that maybe for her motherhood does count as 80+ hours a week doing a terrifyingly high-stakes job, and although I do have to say that taking kids to soccer practice and the gourmet cheese store doesn't sound THAT stressful, what do I know?

Anyway, I realized that my reaction to her was not about her. It was about my stress, and how annoyed I was that someone else would claim to be as stressed as I am. In other words, I'm starting to feel sorry for myself. It was inevitable that it would start sometime--self-pity is probably the one thing that almost all medical interns have in common at one point or another--and I now recognize that it has started.

But I have always been willing to work reasonably hard, and for long hours. And there are many things about the work that is interesting and challenging in all sorts of good ways. So it isn't the time or the work that makes me feel burdened and sorry for myself. It's the fear.

I have a low-grade fear that never really disappears, like watching a scary movie while the main characters are driving around doing something innocuous. You know something bad is going to happen, but you’re not sure what.

I make mistakes all the time. Most aren't a big deal, and the few mistakes that could have become more worrying were caught by other people. There are only one or two mistakes that can still haunt me. The worst one came very early on in internship, when I didn't recognize an acute problem as it was beginning, until it required more serious intervention than it might have if I'd recognized it earlier. No one blamed me for it. Like many intern mistakes, it was an error shared by several people. And the outcome of the patient's hospital course was unlikely to have been any different as a result.

When I came back to the incident a couple of days later in a check-in session with my attending of the time, he said, "This is why you do residency. You just have to see it often enough to recognize it. If medicine was all things you could learn in books, we could just turn you loose after medical school. You can go ahead and feel bad about it, and in fact, you should, so it won't happen again. But this is what residency is about." He said that I was right on track for where I should be in terms of my skills as a physician.

I guess I took his advice: I didn't let the mistake stop me from coming to work the next day. But remembering that morning can still clench my stomach with a special force. No matter how much I reassure myself or other people reassure me that such mistakes are part of the normal course of my development, mistakes still frighten me.

It's mostly just the most recent mistake or two I've made that I remember at any given time, though, because the main reason the more inconsequential mistakes matter is that they remind me of my potential to create harm. That clutching clenching weight inside my abdomen, the horror of the near-miss, returns even when I think about the smallest errors. It's not usually the errors themselves that make me feel that way; it's the fact that I continue to make errors.

For the first couple of months the excitement of being a doctor, and the new confidence I have as an intern that I didn’t have as a medical student, was enough to compensate for this sensation, enough to keep my energy and enthusiasm high. But recently I think that constant sense of near-miss or about-to-hit, that chronic fear, is starting to exhaust me a little bit.

I don’t want to get rid of the fear, because it makes me a better doctor as I make my lists and check them twice. But I want to figure out a way to live with the fear. I don't think it stops with internship. There are doctors I see who look totally relaxed, but they've been doctors for a long long time, and anyway, I'm not sure they should be as relaxed as they are. What's worse in a doctor than overconfidence?

In other words, fear is necessary. But it is also burdensome. More than the hours, more than the work itself, fear is what makes me feel like this is especially hard. Fear is what makes me feel secretly sorry for myself. Fear is what makes me tired and irritable; fear makes me hate some mom in a grocery store. My task for the year is not only to become a good doctor. It is learning how to live with the constant fear of being a bad doctor.

Musical break: Senegal Fast Food

Listening to Manu Chao's new album on this rainy day off from the hospital, I went to his website and found this song ("Senegal Fast Food") he did with Amadou & Mariam--not on the new album, which like this song is both infectious and addictive. The plot of the video sneaks up on you, especially if (like me) you only get 1/10 or 1/15th of the French.

How I'm changing... part 3

As internship was about to start, I was writing about how medical school had changed me; now internship is 25% done and I'm watching myself change in new ways. Back then I wrote wondering about whether I should aspire to having some kind of secular-spiritual version of love for all my patients. Now I feel like that's beside the point. One of my friends wrote back then that love like that might or might not be a good thing, but either way it's exhausting, and a different job than the one I already have to do.

She was right, as it turns out. The other day I was at work and was thinking, maybe there is still something to be said for the idea that I should love all my patients, but whether or not I should, I just can't, and don't. One of my co-interns says that in some way the definition of professionalism is acting like you care about people that you don't necessarily care about. That might be a little harsh--there is still something about human decency and compassion that I'd like to think exceeds simple professionalism. But right now, it's too much work to love everyone and also get all their discharge paperwork done and lab tests ordered; human decency has to be enough.

I do love some of my patients because they are sweet, or thoughtful, or charismatic in some way. And some of them are so totally insufferable as to become comic and therefore lovable in their own way.

But these days, what moves me through the day is not love. It's something much simpler: I move through the day because I need to get to the end of the day.

Becoming a doctor requires imagining the obvious.

When I was in medical school, I worked hard; I was thoughtful about my patients; I got along well with most of the people I worked with. But my grades weren't as good as some of my colleagues' grades were. They were fine, but more often than I liked, I seemed to just miss the highest grade in my overall evaluations. Sometimes that was for blatantly unfair reasons, other times for reasons I understood perfectly. But most of the time, it was harder to tell why I'd just missed. I spent a lot of time thinking about how to improve, and asking people how I should be improving.

In the last part of medical school I was starting to get it. An ICU rotation gave me the biggest transition: I went from doing some of my worst clinical work (in that I was disorganized and confused in presentations and in my thinking about patients) to some of my best. A couple of other rotations towards the end of medical school also went well. Still, I wasn't sure exactly what had changed, and which of the things I'd done to try to improve had actually worked.

Now that I'm an intern, I still have a lot to learn. And I'm sure I'll still have many stumbles and falls ahead. But I feel more confident in a way that surprises me, but also explains a lot of my medical school experience. I recently realized that it took me until some point between getting my diploma and my 20th hour of internship to actually believe that I was going to be a doctor. In other words, until I became a doctor, there was some part of me that didn't understand that I was actually going to be one.

In fact, even during my first day on call the meaning of the job still hadn't 100% sunk in. I was just trying to keep up, to not do anything wrong, to keep my feet on the floor and my pulse within normal limits. Before I started, everyone told me to listen to the nurses, and especially with a bunch of ICU veterans like the nurses working with me, that seemed like great advice. Nurses were coming up to me and saying, "Mr T's pressure is dropping; I think we should give him a bolus of fluids." Great, I'd say. "Half a liter sound good to you?" I'd say, entering the order into the computer. "Mrs S's potassium is down," another would tell me; "Thanks, I'll order that now," I'd say, looking at the sliding scale to replete the potassium.

For most of that first day on call, this worked excellently. Our hospital's critical care nurses are excellent, my resident and attending were watching closely, and our patients did well.

At some point early in the morning, a nurse suggested another bolus of fluids on a patient. The patient had already had a fair amount of fluid through the day. I started worrying about what another half a liter was going to do to his lungs. "Actually, I'm hesitant to do that," I said to the nurse, explaining my reasoning. Together the nurse and I talked through an alternative plan, and I checked in with my resident. It was a tiny step, a tiny transformation, but I recognized it: actually, I was a doctor. The MD on my badge was more than some iconic token of my education.

Later, as I realized that I understood some of the physiology and basic science of another one of my patient's problems, and that my patient's nurse did not understand it in the way I understood it, I realized that those years of medical school did teach me something. It's not that her education and experience and observations didn't add up to anything. But it added up to something different. Patients are safer and better-served when nurses tell doctors when their medical interventions will cause unforeseen harm, and when they are partners in the conversation about what might be done next. But that doesn't mean that doctors, even new ones, can get away with just relying on the nurse to keep the patient well.

All of this is pretty obvious to an outsider, and probably to most medical students too. But now I realize that I hadn't ever 100% believed that I would become a doctor. That belief, I see now, is a big part of the intangible confidence that some of my colleagues with better grades had. It's part of how they looked like future doctors instead of current medical students. And when I at least mostly believed that I was responsible for being a doctor--as in my ICU rotation, and a couple of others--I did well.

Now I'm a doctor. And I actually believe it. As soon as I started believing it, I became a better doctor, in an instant.

Now, looking back and recalling that a medical student will, 98-99% of the time, graduate and become a doctor, I've been thinking about what part of me wasn't registering the obvious likelihood that I would also soon become a doctor. Some of the answer comes from who I was before medical school. The people who love me the most have always had great faith in me, and believed that I was capable of many things, but I don't think that when I was in my teens and up to my mid-twenties that anyone who knew me well would have predicted what I'm doing now. I thought of myself as an artistic person, and a political person, but not as a scientific person, nor as a person who would ever become such a normal thing. Willie Nelson instructed, "Mamas don't let your babies grow up to be cowboys"--instead, he sings, "make 'em be doctors and lawyers and such." I never thought I'd be a cowboy, but I didn't think I'd be one of those and-suches either.

Many of my classmates come from medical families. They believed they'd become doctors because the job and the social identity seemed natural to them. They might have resisted it when they were younger, in order to walk their own paths and not their parents', but when they returned to the path of medical training, the terrain was familiar. The medical students who didn't come from medical families often spent their lives, since they were children, working towards the goal of becoming a doctor. I think that many of these classmates, in both categories, always believed in their future as doctors, as soon as they walked into the hospital. They started to become doctors well before they were qualified to earn a medical license. That's actually sensible. You're 66% a doctor at some point in the third year of medical school; at that point you are really more a doctor than not.

When I look back and see the ways I was improving in the last part of medical school, I see that I was becoming a doctor, that the 85% doctor I already had become was directing my actions, even if my consciousness was still too aware of the 15% doctor that I was not.

It seems easier to imagine becoming an excellent and experienced doctor (which, nearly by definition, I am not) than it was to imagine becoming a doctor at all. The next part of my training will require more work, more cognitive strain, and a steeper learning curve than medical school ever asked of me. But in terms of how I see myself, and how I've had to change how I see myself, the hardest part might have just ended.

Post-call

A keep-moving, no-sleep, two-declarations-of-death my-signature-on-the-death-certificates, multiple-family-meetings, this-is-great/I-totally-suck medical intensive care unit call night, in which I had some of my best and my most horrible times in my medical training so far. Post-call after a night like that--not like I've ever had a night quite like that one--I'm always emotionally raw.

Ms H and I have our call schedules off sync right now; she's on call in another MICU tonight. So I'm alone after a long nap; wandering through Harvard Square in the hot summer night, and now at home, everything seems beautiful or tragic or profound or all of the above. A pair of young guys singing bluegrass harmony in the square; a schmaltzy tribute to Paul Simon on TV; the Hemodynamic Cat stretching out on the bed. Pop songs make me cry. Time for bed. More soon.

The bag kills the fear. The bag is the mindsaver.

Above: retro/vintage flight bags from KLM and Aeroflot, from inretro.net. Below: my bag..

Today, I bought a bag, and I fell in love with my bag.

My bag is a dorky bag. I wouldn't buy or wear it under other circumstances. It's like a wierd zipper-heavy backpack-influenced re-creation of airplane bags that the airlines used to give out in the 1960s, but without the cool retro airline logo design.

REI calls it a "Boarding Bag"; like its predecessors, it's designed to be a small carry-on bag that holds the stuff you want on an airplane journey. Probably only someone who was a little worried about flying would buy such a thing. I didn't buy it for flying. I bought it for the hospital. But I did buy it because I was worried.

To explain this dorky-bag purchase, I must first explain that among medical students, interns, and residents, there are white coat people and there are bag people.

White coat people take their notes and reference books and PDAs and energy bars and reflex hammers and shove them all into the various pockets of their short white coats. The very disciplined or the wildly neglectful can get away with this easily: either you pare your carry-around stuff down to an incredibly small amount of stuff, in which case your white coat can easily handle it; or you simply leave all your stuff at home and try to get by without it. (In which case you never look anything up unless you're sitting at a computer terminal, and you test your patients' reflexes by hitting them with the end of your stethoscope.)

The much more common approach is to jam your pockets full of as much stuff as you can get into them--and at my hospital, the pockets are really big, and durable. A woman at the education office said, "I had students show me how big the other hospitals' white coat pockets were, and then I went bigger." My hospital is nothing if not scrappily competitive.

Unfortunately, this creates two more problems: the gunfighter problem, and the water-carrier problem. Because there is so much stuff bulging out of your pockets, you have to walk around with your arms out, like a gunfighter, or a police officer. Also, the stuff is heavy and usually poorly-balanced, and weighs down on the doctor-in-training's shoulders and back, leading the unfortunate coat-wearer to walk around burdened as if constantly carrying water from a well.

For these reasons I've almost always been a bag person. But my bags are usually too big. For instance, I have a big black messenger bag that can carry a whole desk inside of it, and I'm a little bit of a pack rat, so that by the end of a rotation the bag usually does actually have about as much in it as my desk at home has on it. That means that the bags are heavy, and therefore they solve only the gunfighter problem but not the water-carrier problem.

Worse still, I'm constantly having to leave the bags in places like underneath desks in nursing stations, or in call rooms, because I need to go do something where I don't want the extra weight. Or I take the bags off when I'm examining patients, in which case I end up leaving the bags in patients' rooms. Having to come back into a patient's room to retrieve my stuff is a little embarrassing; it seems like a pretty amateur move, and not very confidence-inspiring, especially in terms of my confidence in myself if not for my patients' confidence in me.

I saw an intern this spring with a bag that seemed to solve these problems. Small enough to keep with him, large enough to carry the right amount of stuff, it looked just right. I asked him where he'd got it; and today, I chose this bag as my version of it.

Afterwards, I kept looking at the bag; looking inside it again to think about what I would put in its pockets; zipping and unzipping its various compartments. I would be able to put private personal things in private personal places, my notes in easily accessible places, and my reflex hammer somewhere handy. I could carry my medicine manual and my energy bars and my headache medicine and a little bottle of water. But the bag won't carry more than that--so I don't think I'll be able to jam it so full of stuff that it will become unwieldy and impossibly heavy, like most of my other bags.

I was so in love with my bag that it became clear that my love had gone far beyond the bag itself. My bag had become my metaphor: it would give me organization, control, and my own little secure space within the hospital, even if it is only about 9 inches by 12 inches by 4 inches. Seeing all of these things in my bag, I realized not only why I loved my bag--or at least, the idea of my bag--but also what I had been fearing the most about internship. I fear becoming disorganized; losing control; and never having a space of my own. The first two might harm my patients; the third will make me crazy. Until now. Now I have my bag. Now I need not fear, and I will not. Because fear is the mindkiller.

"Found Down": HMS/HSDM Commencement speech

"Each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?"
Photo: rescue staging area after Hurricane Katrina.


...More to write about graduation soon (it was yesterday, June 7). First, here's the speech I gave at the commencement ceremony of the Harvard Medical School and Harvard School of Dental Medicine.

I’m going to start with a story. It starts when a man falls down on the sidewalk. He might be drunk, or he might not. He might be unconscious because he fell, or he might have fallen because he became unconscious. Hopefully sooner than later, someone realizes that he has fallen down.

The call to 911 comes from the first person to realize this and to care. Next comes the ambulance crew, and even the cars that get out of the way when the siren goes on. As the story continues, there are triage nurses and doctors, x-ray technicians and respiratory therapists. Maybe the man found down has a strange rash, goes to cardiac cath, or needs a CT scan; maybe he has blood in one of his eyes, or a shattered bone. There will be more to the story, but this is its essence: a person falls, and in small and large ways, a huge network of people begins to pick him up again.

Today, we step into a new role within this network. But we have already been part of this group of people: those who go to the man found down, and try to help him up.

We can’t be too romantic about this story. Almost as soon as the man’s story begins, promises and demands of money start moving through the wires underneath the sidewalk onto which he fell, perhaps even before he has been picked up off of it. But today is not about that part of the story. Today is about what we do because of who we are, and not just who we are paid to be.

Each of us will encounter different versions of this story in our work. A child is frightened of her father. A veteran is overwhelmed with anxiety inside an MRI machine. And a family is just down the hall, waiting to hear the news of an operation, and someone must tell them that the operation went badly. Hundreds and maybe thousands of stories like this are unfolding at this moment, right outside this tent, in the hospital and clinic buildings all around us. And each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?

We’ll have to answer this question day after day. I once heard an ICU nurse in an urban hospital say, “All of our patients have the same chief complaint: found down.” July’s novelty and excitement will be followed by February’s bleak repetition. Just about any hospital has many people found down for reasons that are easy to diagnose, but can seem impossible to solve.

To respond to this sometimes relentless suffering, we’ll have to push back against huge impersonal systems, even when those systems beat us back again and again. And we’ll sometimes have to forgive terrible human frailty even as that frailty pushes us to our limits of forgiveness. And so nearly all of us will succumb to frustration and even cynicism from time to time. This is nothing to be ashamed of, as long as we don’t wallow in it, and as long as we don’t mistake bitterness for truth. We are graduating from medical school, not saint school.

Nonetheless, we can hope to meet the basic moral standard of looking towards suffering instead of away from it. In clinics and hospitals, in our personal lives, and in research and policy, we’ll constantly face this moral challenge. Even the best of us will often fail it. But that should not stop us from continuing to try.

When we do reach this standard, we have one final important task: to avoid congratulating ourselves too vigorously for our own forms of benevolence. Sentimentality about our special virtue as doctors can be as dangerous as cynicism, because it causes us to forget that we are joining something much larger.

Our medical training means that we will bring our expertise, our intellectual curiosity, our readiness to work hard. We can be justifiably proud of ourselves for what we have already accomplished, and we know for sure that the people in the audience today are already proud of us.

But today we also join others—paramedics, nurses, social workers—and dentists—and many others who spend their lives responding to suffering. In the few blocks around us, there are thousands of people like this. And even more importantly, there are many other people who are not healthcare workers, but just caring people who also see suffering and find ways to respond. I came to medical school because of people like this—people who responded to the crisis of the AIDS epidemic in San Francisco, people who taught me about courage in the face of disaster.

In small or large ways, most of us have probably come to sit here today partly because of people like this, people who taught us how to behave in the face of suffering: teachers, friends, family. They have usually taught us by example, often because they cared for us when we were suffering. Some of those people are here today. They have seen us fall; in one way or another, they have found us down and helped us up, sometimes many times. As we graduate, we honor their acts of faith in us. Today we mark a moment in which their gifts to us have come to fruition. Now, we will join them in helping those who are found down.

In brief: Poz blog carnival, internship preparation

1. The International Carnival of Pozitivities was kind enough to include my AIDS vaccine post in its recent round-up of blog posts related to HIV, AIDS, and especially, living with HIV.

2. I went to pick up my Advanced Cardiac Life Support manual from the hospital. Walking back from getting the ACLS manual, I saw a woman and a man walking in the corridor in the opposite direction; the man was in scrubs and was carrying a portable defibrillator. As they passed me, she said, "So, you're going to do the spiel to the new interns, right?" "Yeah," he said. She said, "That's a big one. Like, 200 MDs."

I thought:
--People are preparing for us showing up, and it's a big event.
...and...
--Ha! She said, "MDs!" She meant us! Ha ha ha! ... oh crap! I realized that other people think of us as doctors, more than they distinguish us from other doctors--even when, as in this case, they understand the distinction between us and other doctors. And that means that I won't be just an intern--I'll actually be a doctor also. Of course I know that the two categories of intern and doctor overlap, with intern completely contained within the larger sphere of doctor. But I've been a sub-intern and I can imagine being an intern. Imagining being a doctor seems harder. Even though, as I remember with a combination of delight and dread from time to time, it's actually the same thing.

How I changed, part 2: love and faith

Image: from Harvard Medical School's Countway library: a fifteenth century view of the Antichrist being born by C-section.

* * *

More in how my view of the world has changed since I started medical school, now that I’m graduating:

Before medical school, I used to believe that people were inherently good and that their bad qualities were the product of bad events that happened later. Now I don’t believe that people are inherently anything. Now what I wonder about is whether it is still important to love them.

I understand now that the willingness to try to love everyone in some way is not based on some factual insight about character, but on a large and partly irrational secular leap of faith. For example, when I am feeling nervous about a public speech, one of the things I try in order to summon the best part of myself is to actively think about loving the members of the audience, each one of them. This allows me to try to be my most generous, my most honest, my most enthusiastic. They may not like what I say or how I say it, but if I am in this mood, at least I can be sure that I have given them the gifts I have to offer, as best I can. Loving them is not the same as thinking that they are inherently good (whatever good is), but maybe it involves some faith in their potential for goodness.

At least sometimes, this is how I think I want to be a doctor. And talking about this to Ms Hemodynamics, I said, “I think I need that faith to be a good primary care doctor.”

Ms. Hemodynamics disagrees with this idea. She says that being a good physician means meeting people where they are, whether they’re good or bad; whether they’re good or bad isn’t even part of the question. And she says that she believes that who ever you are, you don’t deserve to suffer, or to be afraid, and that a doctor should believe that; but that a doctor does not need to believe that people are good, and does not need to love them.

I know that she and I both reserve some of our most pointed skepticism about a set of doctors who would at first seem to have much in common with us in their politics and their relationship to the medical-industrial complex. These doctors claim to love people, but actually when you get to know them as clinicians or teachers, you realize that sometimes they love The People more than they love actual people. And one can’t help but think that some portion of them love the idea of being loved by The People more than the idea of actually loving them. The line between The People and actual people is a fine one, but I want to stay on the right side of it: I’m no Ché Guevara, and I’m in no way convinced that The People even exist.

So maybe her approach is the best one: don’t worry about who the people are, or who The People are, and don’t worry about loving them, and definitely don’t worry about being loved by them. Just meet them where they are; figure out what they need; help them get it. When I think about it, this is how I often operate in a day-to-day way.

And yet I think that when I do the best job it is at least sometimes because I have found some kind of love for my patients. This is not always with my most lovable patients. In fact, to persist in trying to do a good job for some of my least loveable patients, I sometimes need to remind myself to try to love them—and that when I do, I often do a better job. This is an active process of trying to summon up some version of Buddhist loving-kindness—again without believing in the larger Buddhist scheme of things. The challenge, I think now, is to love people without becoming attached to the outcome of that love—to not be too upset, for example, when you know a patient is saying one thing to you and actually doing the exact opposite.

“But I love you,” some internal voice of mine has said at a couple of times in medical school with patients I’ve hoped might behave differently, mostly without clear words but just the feeling: “Why are you lying to me and letting me down?”

Given the inevitability of the range of human behavior, including some not entirely palatable kinds of behavior, and the inevitability that some of that behavior will take place in a clinic or in a hospital, it may be too much to ask of myself to love my patients. Or it may not. I’m not sure.

What I think now that is different from before I started medical school is that I don't think that people are inherently good, or inherently anything; I've stopped expecting to be able to find that in everyone. To walk into the clinic expecting something from one’s patients is a sucker’s game, and a sure path to bitterness.

Is unconditional love for my patients the cure for the cynicism that comes from disappointed expectations? Or is it a risk factor for disappointment, and thus, cynicism?

Or, probably most likely, both?