what’s that thing on your head

Slowing my pace and breath, my face blooming into the unfortunate crimson red that is my natural post-running state, I noticed the two women standing by the car peering at me.  They were perhaps at the end of an afternoon walk and coffee, with conversation about their working-aged sons in the city, about the jobs from which they have recently retired, potentially fear about my beet-red face.

I notice that they are looking at me a bit quizzically, one woman’s hand frozen on the car door, the other retreating from a quick hug goodbye.  Their mouths are silent, turning upwards until crooked, well-meaning smiles battle the questioning in their eyes.  They must decide that I am something sweet, for the smile triumphs, and they follow my person with their gazes until I pass by, giving a halting smile in return.

I glance back again at these women, taking in the warmth of their meaning.  Thoughts gather in my mind, undulating, until I reach the house, then my eyes catch the mirror as I bend down to splash my face with water.  What is that red thing on my head?

oh my.

My mind bounces back to the course of the run.  Back to the cyclists who stared at me as they whizzed by, the pedestrians looking up and doubling back to confirm what they saw. I see a recognition of foreignness but a clash when faced with my running shoes and mesh shorts, the signs of a summertime pavement warrior mixing with that of a faraway wife.

It was an Indian holiday, a day to ask for the health and prosperity of my new extended family.  I had brought in flowers, dabbed a circle of red powder to my forehead, completed a short, beautiful ritual in a suburban home, where windows framed with hopeful tomato plants and ever-present hum of a lawnmower foster a summer backdrop to my interwoven life.  The women on the side of the road had looked at me with interest, seeing in me a newcomer, something different, curious, a hybrid.  Although I am firmly rooted in this country, and the rituals which I haltingly perform can seem more foreign than the sidewalks and politics of America, that same foreignness is an undeniable and visible part of my identity.  Yet, to be identified as Indian above all other identifiers always surprises me and gives me pause.

Day to day, the Indian pieces of my life slip in and support the rest.  Colorful and spicy, these powerful influences help me to mold me into my next self, taking me into and through the swirling eddies of each circumstance.

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3 am

worry comes in waves.

there is a certain character to the thoughts that appear in dark hours.  they steal in, unwanted yet irresistible, pushing at your crusty eyelids, dilating your pupils with their shadowy, ill-conceived forms.  they are often of worry, of thoughts rationalized and made optimistic or dismissed as absurd in the light of day.  they lie within your brain, sinewy and sticky, reaching their thorny tendrils into the restless interior.  they pluck at your insecurities, encouraging you to emerge completely from sleep into that painfully wide-eyed state of unproductive thoughtfulness.

as you shift and struggle to find a cool patch in the bedsheets, the thoughts encompass your brain and body, ultimately resulting in a long sigh of defeat at any plans of resuming peaceful slumber.  you open your eyes, lie on your back, turn down the volume on the radio alarm so that stories of a mine collapse or gas plant explosion will not scream into the air when morning arises.

these thoughts of worry may be spurred by genuine incredulity at the good things in your present life, of looming changes or obvious uncertainties.  life catches up with you, and your brain reacts by working overtime to create emergency plans in case that life falls through.  in the midst of chaos, the thoughts become organized with a self-destructive yet predictable calm:

step 1: think of something that can fall through

step 2: convince yourself how plausible it is for this thing to fall through

step 3: speak to yourself rationally about why its failure was guaranteed from the start

step 4: consider options that have been tossed aside from the start OR reconsider a radically different plan than your completely conscious self has decided upon

step 5: convince yourself that it “wouldn’t be so bad” to take up those options

step 6: pick one and begin to plan your future in that place, find all of the ways that it could actually *improve* your life

at this point, the light peeking through your windows is no longer that of the streetlamp and you struggle fully awake, resigned to a day in which those thoughts will linger and resurface and be tossed away.

although fortunately a rare occurrence for me, the one positive of such a night is that unlike the insomnia and anxiety prompted by a fruit bat circling above my head in my bedroom (yes, this happened) or of a pager stabbing at my REM sleep with its pointy shriek, this often leads to a newfound realization of those things I value for the quality of my life.  to accept my backup plans for what they are: backup plans.  to work extra hard towards those goals that are well-established and become ever more clear when the radio alarm finally does whisper softly awake.

hello, day.

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40 years and counting

The lines of love are curious.

There is an unseen yet sought-after threshold…a point where the smoky haze of confusion and doubt opens into a verdant and beautiful place, where there is a constancy and a connection of respect.  There is comfort and peace, and a deep agreement about matters that matter, and a playfulness and sillyness about those that simply don’t.

Beyond this line, however, there is still terrain to negotiate and character to build.  It is a garden of potential, one that is secure with ample nourishment from love and common goals, but in which the bounty, array and health of the blooms depends upon further labor.  We drape the vines so that they receive the most sunlight and nourishment, but must tend them so that unruly blossoms do not choke further maturity and growth.  It is a tricky business, carving delicate paths to enhance two lives which are reaching towards one another, careful to maintain the integrity of both but also cultivate togetherness and harmony.

My parents began their own journey through written words, sent between two continents, thoughts and dreams and understanding tumbling between and flowing through the curved script.  They had met at an inopportune time, in a hot Indian city, breathing in the same red dust and omnipresent incense, unaware of each other’s existence until nudged into view by their discerning parents.   A city where time is measured by the appearance of colored laundry on the lines and the milkman’s bellow outside the door, the bright green vegetables hawked on the streets below the apartment complex by the brassy-voiced vegetable-wala.  My mother, famously, was wearing an old sari, her anxiety and dread for the next day’s medical school exam results rippling through her her face.  My father chuckled sheepishly under the weight of his now infamous quip…handing her a red fruit: “An apple a day keeps the doctor away!”

Then the letters, the lengthy phrases, the craft of my father’s penmanship, the unmistakable illegibility of a future doctor etched into my mother’s.  I still wonder if he could read her words, or if somehow the meaning was transmitted despite them.

Then the move to America, the requisite walk-up apartment in Queens, the stories of  “Famous Pizza” with extra chilis on top, a yearning for the spicy food of home, but quickly finding success with work and communities to settle into.

I stood in front of my parents a few weeks ago, raising a glass of champagne for their 40th anniversary, watching them sitting together in the middle of the beige loveseat in the house that has now been home for 30 years.  My father’s green eyes joyously surveyed the crowd of family before them, my mom smiling as she rearranged her scarf and made sure that my father did not knock over her champagne as he sat down.  My father, as he is apt, pulled a thrice-folded piece of paper from his pocket, and recited some “rules for a happy marriage” to the crowd.  As he read them out in his best professorial voice: the virtues of marrying early, doing away with a family-filled wedding and eloping, etc….I realized quickly that they had abided by none of these written “rules,”  yet, their marriage is one of stability, growth, career independence yet personal partnership.

My father will always be the one to don his cap and shoes, get in the car first and buy the garden flowers, but it is my mother who will insist on staying there long enough to choose a variety of colors and fragrances.  Then they will come home, have a cup of tea and take the time to plant them together.

They have drawn their own lines of love.  I hope I can do the same.

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am I an expert yet?

In the field of academic general internal medicine, a far-reaching range of discourse defines our daily reality.  We thrive on diversity, and, as befitting our clinical world of primary care, where we are the gateway for….everything…a breadth and depth of knowledge is encouraged and expected.

If a patient comes to us with Parkinson’s disease, we must initially asses whether it is truly the diagnosis or whether other conditions are mimicking its symptoms.  When the complaint is swelling, we look to several different organ systems as possible culprits.  If seven subspecialists and a prior primary care physician have not found the etiology of a disease, we need to know when to keep looking and when is the appropriate time to stop and help the patient make peace with himself.

In my academic world, my neighbors in my office suite are each generalists in practice, and purse research on: healthcare disparities, obesity in those with mental health disorders, how neighborhoods affect health.  And this just within 10 feet.  Broaden your view to the entire floor of my office, and you will quickly encounter healthcare policy, genetics, diabetes, the intersection of psychology with the treatment of sickle cell anemia and ethics in our global health systems.  It is impossible to be well-read on everything, but that is why the environment of academics is so coveted and stimulating.  Each time I step out of my office, I encounter something that is new and potentially revelatory.

This is the draw and timeless appeal of academia.  The quote on my wall is taken from Albert Szent-Gyorgyi, the 1937 winner of the Nobel prize:  “Discovery consists in seeing what everyone else has seen and thinking what no one else has thought.”  A golden ideal, this swirls above my head as I pour over the details of our latest manuscript or sharply draw in my breath as I receive the response to my article submission.

All the while, my hours are peppered with more tangible questions from my trusting patients, which flow in throughout the day, night and weekend.  I read about this medication on the internet, what do you think of it? they query.  My foot hurts, I have a rash, my blood sugars are our of whack, I have just been so incredibly tired for the past year and no one knows what it means…can I come in and see you?

This quick alternation between the relatively new rigors and stamina required of academic life, and the more familiar patient concerns and grueling life as a health care provider can aid and inform each other, however, their intersection produces a different kind of strain.  I often pass my colleagues in the hallway, those at the same level in training, and we shake our heads at one another while simultaneously considering new projects and that difficult patient and the homework for that extra class we are taking.  Our time burden is noticeably shifted from what it would be if we were seeing our patients full-time, and allows for the flexibility we enjoy in collaborating on papers, traveling to conferences, and taking on extra training.  This fractionaction of time, however, leads to the feeling that I am a student of all and master of none. While anyone can benefit from more practice in his field of choice, our lives force us to feel like novices at everything until we have spent three times as long as someone who has chosen to focus on one part.

For my friends enmeshed in daily clinical care, their work provides new challenges as unique as each patient, and now, several years out of residency, they have become comfortable with their knowledge base in patient care.  On the other hand, those around me who chose to pursue PhDs instead of MDs now have the knowledge of epidemiologic methods and statistics flowing through their veins while I still often struggle to solidify the same content acquired more recently.  I love the multifacted nature of my work, but it can often be a demon – splintering my attention and focus to different skills, requiring years to gain as much expertise in everything as it would have taken if I had just chosen one.

I think I will always ponder that elusive balance of stress and confidence, inspiration and boredom, broad engagement and focus.  It is both being an “expert,” yet having enough of an open mind to look at new means of clinical practice and investigation that I crave.  Am I an expert yet?  I’m working on it, and probably will be for the duration of my career.  Thoughts and advice are most welcome!  Until then, my searching continues.

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TV or not?

A question that has crossed my mind countless times in the past 7-8 years.  When I was a child, I used to be required to ask permission to go downstairs and watch TV.  It would be a somewhat anxiety-provoking task, to have my eyes rake slowly down to the floor while turning my right toe inward in a bashful pose, my entire demeanor the definition of sheepish.  We had one TV, in the family room, which was a thoroughfare for my parents. My Dad would trudge with an armful of starched and ironed shirts from the ironing board in the basement to the closet in my parents’ bedroom upstairs.  My Dad (and later, come to think of it, my Mom) had this habit of slowing his steps at the bottom of the stairs, threatening to stop and survey the shows that I was watching.  There was always a moment of tension, my body would freeze with trepidation as he would shift the shirts to balance over one arm, potentially, if it was Friday night, with a glass of beer in hand, his attention drifting to the colorful screen.  He would stop, foot on the first step, looking over with mild interest and amusement at what could possibly be so engaging.  My muscles would tense, hoping that Jesse and Becky on Full House wouldn’t do something awful like kiss (ugh, no, please) provoking that kind of heart-stopping embarrassment that one routinely experiences as a pre-teen.  This generally led to a swift change of to the Discovery Channel and a program about dolphins or possums or an otherwise acceptable animal.

Even as I grew older and learned to manage my own schedule, I found that if I didn’t rip myself away, this electric box seemed aptly designed to leach time away from my unsuspecting brain.  Minutes slithered into hours of Cosby show reruns, and I would emerge, bleary-eyed and inevitably hungry, suddenly shocked by how much I hadn’t accomplished.  Senior year of high school, after college applications were signed and my fate rested in other hands, when the weather had not yet improved enough to spend long afternoons outdoors, and before the descent of AP exams in May, my after school hours often morphed into a gray haze of terrible commercials and questionable Rachel Ray 30-minute meals.

In college, we did not have a television freshman and senior year, sophomore and junior year it was relegated to the common room which was rarely used.  In med school we had one with full cable and too many channels, and certain afternoons were sucked away into that void.  Residency brought with it a 20-year old TV without cable, and the conversion of my wired antenna to a digital one, replete with threatening commercials about the future of digital cable clearly aimed at the technologically impaired and the post-AARP generation (and me).  Lately, I watch almost everything online, Netflix reaching out with its claws to draw in my relaxing free time to Downton Abbey and Sherlock Holmes.

Despite my obvious aptitude for wasting time and thus immense responsibility that would accompany ownership of a picture box,  there are times when Wimbledon and the US Open, the Olympics and the joys of the Food Network call out to me beseechingly.  Then, I waste countless frustrating hours trying to make ESPN3 work and reloading it when the simultaneous usage of my statistics program, chat window and live replay of tennis prove too much for the poor laptop.

What is the secret of a TV balance?  I’d rather not find myself in my 15-year old white terry bathrobe with a pink ribbon, eating salty caramel ice cream and whiling away the day in front of Days of Our Lives.  But maybe, just maybe, I’ve grown up enough to have one now?  Well, maybe next year…

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thriving in the shadows

There is a fern that sits in my window, bright green in color with spiky leaves that have, on occasion, painfully sunk themselves into my fingertips.  This window is a hospitable place for the fern, with his brethren the rubber plant, the oxygen-generating calathea and a flamingo flower that shoots curled hot pink flowers out from behind its leaves.  This is the first time that I’ve had a place where abundant sunlight meets space inside the house, where these plants have thrived and where they stand on the silver shelving glossy and healthy.  They reach out to fill the space, sprawling towards the window, the fern’s tentacles reaching for the glass and resting on the window ledge to capture the maximum sunlight.

There is another plant, one for whom the sunny window is too bright, too glorious.  This one looked sickly and dry until moved into the relative shadows.  It is not a nocturnal creature, nor does it shun others.  It simply cannot stand the hot rays shining forth with all their intensity.  Moved into the shade, watered less, but loved just the same, it has dropped its brown leaves in favor of long, pointed, dark green ones that now even envelop a delicate celery-hued green flower.

I see this behavior in people as well.  At first meeting, they are shy and subdued, for me, often in the confines of an office with shiny instruments and the light scent of hand sanitizer.  I whisk in, white coat whirling, making space between the absurdly placed chairs between and the brown exam table and the slow computer containing data from all reaches of their distant past.  With new patients, it is often a blessing to have a blank record.  I sit and face them and listen.  They start tentatively, some with a list, others lamenting the loss of their old doctors, many moving from far away places to start a new life.  Often it is in times of great stress, handing over trust in healthcare to a little girl with a stethoscope, thoughts swirling about damage from the movers, children settling into a new school, meeting with a new oncologist, their new job in banking or HR.  It is with this ultimate trepidation, the apprehension lining the corners of their eyes, that they come to me.

Sometimes even when they leave I do not have a sense of their impressions, polite thank yous and great to meet yous peppering the widening space between us as they turn down the carpeted hallway to the checkout desk.  Sometimes it seems that they are still trying to figure out how we will fit together, what will happen as the months go on.  They look searchingly into my eyes, sometimes surprised at the answers, waiting until 15 minutes or so into the visit to shed tears, to confess the spiky things in life which are likely to blame for their stress and their ill health.  There are fights with only children, recent separations from long-term partners, bouts of anxiety at a diagnosis and workup.  All poured out to a young stranger with green-rimmed glasses and a sympathetic expression.

They walk out with papers in hand for tests and notes for work, with my explanations and guidance swirling around in their heads.  I have no idea how much they will remember of it, if they will think of questions later (I would).  I often call back, with new information, or to remind them of a test, to check on them after they’ve had a particularly tragic life experience.

I understand those quiet and reserved few because I am also this way…I shy away from the harshness of blinding light and attention, preferring to organize and direct in the penumbra.  These patients thrive when they are able to go home and process, take the time to weigh actions and consequences, to talk to others and process instructions.  They are the ones for whom I cannot tell the initial reaction to my words, or my presence, who communicate with me but not excessively, who quietly have tests completed and wait on the results.  They are also the few who ultimately write emails and cards, who bring presents thanking the office and their doctors for our care.

Caring for people requires entwining flexibility with persistence, and adjusting the pace of change to the individual.  I have a long way to go to be as excellent as I want to be, and I anticipate this will always seem like a remote goal.  As much as we learn there is always so much more.  I know, however, that the episodes of listening and action lead to understanding and development toward individual success.  These are the true origins of personalized medicine.

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flight maneuvers

I have been traveling more than usual lately – conferences and visits to friends, weddings and family celebrations.  There is a certain sentence that, declared by the chief flight attendant at the beginning of every flight, while all of us are shifting in our seats, placing airport-purchased bottles of water and sandwiches with too many onions in our carry-ons stowed safely within reach when the flight begins.  “This will be a completely full flight.”  Wonderful.

There is also the chance to meet new and different people each time we ascend that thoroughfare to the plane.  Some have conversations spanning whole trips, meeting new acquaintances, sharing stories about successful grandchildren and new vacation spots, ending with phone numbers clicked into smartphones and promises of a future grounded rendez-vous.  The rest of us become somewhat insular, making sure not to have elbows graze past the armrest divisions between seats – a hard boundary causing panic and consternation when threatened.  We retreat into our cubbyholes, pulling out laptops to work, cultivating busyness, pausing for drinks or a particularly breathtaking view of the sunset.

It is when delays and mishaps creep into the fold, barriers between these sovereign seats begin to break down.  Complaints flow across party lines, offerings of food and magazine articles, stories traded about other “better-handled” situations escape frustrated lips.  Quiet people are drawn into conversation, willingly or not, as exasperation can often dissolve the steel of introversion.  It is in these moments that who were not willingly drawn into conversation before put down their papers with a sigh, amalgamate all that they have heard and unwittingly blurt out something infused with disdain as a commentary to all of the above in one sentence.

This may have happened to me the other day.  I was sitting calmly in my window seat, perfectly nice people sitting to my left.  We were chatting briefly, eating almonds offered by one generous outstretched hand, thinking of Italian days in the history of another.  We had left one hour late, one of those delays that begins as 20 minutes, and you watch bedraggled passengers struggling off the plane only to have your anticipation thwarted by “Ladies and gentlemen, I have some bad news.”  There is a mechanical failure.  This inspires mixed feelings.  Ok, well, I don’t want there to be a mechanical failure, but if there is a failure, on a PLANE, do I really want the mechanics to go fix it and then fly on this plane immediately afterwards?

Although half of the plane promptly scurried away and sought out the nearest tall glass of micobrewed happiness, 15 minutes later the flight personnel were back on the PA system, announcing that he mechanics had “solved the problem” and that we would be boarding.  Fantastic.

Plane seats generally make you feel urgent pressure to lose weight.  Not just lose weight.  Dehydrate yourself away to a fraction of your mortal being, so that you may lay your paper-thin corporeal self upon the strangely uncomfortable contours of the seat.  We shifted, smiling apologetically when a limb left our designated space for a moment, pretending to be absorbed in the luggage carts dawdling outside the window.

At last we were off.  A beautiful, sunny, hot day, the sky was clear, the neighborhoods and coastline visible from even such great heights, blue and peaceful enough to inspire daydreams and envy.  I closed my eyes for 5 minutes (literally 5 minutes, as the plane ride was a total of 25 minutes), and suddenly I hear an exasperated voice over the loudspeaker saying something like this.  “Well, folks, for those of you who have been looking out of the window, you may have noticed that you’ve seen the same thing several times.  We’re in a holding pattern, very unusual for this airport” Some muffled words.  “This airport has one runway…and there is a disabled plane on it.  They’re currently offloading passengers, but it will probably take a while longer.”

Ok, fine, a slight further delay.  How long can it take to offload passenge….. “Unfortunately, we don’t have that much gas, as this was a short flight.”  Silence thrums in my ears.  “Worst case scenario, we will have to fly back to Baltimore, get gas, then come back here.”

I don’t need to tell you the rest.  When someone in a position of power says worst case scenario, you pay attention.  My fellow seat-mates and I were contemplating pulling out the lifejackets and making a dive for the beach.  In a matter of minutes, we were turning northwards, on our way back to Baltimore, and after some phone calls and wisdom from fellow passengers, we learned that the reason for the plane malfunction was a tire that had blown out upon landing.  There were calls of “fill’er up!!” chorusing through the plane.

It is here that conversations turned towards a tired introvert’s nightmare.  My row-mate began talking about possible strategies to have avoided this disaster, generally focusing on Italy, and suggesting that they should have driven the plane to the gate, with the flat tire.

Here, all my force of disagreement kicked into gear.  I had been mostly quiet for the flight, tired and slightly exasperated at the length of my journey (a 3 hour plane trip would be extended by about 3 hours).  I began to disagree.  (Bad move).  I may have possibly said something like “Well, would you have driven your car with a flat tire?” I just thought that driving the plane with a flat tire wasn’t feasible because of the weight of the passengers, damage to the plane, and possible loss of control of the steering if the tire wasn’t intact…  Basically, I was trying to say that the airport people probably knew what they were doing.  Why do I try to defend the people who are making my trip look like a 6-hour nightmare?  I don’t know, probably because we have all had to deal with disaster, and you know that people aren’t whiling away time while we fly back and forth over the eastern coastline.  I have this strange tendency to think that people are working to the best of their ability, unless I see otherwise.  Call me generous.

Note to all the introverts.  When you’re tired, and your flight has become a round-trip without you asking for it, when you left your house at 2pm and there is no sign of reaching your destination until 10pm, when your only reading material is a JAMA (Journal of the American Medical Association), and when you didn’t want to be drawn into a conversation in the first place, LISTEN to your first thought.  Smile prettily, eat the rest of your pretzels, and pretend to read about the latest combination of cisplatin and biologics that will cure colon cancer.  An airplane, perhaps, is not the best time to get into an argument.  Especially if you have the window seat.

Truthfully, it wasn’t that bad, but there are those sentences that reverberate in my head long after I’ve said them, the “do-overs” when a tendency towards keeping mum may have served me best.  Sometimes thinking about them make me cringe.  Thankfully it doesn’t happen often, but sometimes fatigue and lack of control of a situation sharpens words into unintended weapons.  Why do some things come out with exactly the wrong intonation just when is the worst time to do it?  I don’t think I will ever know.  All I can do is catch myself the next time it threatens to show itself.  Or chatter away from the beginning like the others.  Next airplane neighbor, be prepared for a rundown of the pros and cons of my new Kindle….

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