What do you want to be when you grow up?

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“What do you want to be when you grow up?” one of my Paraguayan friends, who used to be my student, asked during my last visit to Paraguay.

I paused a moment before answering. I was surprised by the question because he and I don’t often talk about abstract things and because I’ve been feeling awfully grown up recently. “A doctor,” I said.

“That’s it? You don’t want to be a diplomat or someone rich or famous?” my friend asked.

“Nope,” I said.

“Oh, that’s cool,” my friend said. The conversation continued as I asked him about what he wanted to be when he grew up and we discussed more details of what I hope to do as a doctor.

I graduated from medical school on May 21, 2023. I received my resident medical license yesterday. I’m officially an MD! All that remains between me and practicing independently as a physician is residency (and fellowship if I further specialize).

People like to say “it’s hard to believe” when they achieve a particularly hard goal like graduating from medical school. But, let me tell you the truth, I don’t find it hard to believe that I graduated medical school. Why? Because I was there every minute that I studied at my desk and learned how to care for patients in the clinic and hospital. I read every test question and picked an answer. I showed up on time, managed my email inbox, pestered school administrators to get answers, and did voluntary projects to expand my learning beyond the medical school curriculum.

Becoming a MD is a lot of work; I did the work to earn my degree. Becoming an MD is also an amazing quest. I was excited when my patients were cured, I was humbled that so many people allowed me to take part in their journey to death or to better health, and I loved uncovering the mysteries of how the body works and what medicine can do. I’m grateful for every person who helped me along the way – from my family who cheered me on to the patients who let me care for them, from my classmates who struggled and soared beside me to the numerous physicians who taught me. I did the work, but becoming an MD takes a village. There were many people in my village who were my heroes and who guided and supported me as I journeyed through medical school.

The last months of medical school left me feeling awfully grown up. Grown up in the tiring kind of way. My friend’s question helped remind me how much growing is left. And how, somehow, I’m lucky enough to be growing while building my dream. Next stop on the Doctorhood Quest, residency!   

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The Happy Stillness Between

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I find myself sipping mate and gazing over my desk and plants out at a new skyline. Several days ago, I moved to Richmond, VA from Danbury, CT. The move was a grueling 28-hours of loading the truck, driving overnight, and unloading the truck. My partner and I took only a 30-minute nap to get us through the driving, knowing that there are an infinite number of less tiring ways to move, we wanted it done as quickly as possible. Our main hiccup was finding a way to navigate the ~400 miles along the East Coast on highways that allowed trucks because our U-Haul was quite robust. We learned that there is no setting on Google maps for truck routes. Luckily, we know how to read maps despite the prevalence of technology in our lives and found a route using our brains, yes unusual.

We’re mostly unpacked now, just a few more projects to do before we will be completely settled. We’re chipping away at these tasks, such as hanging paintings and donating no-longer needed items. Knowing our apartment is in a good place, my focus has shifted to the next adventure. Later this week we travel to Paraguay to visit my friends there. It’ll be my partner’s first time to the country where I did the Peace Corps and where my mind always wanders when time slows. Slow as it is now.

Medical school, at least as it is organized at my school, is a sprint that comes to a halt not at graduation but at Match Day, several months before graduation. It’s not a bad system. It leaves time for vacation and residency onboarding tasks while also giving us students a moment to enjoy non-medical pursuits before we plunge into the rigors of residency. But, when one is accustomed to a sprint too fast to breathe, as those of us in medical school are, the slowness of these days between Match Day and residency is as strange as a journey to a new, very different country. I’ve read more books for fun these past few months than I have in years. I’ve hiked and slept and pondered life. I started baking again, something I hadn’t done since I returned to the US from Paraguay in 2016. I’ve planned trips and moved.

I wanted to come to Richmond early, many of my peers won’t move to their residency locations until weeks prior to our start date this summer. I’m a person who centers at home, regardless of how new the home is to me. I like moving, but I also like time to settle before I’m expected to excel in life pursuits. I like time to find the grocery store and walk the neighborhoods that’ll be my stomping ground. Yesterday I did both of those things – I found a grocery store which had nice spinach (the primary way I grade grocery stores) and I strolled through a giant cemetery not far from my house with trees that had new, full leaves and singing birds.

It’s beautiful in Richmond and the politeness of the South is a welcome kindness after living in New England for years. New Englanders don’t, for example, say “hi” when you pass them on the street in a city or let you cross the street without threatening to run you over, even though there’s a red light for oncoming traffic. I’m too new to Richmond to have major complaints, but so far, the things that bothered me in Connecticut aren’t present to the same extent. I do admit, I’m not used to having streets named after important people from the Confederacy. I don’t yet fully understand how those imposing names from the past will impact my life though I know they already do and will in new ways here.

Richmond is green and quiet for a city. My apartment is high up without taller buildings around it. It has ample windows. What this means is that I’m surrounded by sun and have a stunning view of the sky. My few days living in Richmond have taught me that it’s a place of expressive skies – which is something I always loved about Paraguay too. The clouds cross the sky with bright colors and exciting shapes. The morning, afternoon, and evening look different in the clouds and sky of Richmond. My apartment, specifically, has a magnificent view of the sunset.

I lived in Washington, DC for 6 years before I did the Peace Corps. And while Richmond is distinct from DC, coming back to the DC-VA-MD area feels like returning home. I’m happy to be back. I’m happy to have arrived when the weather is absolutely perfect, just before the humidity and heat of the summer set in. I have about a month to explore Richmond before I start work. Richmond feels completely different from Vermont or Connecticut. I’m happy to uncover the opportunities hidden in this new place. Opportunity to learn to be an excellent doctor but, also, opportunities to explore life beyond medicine. I’m excited to reconnect with the urban passions I have and to find new ones that suit me in a green, urban home. And small mountains aren’t too far away in Shenandoah. I’m grateful for the slowness of these days so that I can sit with my happiness. Life has taught me that, much like sorrow, complete happiness is fleeting. So, I’m pleased to have time to revel in this happiness storm until the next emotion rolls in.

Goodbye Danbury, CT

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I rose before the sun because that’s what I like to do sometimes. I looked out the window as I sipped my mate. The horizon over the buildings on Main Street slowly changed from black to blue to gray to yellow. I surveyed my plants which sat merrily between the window and me. I watered the dry ones and sipped my mate a little more. I could tell from the sunrise that the day was going to be sparkly and sunny. It was a slow morning, so I didn’t load my backpack into my car while it was still dark to go to the Catskill Mountains as I might have a different day.

Later in the morning, my husband and I crossed Main Street and went to our favorite café in Danbury. They served delicious guayaba pastries and a very good breakfast skillet. Later, I walked down Main Street, which was lined with family-owned businesses. I passed my favorite corner store where I could buy all the ingredients to make chipa. I then passed my favorite Danbury restaurant – a Peruvian place that served ceviche and had the most colorful murals depicting the collision between a traditional Peru and a futuristic one. My favorite mural included a llama and a UFO. Next came the public library where my husband so reverently got a library card as soon as he moved here; his love of libraries comes from his mom, and he takes library cards very seriously. I turned up a side street and walked by the newish office of a nonprofit I’d worked with for a few years. They did many things, but in our work together we strove to increase health literacy among Spanish speaking communities. I then turned up another side street. This street was lined with giant, fancy houses. There were also flowers along the way.

I continued my walk through the streets to a large park. I climbed a small mountain (perhaps better called a hill) and stopped at the lookout. The view was especially good because the leaves weren’t out yet. I saw Danbury spread before me. I could see the hospital where I’d spent the last few years training as a medical student. I was done with my studies there and was preparing to move to a new city for residency. It was odd to look at the hospital from this vantage point at this stage in my medical training. I did this same walk shortly after moving to Danbury. That first time, I remember being so excited to see the hospital view which then foreshadowed the learning I would do there. It seemed that both a million years and only seconds had passed since I first saw this view of the hospital.

Medical school was consuming. Yet, the years I lived in Connecticut and the year I lived in Danbury were filled with many non-school endeavors not limited to having ice cream from many different local shops, exploring the abundant water features in Connecticut’s parks, and trotting more than 100 miles of trails in parks surrounding the city. As I reflected on my years in Connecticut, the sun twinkled around me. I dwelled on my mixed feelings of on one hand being excited to move and to start a new adventure while on the other hand being sad to leave Danbury.

Danbury surprised me.  I didn’t know anything about it before I moved to Connecticut to do my clinical training. The city quickly won me over. Danbury treaded a perfect line between being an urban region reasonably close to New York City while also being far enough from the big city to have many parks and proximity to natural spaces. Many things on my Danbury bucket list remained uncrossed off as I prepared for departure. And, yet, while life in Danbury could have continued, it felt like the perfect time to move. I wasn’t seeking greener grass, the grass was plenty green, just a new place with different opportunities.

There’s nothing fantastic about Danbury like The Mall in Washington, DC or Broadway in New York City. The small details and the community of Danbury held my attention during my time here. I liked the down-to-earth nature of the people in Danbury. I liked the brightly colored murals that dotted the buildings along Main Street. I liked that I could easily find empanada shells, plantains, and all the ingredients for chipa. I liked that I heard many languages in the hospital. I liked that there were many different cultures represented in the parades I was never aware of ahead of time and always got caught in somehow. I liked the green spaces within the town. Thinking about leaving, I’d most miss the people I worked with in the city and in the hospital. I’d also miss having the Catskill Mountains nearby. Those mountains filled my soul with joy each time I hiked them.

I turned from the view of Danbury and the hospital and started walking down the small mountain. I’d started out this walk with the intent to reflect on my favorite things about Danbury and I had done that. Now, it was time to be present. It was spring. I’d done this walk so many times that I knew where to expect the skunk cabbage that was always the first spring plant in the wetlands here. It seemed right that as Danbury was coming alive with spring, I was preparing for my own new beginnings. I knew the seasons in Danbury well. I was curious how they’d compare to my new city many 100s of miles south. I knew they’d be different.

I smiled. I liked how sunny Danbury was and how mild the weather was for a New England city. “Goodbye for now, Danbury,” I thought as I saw a skunk cabbage near the trail. I noted the contrast between the sunlight and tree shadows on the leaves below my feet. I started back toward my Danbury home, not home for much longer but still my home that day. “Goodbye for now, Danbury,” I thought. I watched a robin hop near me. I loved spring in Connecticut.

6 Pieces of Advice for Just-Starting Third Year Medical Students

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Now that I know where I’m headed for residency and recently worked with some just-starting 3rd year medical students as a teaching assistant, I feel ready to offer a few practices that helped me through my 3rd and 4th years of medical school. Years 3-4 of medical school are clinical practice years and years 1-2 are academic years, so the transition between the 2nd and 3rd year is challenging for most students.

My survival tidbits aren’t profound, but survival isn’t that profound either.

In no particular order:

  1. Use a sunrise light alarm clock. You’ll be surprised how waking to light transforms even the grimmest before-sunrise wakeups.
  2. Have a pump-up song and listen to it as you arrive at the hospital each morning. Switch up the song as frequently (or infrequently) as needed to ensure it helps you put on your game face…every…single…time…you…enter…the…hospital.
  3. Work hard, do all your work and beyond, and then strive to leave if you aren’t needed. Of course, only leave if you’re done with your work and it won’t compromise your grade or learning. I call this practicing self-dismissal. You’ll have plenty of time to be in the hospital at all hours during residency and at least you’ll be meagerly paid then, so go home when you’re done during medical school.
  4. Fight for moments to eat if they aren’t given. Try to eat all the food groups, just like you teach your patients to do. I know eating properly seems impossible at times, but anemia and other diet doldrums will make learning harder.
  5. Periodically take a moment to remember why you went into medicine in the first place – it can be a literal moment. This is most important during those periods when you aren’t sure you will survive. You will survive and there’s a reason you went to medical school so try to remember it.
  6. During the busiest rotations you can’t sleep enough, see friends, exercise enough, and study… so pick the two most important ones each busy rotation. It doesn’t have to be the same two each rotation. Know that there are slower rotations where you can do all these things, but sometimes you simply can’t have it all.

That’s it. You got this.

At Long Last, I Know Where I’m Doing Residency

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Last time I wrote, I was waiting for Match Day (the day graduating medical students find out where they’re headed to residency). I’m now on the other side and know that I’m heading to Richmond, VA for internal medicine residency! I’m stoked!

Having never applied to residency before, I wasn’t sure what it would be like when I started the application process last April. Now that the year-long application cycle is done, the thing that surprised me most about applying to residency programs was how hard it was to decide which program/location I wanted to go to most. Let me explain a little bit about how the residency application process works to put my challenge into context. Then I’ll explain my process.

Applying to Internal Medicine Residency

When applying for residency, medical students rank all the residency programs where they interviewed from their favorite to least favorite, and residency programs rank all the applicants they interviewed from their preferred to least preferred. Both the applicant’s list and the program’s list are called “rank lists” because they rank their options in order of preference. Then, a computer program attempts to match the students with the highest program choice on their rank list and the programs with preferred applicants on their rank list – if you’re familiar with sororities then you’ll realize it’s the same system used to place new recruits in sororities.

There are many internal medicine residency programs each with multiple positions to fill, so entering internal medicine is less competitive than entering a specialty with fewer available residency positions (for example surgery or radiology). What this means is that, if they have between 10-15 interviews (the magic number that almost guarantees a match somewhere), US-based MD internal medicine applicants (like me) have a lot of control over where they go for residency. According to my research, most US-based MD students will end up in one of their top 5 internal medicine residency choices. So, I knew the order in which I placed the top 5 programs on my rank list had a large influence on where I’d end up for residency.

Challenge of Forming My Program Rank List

Having the above background, here’s my processes for creating my rank list (realizing every medical student has their own process). You might think that the programs (themselves) would have enough unique features to guide how I ranked them. However, the more I researched and thought, the more it seemed that all my programs were more similar than disparate when it came to almost everything except location. Using program culture as gathered from my interview and academic rigor together, I was able to determine which programs I would rank in my bottom third (well below the top 5). I still had to put all the programs in order from my first to last choice with special emphasis on the top 5. In other words, I felt confident that I’d become a good physician regardless of which of the programs in my top two thirds I attended. I also came to realize that the location could potentially change the course of who I would become as a physician and my future life. This did not simplify things but rather made them more challenging.

Being a geographically flexible person, I interviewed with programs mostly on the West Coast and in the mid-Atlantic region (plus a few outliers) with no preference for one region over another. The geographic clustering came out of a long list of criteria I used to define the ideal place where I’d like to live and was how I determined which residency programs to apply to in the first place. As I continued to research after interviewing, I found that these same criteria (which I hoped to use to rank program locations) were often mutually exclusive. For example, I wanted a location with a diverse patient and physician population that was also close to mountains. My list of comparisons went in a similar fashion with all programs missing several criteria (just different ones). I realized the hard truth that I simply couldn’t have it all when it came to location.

“Great,” I thought. “I can’t have it all when it comes to location and I’m confident that any program in my top two thirds will teach me to be a good physician…Now how do I put them in order?”

Having exhausted external factors to rank programs, I turned to self-reflection on my personal values and how those values might be upheld in the different program locations. Reflecting on personal values is a funny exercise and it’s not one I’ve had time to do since starting medical school (however it was a large part of my life as a Peace Corps volunteer so it’s quite familiar to me). It’s an odd and uncomfortable place looking inward and trying to make sense of the thoughts and feelings zooming around your mind. It’s uncomfortable in a different way than standing in the operating room for 8 hours or getting up at 4am to go to hospital so you can see patients are uncomfortable. I felt lucky and privileged to be in a place where I had enough choice over where I’d go to residency to grapple with something like personal values as a key part of my choice, but it was still uncomfortable.

The curious thing about values is that they form the core of who you are and while they shift with time my experience suggests they don’t change dramatically. Despite going around in circles trying to decide how to rank residency programs, I found myself most valuing the same things that sent me to Washington, DC for undergrad so many years ago: weather, quality of life, diversity, and politics. (I also value challenge, but residency is always challenging so that wasn’t helpful). So weather, quality of life, diversity, and politics are what ultimately determined my residency rank list order. All that hullabaloo to decide on a program based on 4 things that have nothing (and yet, perhaps, everything) to do with medicine.

Like many things in life, I won’t be able to go back and see how attending a different residency program would change the course of my career and life. But, in addition to being thrilled with where I matched, I’m at peace knowing I had a chance to look inward before I cast my dice this time. I find that in America we spend a lot of time looking outward, yet often the answer comes from within and not from without. I try to break this trend and make space to sit uncomfortably for a while to find the answer within when it comes to big decisions. I was successful this time around.  

Waiting Impatiently

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The gray of New England spring hung low as I traveled home from the airport. In short time, March would deliver the snow-rain I know the month for in the region where I grew up. I learned that the cold and gray, which can span 9 months out of the year here, was not for me when I left New England the first time. I stayed away for almost a decade until a desire deeper than my love of sun brought back to the state my parents chose for us so long ago, Vermont. I wanted to become a doctor. Medical school takes a forest of strong trees by your side – it takes a lot of willpower on your part coupled with family and friends to complete. Something made me pause when my medical school acceptances gave me the option to leave New England again. I didn’t leave then, choosing to stay close to my parents, my siblings, and my new Vermont friends. My compromise was a plan to move to southern New England, Connecticut, for the second half of medical school because my school had a clinical campus there and it suited me better than their Vermont campus.

I think the choice to stay close to family worked. As I write this, I’m waiting impatiently because in a few long days I learn where I’m headed for residency and, unless I’m gravely mistaken, I’ll leave New England once again. As a side adventure during the Doctorhood Quest, I scooped up a New England-grown husband. I often wonder if understanding the winters here is an important thing he and I have in common or if it’s just everything else that makes us a good match. I’ve also gotten to see my parents and sister more during medical school than in the almost decade leading up to it. I have good friends who saw me through the worst days as a medical student. I’ve come to call my Connecticut town home, even if the designation is fleeting.

This March’s late rain and snow squall isn’t unique to this region at this time of year – though it would seem other places where snow is unusual are getting slammed, weather patterns are becoming more and more confusing as climate change forges on. And while my roots are familiar with the snow and the cold, a few days ago I returned from 7 weeks in Puerto Rico so the coldness and gray is particularly unpleasant this week. It stands out to me how miserable March is here as I look out my window over my flowering orchids and assorted houseplants, many of which grow as weeds in Puerto Rico. It was at the ripe age of 18 that I learned how much I love the sun and living in sunny places even though I require sunblock, shade trees, hats, and other sun protection to enjoy the sun without turning into a lobster.

On Monday this week, I and many medical students across the country found out we matched into residency. And now, in a typical medical school approach of drawing things out longer than is reasonable and with no efficiency and minimal logic, we are all waiting until Friday until we learn the magic WHERE we matched. The day we learn where we will go for residency is called Match Day. Transitioning from medical school to residency is a boring process that makes little sense, so don’t ask about it. Just know that this week is moving at half the speed of any other week these past 4 years and that my excitement for Friday’s discovery is exploding. My excitement even makes the cold and gray outside acceptable though not welcome. Residency is the next and the last phase of the Doctorhood Quest before I am a doctor. I could, of course, continue onto fellowship after residency but that would be to further specialize. Residency will give me the skills needed to practice as an independent generalist in internal medicine (in my case, those pursuing other medical paths might finish residency as surgeons, psychiatrists, or neurologists to name a few areas of medicine that can start after residency).

I’m excited for what’s to come. I made a picture frame for taking pictures at my Match Day party with “Adventure Awaits!!!” written on it. Perhaps you get the Up reference. The picture frame is a party feature that’s a throwback to my Paraguay days. Paraguayans know how to throw a good party. At my Match Day party, there will be an ice cream cake, food, a banner, and streamers. And, of course, I’ll celebrate with my family. I’ve been working towards this day, the day I get into residency, for 10 years. It’s hard to believe I’m here, but it feels real. I can’t wait for it to be Friday, March 17 aka Match Day 2023.

I Don’t Think That Thought Process Means What You Think It Means*

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One day on rounds (the time when physicians, residents, and students discuss the day’s plan for each patient they’re caring for) I commented on a patient’s amazing carpenter veins (colloquial term for veins on the back of the forearm which tend to be prominent in people who work with their hands). Having once put in IVs for a living, it’s hard to shake my deep appreciation for a good vein when I see one. The physician leading the team and a resident both stopped and asked, “What do you know about carpenters?” They asked this as if I couldn’t possibly know anything about people who are carpenters. It was a joking question which is common in medicine when calling out someone’s knowledge gap.

I was completely dumbstruck by their assertion that I couldn’t have interacted with many carpenters in my life. After a long pause, I mumbled something about having put in IVs as part of my work before medical school where I had many carpenter patients with these veins. I was confused because sometimes I forgot that many people assume all med students have no experience outside of university classrooms and have doctor parents, or at least white-collar parents. If I had been less taken aback, I would have told them I know a lot about carpenters in a happy, matter-of-fact tone.

My father is a carpenter. My stepfather and mother don’t call themselves carpenters but they both do a lot of carpentry as part of their regular lives and as part of their work. I, myself, have helped build houses, furniture, and theater sets. In fact, one of the more memorable childhood photos of me depicts an elementary-aged me hammering a bolt into some floor beams. In double fact, my first work was in carpentry helping my parents build our house and working on paid building projects. Which is to say, short of being a carpenter, I feel confident calling myself an expert in what the life of a carpenter is like (without even mentioning all the carpenters I’ve cared for as patients since I started working in healthcare as an EMT years before medical school).

As humans we make many assumptions because it helps us organize the world – for better or for worse. Physicians are trained to come to quick conclusions and identify disease patterns almost as quickly as their patients decide if they like their new doctor or not. This is why your doctor will often only ask four questions before they decide how to investigate your knee pain – their experience has taught them how best to understand medical situations and make a strategy for those situations in a 15-minute appointment. Obviously, there are many medical situations where more than 4 questions are needed, but I say this as an example of how physicians are trained to make even more assumptions than the average person already does.

Often, the assumptions physicians make about medical symptoms are helpful because they lead to quick recognition of life-threatening medical conditions so they can be addressed in time to save someone’s life or allow the physician to develop a reasonable method for exploring the situation further in the confines of an overburdened, short-for-time system like the US medical system. But, as we all hopefully know, assumptions are dangerous when they come to making conclusions about whole persons. Note the difference between assumptions about symptoms versus about people. It’s assumptions about people that lead to biases.

It’s assumptions that play a role in the dark side of healthcare – like black people having their pain undertreated or receiving inferior medical treatment and transpeople receiving poor medical care (Google these if you want to know more, there’s plenty of data. There are also numerous other examples of disparities in health stemming from biases and assumptions about people).

Now, the assumption that I, a medical student, hadn’t interacted with carpenters before was erroneous on the part of my supervising physician and resident, but it doesn’t compare to disparities in care secondary to biases and assumptions. I brought those up in the previous paragraph to illustrate some of the ways assumptions infiltrate medicine beyond what I experienced and beyond their helpfulness in identifying diseases quickly.

What my situation does show is that the mental picture that many people in the US (including physicians themselves) have of who US doctors are is a bit out-of-date. There was a time when almost all doctors were white men, and many were from doctor families. And, today, the percentage of white male physicians is still greater than the percentage of white males in the population. And, separate category, there are still many medical students who have doctor parents or white-collar parents. Yet, while this is true, it is also true that things have changed a lot in medicine.

Today, there are more women than men enrolled in US medical schools. There is also a growing contingency of doctors and medical students who aren’t Caucasian (check out this article). There is also a growing percentage of medical students who will be the first doctors in their families (check out this article and this data)

There was a time when most physicians became physicians without ever leaving school – they’d pass from high school to college to medical school to residency. Today, the average age of people starting medical school is 24, which means that they took 1-2 years off from school somewhere along the pipeline. And that’s the average, meaning a significant portion of people starting medical school are older than 24; people like me, I was 29.

All this is to say that who medical students are now is different from what most of our older patients and seasoned physicians have seen most of their lives. For example, as the carpenter story suggests, my teaching physicians thought I was naiver than I am and had a different background than I do. As a different example, as a female medical student my older patients (mostly the men) think I’m a nurse. I find this particularly ironic and amusing because my husband is a nurse; he has no interest in being a doctor and he is a far better nurse than I ever would or could be given my nature.

Looking at the modern world of medicine and the medical world we want for our future, it’s time to check our assumptions about medical students and reevaluate who they are because their backgrounds may surprise you. And to disclose one of my biases, I think the diversifying of the physician force is awesome and, perhaps more doomsday, the only way we’ll solve many of the medical profession’s problems.

*Attempted The Princess Bride reference, not sorry because Inigo Montoya summarizes my thoughts more often than I would like to admit

Tropical Paradise Has Challenges Too

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“I didn’t have power for 4 months. My daughter got lice because we couldn’t bathe properly; with my long hair, I got them too when I picked them out for her. We washed our clothes by hand. During those months, some areas started to get power and I was able to bring my big items (like bedding) to a laundromat. I lived in a place where I wasn’t allowed to have a generator. But even the rich people with generators didn’t have power because you need gas to run generators and we didn’t have that. I couldn’t keep food all that time because my fridge didn’t work. It was hard… So, I think we all have a little PTSD when it comes to hurricane season,” a Puerto Rican said, recalling her experience during Hurricane Maria. She’d just given me a tour of San Juan’s primary hospital campus, including pointing out the street where they used to have shipping containers lined up to hold corpses during Hurricane Maria because they couldn’t identify them fast enough.

“It was bad. Help didn’t come or it was delayed,” she said. I remembered this; it was all over the news. Hurricane Maria hit Puerto Rico in 2017. You might remember the politics of the US then; there was a lot of news about the hurricane’s effects and how the US government delayed or didn’t send aid. Perhaps 3,000 Puerto Ricans died, but we’re not exactly sure of the true number. Many more lost their homes.

I remember someone asking me if Puerto Rico had been rebuilt since Hurricane Maria when I left for Puerto Rico. At the time, I found the question odd because it’s been 6 years since that hurricane struck. But I have an answer now and have come to realize that it was a good question. The answer is: yes and no. If you visited Puerto Rico today, your first impression would be that it’s a tropical paradise and you might fall in love with the place. There’s a reason why Puerto Ricans are so proud of their home. As a tourist you’ll enjoy both friendly hosts and living accommodations equivalent to those in the continental US. But if you dig deeper than the average tourist experience, you’ll discover that the island has challenges. Despite the beauty of the island and its strong identity people are leaving Puerto Rico. This Washington Post article describes the situation of Puerto Rican’s leaving their home (and people leaving other US territories too).

If you explore beyond San Juan (Puerto Rico’s capital and biggest city), you will see shadows of Puerto Rico’s complicated situation. In the town where I’m staying (and all throughout the island), you find deserted houses on most blocks. A coworker explained that sometimes people just leave their homes and move, often to the continental US. The pay here is lower than in the continental US (often in general) but especially in industries of interest to me such as healthcare. Infrastructure throughout the island, like healthcare, is much like in rural regions of the continental US, which is to say that many people don’t have easy access to the healthcare they need.

My husband and I visited a small island just off Puerto Rico’s coast called Vieques. It’s where the brightest of the 3 bioluminescent bays in Puerto Rico is and that’s why we visited. Being me, I had us walk the 5ish miles from the ferry to the town in which we were staying. Again, being me, I googled to see if there was a hospital on Vieques and the number of beds it has (as I do everywhere I go) just in case I wanted to move there and work. I learned that Vieques doesn’t have a hospital because it wasn’t rebuilt after being destroyed in Hurricane Maria. I also noticed signs demanding that the hospital be rebuilt on a chain-link fence as we walked across the island. On our walk back to the ferry from our Airbnb, a local stopped to offer us a ride because it was hot. We accepted. I can’t remember if I asked about the hospital or if it came up naturally in conversation, but the local explained that the hospital hadn’t been rebuilt and it was a point of political tension. Further, in 2020, a teenage girl died because there wasn’t available transport to San Juan when she needed it and Vieques didn’t have a ventilator to help her breathe. According to the local, even the family of the girl helped manually give her breaths (with a bag-mouth mask which is what EMTs use on ambulances until they get to the hospital), but she died anyway.  

From these conversations, I’ve learned that Puerto Rico has a complexity that can be overlooked as a tourist. Living here a few weeks has not made me an expert (or even a novice) in Puerto Rican anything…except maybe dengue because I’m doing an internship about it and fruit juices because they are delicious. But my time here has allowed me to see that beyond the beautiful beaches, blended frozen beverages, and seafood Puerto Rico has a historical, political, and economic reality. Puerto Rico reminded me of the confusion I had while living in DC: It is odd to me that there are territories that are part of the US where the inhabitants aren’t granted the right to vote and to have congressional representation because it seems rather undemocratic. I don’t know if it would change anything in Puerto Rico if they were represented in US congress or participated in US presidential elections. I also I don’t know if that is something Puerto Ricans want. But, at the very least, I’ve come to see that I have a lot to learn about Puerto Rico’s history, its current governance, and its relationship with the US before I can fully unpack my experience living here.

Remembering

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I don’t remember them because their case was sad, though it was. Nor do I remember them because their case was complex or unique. I remember them because they were a DJ even though they were well beyond middle age. Who knew you could be a DJ when you were that old? Well, I learned after meeting them that you could be.

I learned of their DJ career when I met them briefly after their first stroke. The stroke was thrombotic (caused by a clot that blocked a blood vessel in the brain). Their balance was severely affected, but they were doing well, despite the stroke. There was no way to predict if they’d get their coordination back, but there was hope that they would recover if they made it past the first couple of days after their first stroke without another stroke. There’s the highest risk of another stroke in the days following a stroke.

When I saw them days later, they were not well. Their stroke had converted from thrombotic to hemorrhagic (caused by bleeding in the brain) and they could no longer speak, had limited movement, and were unaware of the world. I was struck by their deterioration. Lost in my reflection on how much the patient had changed and who they were before their brain filled with blood, I included the fact that they were a DJ in my report to the physician supervising me. I think the physician was looking for a focused medical history, but I slipped in the patient’s profession anyway. The physician teaching me paused and then said, “It’s good to get to know something about your patients as people.” It was the physician’s way of giving me positive feedback, but I found myself thinking, that would seem to go without saying.

As I continue my training, I’ve come to understand why this physician pointed out the importance of knowing patients as people: It’s easy to only ask questions related to diagnosis when you’re crunched for time and are actively thinking about what next tests, exams, medications, and treatments you should do to help the patient with their medical concern. Which is to say, the more responsibilities I have as an aspiring physician, the harder it becomes to emphasize getting to know patients beyond their medical conditions.

And, yet, when I do and can learn a tidbit about people’s lives (pets, careers, grandchildren, or whatever they bring up about their life), I’m always grateful I did. Grateful because it helps me remember each patient’s story and because it reminds me why I do medicine in the first place – to help people.

Medicine is awesome because uncovering diseases and making treatment plans involves solving complex puzzles. But the coolness of solving medical challenges is not enough to get me through all the terrible aspects of working in healthcare. My patients do keep me coming back even after the worst days on the job. Even though our interactions are brief, my patients and I have the potential to learn and achieve so much together. And, without a doubt, every patient is a person with an amazing story that I’m excited to hear a tiny bit about.

The “seasoned” DJ will never be a DJ again. This makes me even more glad that my last memory of them included them as a DJ, not just an ICU (intensive care unit) patient with a likely life-ending stroke. I think they’d have preferred to be remembered as a DJ (something they were very proud of) rather than a sick person. I know, if I were dying in the hospital, I’d want the last people to see me to know something about who I had been before I got sick.

Nothing to Do but Be Happy

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The water is so clear it’s like looking through nothing to see the creatures and plants that are stuck in small salty pools contained in the rocks until the tide comes in again. I’m on the edge of the tide, so an especially high wave crashes on the rocks and skuttles across the other pools and seaweed to reach the pool absorbing my gaze. The longer I gaze into the pool, the more I see and the more the patterns swirl. The wind ripples the surface of the pool, such that I must be patient if I want to take a picture – timing my snapshot for when a high wave isn’t threating to dowse me, and the wind isn’t distorting my image.  

I love walking along the ocean’s edge and gazing into the tidal pools – each is a mini world populated by the randomness of being caught in a rock hole as the ocean slides toward center, letting its edges dry for a few hours. The creatures in the tidal pools are waiting for the ocean to return but, until then, they live their lives and try to avoid the birds and others searching the pools for their next meal.

I can’t help but identify with the little stripy fish in the tidal pools. My life, too, is in the tidal pool phase. The daily requirements of living and being a responsible adult remain, but I’m suspended in time – I’m caught between being a med student lost in her studies and residency. These days I’m finishing up my last medical school credits, by design some of the easiest courses I’ve taken. I continue to strive to remember the medicine I know and solidify and learn new things. But mostly I’m enjoying the salty air while I wait to find out where I’ll do residency.

As my husband pointed out recently, “There’s nothing to do but be happy.” It’s hard as a planner to not think of the future. But, when you’re in limbo there is no future only now, the moment. Once I know where I’m destined to train as a resident there will be hundreds of things to sort out – but none of these things can be tackled until I know where I’m headed. I have about a month of not knowing and shortly after that I wrap up my last rotations of med school.

The stripy fish darts around the tidal pool, at first worried I’m going to eat it. It becomes bolder and still as I wait; its attention span is shorter than mine. I peer into the pool. We stare at each other. The sound of the waves is my soundtrack. The sun is sparkling in the sky. By some happenchance of luck and delivery on the part of my planning nature, 7 of my last 12 weeks of medical school rotations are in Puerto Rico, which is even more awesome when you realize these weeks fall exactly in the worst of New England’s winter. I’m studying while I’m in Puerto Rico, but I have plenty of time to explore the island.

Nothing to do but be happy and be present. And it’s not a hard task with the sun shining down on me, the waves and wind fluffing my hair with salt spray, and a party of palms and plants wearing their best green, red, and yellow dancing at the edge of the beach which abuts a turquoise sea. Nothing to do but be happy, what a wonderful situation. Eventually the tide will come in and I’ll be tossed into the wake of wrapping up school and starting residency, but that’s the tide chart of a different day.