Resilience

Not so long ago, a couple of brilliant new medical students asked me how many notecards I do a day. “Doing a notecard” means quizzing yourself on its contents and making progress in remembering the information it contains so you can answer test questions on the topic. Talking about the number of notecards we do daily is typical shop talk in medical school—everyone is trying to figure out exactly how to learn the mountain of information that makes up medicine. Almost everyone decides early on in their medical school career that the only way to learn what we must learn is with notecards. But, what is the perfect number to do in a day?

I avoided answering those new medical students’ question about how many cards I do a day. I wanted to help but, it’s an unanswerable question. I am not a robot. If I were a robot, I’d do something like 500-1000 notecards a day. But that’s not how life works. Some nights I don’t sleep well. Some days I have meaningless meetings that take up the best study hours. I gotta eat. I gotta move my body. Some days, it’s just too sunny to stay glued to my desk. Sometimes I’m tired and I retain nothing. Sometimes I get bad news and I’m sad. Sometimes I’m sick. Sometimes I’m on fire and I cruise through notecards like a genius.

We talk a lot about resilience in medical school. Here are the typical discussion questions:

  • What is resilience?
  • Why is resilience important?
  • Can resilience be taught?
  • How does one become resilient?

Thinking about notecards led to me some answers. Here they are:

What is resilience? Why is resilience important?

Google defines resilience as “the capacity to recover quickly from difficulties; toughness.” With that definition, it’s obvious that when you’re doing very challenging things like learning medicine it helps to be resilient. Becoming a doctor is a long process and you’re guaranteed to make a lot of mistakes. The only way you’ll make it to the “end” is by becoming an expert in self pep-talks and getting up when you fall.  

Can resilience be taught?

I don’t think so. Not once, ever, has any class, piece of advice, or discussion made me better able to endure a hardship. Every hardship I’ve endured was because I decided to bear it. I had family and friends who supported me along the way, but the healing and “how to do better next time” was mine alone to formulate. But, while I don’t believe we can teach others resilience, I do believe that resilience is learned.

How does one become resilient?

We become resilient by being challenged. The folks who are most resilient are the ones who have endured the most hardship. That’s not to say all people who have faced many obstacles are resilient; it’s just to say that you can’t be resilient if you never face a challenge. If you’ve never failed or been hurt than you can’t know what it’s like to dust off the dirt from a fall and try again. Without challenge, you can’t learn how to adapt your plan as life unfolds new surprises.

This principle is the basis of the answer to the notecard question I was asked. How many notecards do I do a day? I have NEVER, not once, done as many notecards as I hoped to do in a day. Yet, I have passed all my classes comfortably. In fact, not only have I never completed as many notecards as I wanted to…when I started medical school, I didn’t use notecards. Not using notecards was a grave mistake. When I started using them my grades improved by about 5% and, for the first time in my medical career, I had time to exercise, sleep, and socialize a sustainable amount. I switched to notecards ¾ of the way through my first semester of medical school. I was terrible at making notecards. But, I gave them a fair trial because I knew how I was studying before notecards wasn’t working. I had two choice at that point: sink or swim. Swimming involves adaptability. I decided I would rather be an otter than a rock in the deluge that is medical knowledge.

Deciding to use notecards may seem trivial until you consider that I’ve bet around $100,000 (so far) on becoming a doctor. It seems trivial except when you consider that it took me 6 years (of work) from the time I decided I wanted to become a physician to the day I got to decide how to study my medical school material. It seems trivial until you realize that I still have at least 5 years, probably 8, and many licensing exams between me and practicing medicine. The stakes are high. I could have failed upon switching to using notecards. But, I thought it was worth a try and I knew I would fail if I kept up what I was doing.

This past exam (fast-forward to my second year of medical school) was the first time I finally studied all the notecards I’d made for an exam. It’s been a little less than a year since I starting using notecards to study. I’m way better at using notecards than when I started. But, my journey isn’t over. This spring I take the biggest exam of my life (my first board exam – a national exam everyone who becomes a doctor must pass). How well I do on that exam heavily influences what residencies I can apply to and, ultimately, what type of doctor I’m allowed to become. It’s scary. My daily notecard count is only one part of how I will prepare for that exam. The number of notecards I did daily last year, over the summer, and now is different. How many notecards I do today will be different from how many I do each day when I’m in the middle of studying for that looming board exam.

What challenges and failure come to show us is that things can be done in many ways. They also show us that we can only control ourselves. For example, I can’t change how much information I’m expected to know for an exam. I can decide how to learn the information. Resilience is not complaining about something that never could have been. It’s about deciding to make your dream reality. It’s about jumping into the flood, scared out of your mind, with a willingness to evolve until you get to where you’re meant to be.

On Love

When from out of the blanket burrito you’ve created, like extra salsa, your blue eyes emerge, blinking and dazed as if they’ve never seen light. You seem stunned as if you didn’t expect the sun to rise as it has every other day. I’m glad you’re here.

When we each sit, heads bent over our studies, the sun dancing across your hair and alighting on our plants—we created quite a jungle house when we moved in together—I smile before diving back into the world of medicine.

When you scamper away, a mountain goat of a human, taking off when you see a steep incline with rocks on the trail ahead, I chuckle. I’ll find you at the top of the pitch, eyes glistening, waiting. Maybe a kiss before we forge onward. And when we get to the summit we see the world unfold before us. Each of us thinking our own thoughts, but knowing somehow our thoughts fit together like the parts of an ice cream sundae—dazzling all on their own but grander together.

When I’m sitting on the couch, studying or writing, and you ask “Are you hungry darling?” As I light the candle for the dinner table I’m already full.

It’s those times when love seems like such an obvious thing. And, as happy as I am alone, I’m glad you decided to journey with me.

Memory

When it doesn’t occur in an explosion, change often happens in such small increments that we don’t notice it happening. Medical school changed me in both ways. The start of school launched me into a new world of academia. I was pushed to study more efficiently and more than I ever had. I adapted to a new lifestyle. These changes were dramatic but expected. Starting a new job, which is how I view school, is usually that way. However, looking back at my first year of medical school (so far), I changed in unexpected ways that were not obvious in the moment.

Not so long ago I was learning brain anatomy. The topic was interesting and boring at the same time. The individual pieces of information were simple, however, woven together into pathways and functional groups these bits of the brain were quite complex and somewhat indeterminate. As I was considering several parts of the brain involved in forming memories, I found my mind wandering beyond the curriculum. Memory is an interesting thing.

My sister has always had a good memory. She can read a document 3 times and recite in perfectly; this worked well during her acting career. She always remembers things I’ve long forgotten from when we were kids. My memory has never been like hers. As a high school student, I thought that memory was an innate quality. I thought memory wasn’t something that could be trained and changed. I took that belief to college where I worked hard. I’ve always known that most things can be achieved if I work hard enough. Since college and until now, I haven’t thought too much about memory.

Medical school has made me reconsider memory. As I thought about the corticospinal pathway carrying motor signals from the brain and brainstem to the body and the anterolateral pathway carrying temperature and pain signals in a chain of neurons up to the brain, I realized that these things were complicated. But, they didn’t seem as complicated as they would have back in August when I started medical school.

These days, I find myself reading words I can’t pronounce and remembering them. I find myself reading dense documents about the presentation of a disease or the features of a drug and remembering more than I did when I read comparable materials in October.

As I was studying what parts of the brain are responsible for different aspects of memory—working, long-term, emotional—I realized that I have trained my memory since starting medical school. And, while my brain’s approach to remembering is still different from that of my sister’s, memory formation is dynamic. The brain is plastic just like the rest of life. Considering this, I’m curious to see how much my brain will change by the time I reach the end of medical school. Residency. And beyond. 

But, first, time to finish the last 4 weeks of my first year of medical school – hours that will be spent learning many aspects of the central nervous system beyond memory and brain structure.

The Mountains

These days between the hours of studying, the doctorhood quest unfolding slowly and quickly at the same time, I find myself hiking whenever time allows. It’s difficult to describe what I find in the forest as I climb to a mountain’s peak. Some days I go quickly, not observing the trees and moss as I forge up the trail. Other days I step slowly, methodically looking at the ferns and the rocks and the sun rays that scatter across the forest floor.

Sometimes my mind buzzes with thoughts—of friends, family, and school. Of puzzles I still have left to solve or chores that await me when I get home. But, more often as time goes, I find my mind mostly empty. An uncommon feeling in my daily life in town. As I get lost in thoughtless contemplation, the chipmunks make me smile as they scuttle around me and the grouse make me jump as they burst into flight before I see them. The sound of their wings is in stark contrast to the silent trees around me.

I stop for a sip of water partway up a steep stretch of trail. My forehead is crusted with salt from sweating. I feel my heart pounding. The wind picks up and the trees creek and groan. I look up and see their branches waving. Even a brief pause allows my breath to slow before I hoist my backpack to my shoulders again. Onward.

I’ve done enough trails to know which rocks are most likely to make me lose my footing. I avoid them. Mud jumps from the trail to my pants. The trail gets steeper and I shed a jacket layer. Once taking off the layer, I climb higher and the wind gets stronger. I put the jacket back on. It’s a dance of layers—just enough to stay warm, not so many that I roast. I sweat regardless.

As I climb the final pitch to the mountain top I have on my warmest layer—in summer just a windbreaker and in winter a hefty coat. I hike so much, there are many days when I get to the highest rock and there is no view. Clouds never did bother me, so the clearness of the day doesn’t impact my decision to take to the hills. When it is sunny and clear at the summit, the landscape around my mountain stretches away from me. I think about what all the distant hills and valleys have seen, countless stories they can’t tell me.

Some days the wind threatens to push me over as I pause at the summit. On days when I can see the mountains beyond my mountain, I ignore the wind and take time to watch the sunshine. The rolling hills and fields below are a patchwork of cloud shadows and sun patches. Beyond them are the mountains of some other state. When I hike in Vermont, the mountains beyond are always pointer than the one I climbed. The green mountains were scraped by glaciers and, therefore, have softer features than their neighbors in New York and New Hampshire.

I don’t doddle as I descend to my car. My heart is filled by the fresh air of the summit. I’m ready to return to the hustle of regular life by the time I get back to the parking lot. At the same time, as I turn my car toward home, I’m already daydreaming of my next hike. The mountains don’t let me forget them, no matter what adventures I have waiting for me in the lowlands. 

Today I’m Grateful

The past few months have a been a tornado. I’m 3 weeks out from finishing my first semester of medical school. What has “med school” meant for me so far? 4 hours or more of studying a day no matter how many hours I spend in class. Showering the formaldehyde smell out of my hair because I’ve spent hours in the cadaver lab dissecting or practicing structure identification. Discussing the ethics of assisted suicide, abortion, and patient consent. Considering how to evaluate research. Practicing physical exams and asking patients about their health.

But, even on days before an exam, when I’m exhausted and uncertain I know half of what I should, I’m excited to be doing what I do. I know how to feel a heartbeat through someone’s skin. I know how to watch a heart contracting using an ultrasound machine. I’ve held human hearts. I’ve explored their chambers and vessels. I know the path blood takes to and from the heart. I know what makes the heart beat. As the days pass, I know more and more about what makes human bodies function, how the body can break, and what we can do to fix it. For this intimate knowledge of life, I’m grateful.

These past weeks and months haven’t only been studying, despite how it feels at times. I’ve spent time with family. I’ve hiked many a mountain in both the sun, rain, light, and dark. I’ve eaten cake on mountain tops, carved jack-o-lanterns, and shared many a meal and snack with friends. I’ve walked up and down the hill from home to school while chatting with kindred spirits.

Friends new and old along with family aren’t all I’m grateful for this season. I also have a lovely home with a roommate with an eye for creating comfortable spaces where I can sip my mate peacefully. And, I have a partner who enjoys pie as much as I do. Helps keep life in order. Tells me my hair looks beautiful even when it’s greasy and fizzy (who knew hair could be both those things at the same time) and cooks me dinner so I can study.

I feel lucky this season. And, I’m grateful to have a few moments to soak in just how kind life can be. I hope your Thanksgiving is spent with people you care about or, at least, surrounded by tasty food. After all, the stomach feeds the heart. 

Goodbye 20s

Today I turn 30. I find myself in a place I didn’t dream of when I was 20. I live in a world I couldn’t have imagined when I was 10.

I’m in the throes of my first year of medical school. A whirlwind of biochemistry, anatomy, patient evaluation techniques, nerd jokes, and discussions of ethics and why access to health care is a right. But, that’s not all. This morning, I woke to the smell of cinnamon rolls and a bouquet of flowers. Since August, I didn’t just fall down the rabbit hole of medicine, but I might have fallen in love.

October last year, the last October of my 20s, I was forging through medical school applications. Diving into interviews. Wondering if any school would take me. If I was good enough. If I was going to ever be a doctor. I think the feelings I had while applying to medical school aptly summarize my 20s. The 10 years between 19 and 30, I spent self-doubting, reflecting, and growing. The doubt is largely gone now—for that, I’m stoked. My personality won’t allow me to stop reflecting and attempting to be a better, even as I race toward being old, and I think that’s good.

This October comes with its own challenges and misgivings, but there is something surprisingly settling about 30. It helps that a weight lifted when I started school. And though I spend hours daily learning 3-4 letter acronyms that stand for proteins that stand for whole signaling pathways that keep you alive when they work and make you sick when they go wrong, I’m happy underneath it all. I’m happy because I’m exactly where I hoped I would be last year. I’m happy because where I am feels right. It is not often that life follows the course of my plan, so this birthday I’d like to take a moment to celebrate just being here.

Today, I’m grateful for all the people who make me feel loved. I’m grateful for the friends who are there when I need them and who share my joyous moments, who share my love for jokes only a health science dweeb can begin to find funny, and who listen patiently to the latest episode in the chronicles of kombucha making. I’m grateful for the people who have supported me, helped me learn, and pushed me to think differently and be better.

With the joy of being here in mind, bring it on 30. I’m ready for a new decade.

Climbing Mountains

One year when I was young we celebrated my mom’s birthday by hiking a nearby mountain. Our family has loved mountain adventures since our beginning, so it seemed like a perfect way to celebrate another good year.

The hike was beautiful and challenging and magical in the way hours spent in the woods while climbing a slope always are. When we got to the top we settled on the peak rocks to enjoy the view, eat snacks, and let our heartrates drip back to resting. Us kids sat down, pulling out our normal fare—peanuts, bread, cheese, among other easy-to-pack items.

My mom wore a happy smirk as she opened her backpack. First, she unpack a stack of plates and forks. Then came some bags containing several layers of chocolate cake. Then came the Tupperware with the sauce for between the cake layers. And then the whipped cream…She’d also brought sparkling cider.

My mother had secretly packed and carried an entire black forest cake up the mountain. That’s dedication, determination, and the proper way to start a new era.

I’m turning 30 this year, so I’ve been thinking about birthdays a bit because it seems like ending my twenties might be a big deal. I can’t really think of a better way to nod goodbye to my first complete decade of adulthood than cake on top of a mountain. There is something about icing that makes the horizon seem promising and clarifies the path you’ve already trod.

Friendship as a Trendline

When I was young and going through a rough patch with one friend or another, my mother always told me friendships go in waves. Sometimes you’re high on them, doing the most exciting things and seeing each other all the time. Sometimes it’s as though you don’t know each other (except you do, because you remember all the times that are past). I knew she was right, but when I was young I hadn’t had friends for long enough to see what she meant.

These days I’m not old, but I have friends who have been in my life for over 20 years and new ones who just arrived. Each friendship is different; the relationship components undulate as ocean waves do—always the same motion (hi…bye), never the same content (what is said and done, where and when we encounter). It’s only the movement, up and down, that’s constant over these relationships and across relationships.

When I think about friendships as waves, I envision the trendline as straight across with a sine wave tracing the points of each friendship. If you plot every friendship on the same graph, some will have wide peaks and dips, some will have steeper and more frequent slopes. But, regardless of the shape of each wave, when you follow the trendline as a representation of your life unfolding, you find that your time has been filled with moments shared with people you enjoy. Despite all the movement—especially the absences of certain individuals at certain times—you are surrounded by people you consider friends most of the time. In this way, the trendline makes you unshakable when one friendship wave becomes an outliner by dipping too low or dropping off the graph completely. And, also, it’s the trendline that helps you steady yourself if a friend becomes a partner and their friendship wave falls into phase (in sync) with your life wave magnifying your own emotional ups and downs.

For me, the visual of friends as waves (like an ocean view) takes a lot of the pressure off each moment because it makes me see them as part of something larger. It’s reassuring to realize that I can enjoy each crest before it crashes on the literal or metaphorical beach because it will be followed by others.

Making It

The past couple of weeks have been challenging in the same way my first weeks after graduating high school and college or swearing out of the Peace Corps were. Starting a new chapter  because you achieved a goal after hours, days, months, and years fighting for it forces reflection as you hit the reset button. My distilled thought process follows this line, “Well, you’re here, now what?”

When I finished high school and college I was proud, but still unsure of who I’d be or what I wanted to do with my life. When I finished the Peace Corps, I was petrified that I wouldn’t be capable of learning science, getting into medical school, and (ultimately) becoming a doctor. There was so much uncertainty accompanying those transitions. My confidence, not without nervousness, as I get ready to embark on the next phase of the #DoctorhoodQuest is a new feeling for me. Finishing medical school is NOT a guarantee, nothing in life is a guarantee. However, the trust I have in myself to weather the quest unless derailed by forces beyond my control is new and I like it.

I never thought I’d get here, but as I race towards 30 I feel like I know who I am, the values I’ll fight for, and the battles I always avoid. For the first time in the midst of a major professional transition, I’ve focused on setting up all other aspects of my life more than the transition itself. The questions I’ve asked myself include: What do I want my living situation to be like in this phase? Who do I need to visit before school starts? What are my priorities when I have free time? What do I want my work-life balance to look like? What’s missing?

I’ve taken this calm before the storm to bask in the reality that I’m happy. I’ve taken time to think about the things that make me happier and do them or prioritize them. For the first time, I feel 100% content with my professional standing. For once, I have time to focus on every aspect of life. For once, I have a schedule and geographic location that allows me to go hiking multiple times a week and to walk, bike, and run every day if I want.

I find myself asking often, “what’s missing?” Things are always missing, but right now the answer to that question doesn’t include anything major. I have many goals that are years away from being realized. There are things I’d like to add to my life that aren’t even a spark yet. But, for once, I can say “I’ve made it.” I’ve made it to a point where I believe it when I say that life is pretty grand. These days before I take my quest for knowledge to a level I didn’t know existed when I graduated high school and college, I’m enjoying the sunny days and the starry nights of a fresh Vermont summer. I’ve made it to a happy phase and I’m grateful for that.

Home Lab: Kombucha

This winter I started brewing kombucha. Kombucha is a fermented, non-alcoholic drink that (like yogurt) has probiotics that are helpful for your gut. It’s made from tea, sugar, and a SCOBY (symbiotic culture of bacteria and yeast). There are many ways to flavor kombucha, but I use herbal teas—mostly fruity ones.

Kombucha is a little tangy, a little sweet, and a little bitter. When all goes well it’s wonderfully fizzy. The fun part about making kombucha is every batch is a little science experiment. The goal is to produce a drink with a nice flavor combination and delightful carbonation—but it all depends on how happy the SCOBY is. The teas you use, the temperature, the amount of sugar, and the time you wait all influence the kombucha outcome. If you wait too long, the batch turns out very much like vinegar. If you’re too impatient, the kombucha is too sweet (because the microbes haven’t had time to eat it) and flat.

I’m just getting used to brewing in the summer, where the temperature is much warmer and the process goes way faster. Today when I checked my bottles, I had to put each one I opened in the sink because they had so much fizz they overflowed like a shaken soda bottle!

The kombucha process changes the flavor of the tea you use—sometimes for the best, sometimes for the bitter. For example, I DON’T like peach tea, but when I turn it into kombucha it’s quite yummy and not as painfully sweet as I find straight peach tea.

There’s something highly satisfying about cultivating microbes to produce something healthy. Many of us only think of bacteria when we get sick or when we want to kill germs—which makes us forget how many microbes are working for us each and every day. I like the meditation of thinking about microbes as my teammates.

Brewing kombucha has made me think more about the good microbes in my life, and it’s also made me feel better. A glass of kombucha a day, seems to keep the stomach aches away. I noticed this when I traveled in Spain for 2 weeks on vacation recently—many days my stomach hurt even though I was eating healthfully. I think it was a combination of my gut missing kombucha and my digestive system wanting to know where the yerba mate was (mate also changes how you digest food and I drink a lot of mate too). Not entirely by accidentally, the beverages I enjoy daily (mate and kombucha) both help with digestion. When I was younger I used to have a stomach ache almost every time I ate. I almost never do now. It could be growing up. It could be the microbes. Regardless, I enjoy the challenge of making my SCOBY happy so it works for me—I figure one more symbiotic relationship in my life can only be good.