Hello 2025

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The Red Wheelbarrow

By William Carlos Williams

so much depends

upon

a red wheel

barrow

glazed with rain

water

beside the white

chickens

~

2024 was a toilsome year interspersed with joy and success. My themes were quietness, pause, and connectivity. It was the first calendar year spent 100% in residency: the lack of time off, no control over my schedule, and too many hours worked made me weary. Yet, despite these challenges, my year was fulfilling. I took several amazing vacations – a highlight was going to Costa Rica which included a 4-day trek in the mountains. I’ve enjoyed camping, sharing moments with family and friends, and completing my first half-marathon since I started medical school. I added back a few non-medical activities I’d put on hold when I started residency because (back then) I didn’t have the bandwidth for them. It’s exciting to have tangibly more time simply because I’m more efficient than I was in the beginning of residency (hard work paying off). This year I’ve seen my ability as a doctor grow and am proud of my progress. I feel more confident in my clinical decisions and more able to help my patients than ever before. I’ve also started to envision my career after residency – I can’t wait to be an attending physician.

2025 will be the second (and last) complete calendar year of residency. I’ll be halfway through residency on January 1, 2025. On December 31, 2025, I’ll only have 6 months left. 2025 will be a practical year for me. I’m hoping to solidify my medical knowledge and my abilities so I’m ready for residency graduation. By the time I write a post welcoming 2026 it’s highly possible I’ll have a job lined up – amazing how time flies. Yet, while I’ll focus on professional development in 2025, I’ll also work to maximize my life outside of work. On the nonwork side, my focus will be cultivating time with loved ones, embracing non-medical pursuits, and spending as much time outdoors as possible. My themes for 2025 are curiosity, resilience, and gratitude.

Curiosity

Now that I’m settled in Richmond, residency, and my 30s I’ve found that I’ve fallen into a routine of familiarity. This year I’d like to shake up that routine by jumpstarting curiosity. I’d like to see things through new eyes and challenge myself to answer questions I’ve brushed aside because they aren’t central to my daily trudge. I’d like to dig deeper and challenge myself to learn and do new things.

Resilience

Residency is hard and I feel worn down. Further, I find the negative aspects of healthcare sit heavily –examples are healthcare’s money focus and its inequity. When I’m baseline tired because of work I find it hard to flourish in non-professional aspects of life. I think 2025 is a good year to acknowledge how hard residency is and find ways to turn its challenges into strengths. While I don’t have the energy or time to do everything I’d like – I have so many opportunities. I think working as a doctor is a privilege because it allows me to touch people’s lives. I’d like to take 2025 to emphasize the good things residency offers. These good things won’t make up for the negatives but focusing on the good will help me remember that incredible growth occurs during challenging times.

Gratitude

In 2025 I’d like to take more time to be grateful. I’ve achieved my dream – I’m a doctor. I have an amazing husband, a lovely home, and a sunny place to be. It’s easy to forget to be grateful when I’m busy. I’m looking forward to carving out time for it this year.

The Hospital in the Forest

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Looking at the one-story entrance, the building appeared too small to be hospital. To get there, I drove down a neighborhood street. Tall trees lined the final stretch up the hill and then there were several small buildings with several small parking lots. Tall trees stood between the industrial features. The whole hospital was about the size of a city clinic. Tiny but mighty – people could get CT images, surgery, and life-saving medications within the hospital’s walls. There weren’t many specialists available and none on the weekends, but the basics were strong. There was “Emergency Department” in glowing letters on one side and there were hospital beds for patients who needed to be admitted. Though not meeting criteria to be a critical access hospital, this hospital in the forest was the only access to healthcare some people had. It was not as remote as the most desolate places in New Mexico, but the hospital in the forest illustrated the scale of healthcare available to many (most?) rural Americans.

The patients were brave and grateful for care. A large portion of the patients were also frustrating because they didn’t see doctors and didn’t take medications outside of emergencies – thanks to the stoicism of rural people and a lack of access to health resources. The full-time workers at the hospital were a blend of devotion and mediocrity – strengthened by being the only healthcare around while limited by the hospital’s small infrastructure and many slow days on the job. I found myself out of place on one hand, having come from a hospital almost 30 times this hospital’s size. While feeling at home on the other hand, having grown up in rural America.

The hospital also reminded me of the hospitals and clinics of Paraguay. The scale was more in-line with the hospitals of the world. The limited access to specialists also reflected my experiences in Latin America and growing up in rural Vermont. I found myself more interested in the functioning of the hospital in the forest than I thought I would be. When I applied to residency, I limited my search to programs at hospital that had 350 or more beds; this hospital had about 30 beds (a critical access hospital has 25 or less). At larger hospitals there are more patients, more specialists (including medical specialties and surgeons), and more treatment options. In a small hospital like the one in the forest, there is some access to cutting-edge technology but more than anything there is creativity because one must find solutions for problems with fewer resources.

As I settled into taking care of patients at the hospital in the forest, I found myself challenged in a different way than when I was at the large hospital where I spent most of my time. Caring for patients in a low-resource hospital forced me to use the full range of my training. If patients started to decompensate it was on me to figure out why and to what to do about it. If the hospital in the forest didn’t have the treatment that my patient needed, then it was my job to pitch their story and get them accepted to a bigger hospital with more capabilities. If I couldn’t transfer a patient who needed something I didn’t have to a hospital that had what they needed, they’d get worse and maybe die. So, while most days at the hospital in the forest were filled with the bread and butter of medicine (the basic, simple cases), complicated cases required more thought than they did at a large hospital where any treatment my patients needed was at my fingertips.

I felt the ebb and flow of the hospital in the forest. Many days were calm and straight forward. Those days I had so much extra time I progressed rapidly through my non-work to-do list. These lulls made up for the days of insanity when the patient list grew with lightening speed (admission after admission) and my patients were all trying to die at once. The flow was more like that of my days in the emergency room – boomeranging between busy and slow.

When my time at the hospital in the forest ended, I was grateful for the experience. Perhaps the greatest lesson was realizing that I could be happy working at a small hospital. While such a realization may seem trivial, a willingness to work at a small hospital opens the door of possibility. There are so many small hospitals in the US and the world. Knowing rural medicine is interesting to me means that there are now 1000s of miles where I could live that I couldn’t live if I wanted to work at a hospital with 350 beds or more. What a funny thing that I spent years jostling to train in an urban center to realize that rural life has its own set of challenges and joys. I can see myself being happy in either setting in the future. Big, busy hospitals are ideal for learning but now I know they aren’t the only interesting places to work in medicine. As I think about the next steps, the hospital in the forest sits laughing in my mind. It’s laughing because life has a way of sending me to places that I never expected to go.

Lost in Delirium

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The patient was sick. On death’s door kind of sick. They were a nice person – treating all the hospital staff with respect. Saying “please” and “thank you.” Cracking jokes even though they were ill. They were articulate. Earlier in their hospital stay we’d discussed God. They believed strongly in the power of God. The patient explained that they were at peace with their life and were ready to join God whenever he called.

Then one night the nurse found the patient completely naked in their room. At that time, the patient couldn’t remember their name. The nurse was able to redirect them, remind them of their name, and put them back to bed. They were embarrassed by the events the next morning. In the morning, they seemed to still understand what was happening around them.

The next night they became confused again. But, this time, they weren’t better by morning. As the days unfolded, they were usually able to tell me their name. They’d lost track of why they were in the hospital or what the plan for the day was. They didn’t know the month or the year. At times they seemed more lucid and at other times they were so confused that they believed they were on a business trip. Occasionally they were angry. But, more often, they looked scared. They were easily frightened because they didn’t know where they were or what was happening to them.

This patient was a classic example of delirium. Delirium is a state of confusion that waxes and wanes. It occurs because of the unfamiliarity of the hospital setting, the disruptive nature of hospital activity, and the stress of being ill.  Every patient in the hospital is at risk of developing delirium during their stay. Some people are at greater risk of delirium – elderly people, severely ill people, and people with underlying brain illness.

Delirium is complex from a medical standpoint. We try to prevent it but everything about the hospital promotes delirium – from frequent sleep disruptions to the unfamiliar setting and faces of the hospital. Preventing delirium involves encouraging family members to visit, minimizing overnight wake ups for medical care (vitals, blood draws, meds, etc.), and frequently reminding patients of where they are and the date. We try hard to ensure lights are off at night and lights are on during the day (and window shades open). Despite precautions, delirium can still develop. The challenge is that we have no good treatment for it. Overcoming delirium involves the same strategies as preventing it and treating the illness that brought patients to the hospital in the first place. Another difficult aspect of delirium is managing it when it causes patients to become agitated.

When patients are lost in delirium they don’t act as they normally would. They are in a state of confusion. They may scream and cry not because they are in physical distress but because they don’t understand what is happening. They might fight hospital staff or try to run away. They might become dangerous to staff or other patients. They might refuse the medical care they need to get better. Sometimes to keep a delirious patient and staff safe we need to use sedating medications. But sedating medications can prolong delirium. It’s a tricky situation.

Delirium is one of those conditions that takes up a lot of my time as a physician and consumes nursing time but is little-known among people who don’t work in healthcare. In the short term, it can negatively impact patients by making it difficult to care for them. In the long term, it may impact patients’ cognition.  

Everyone should know about delirium because the best way to prevent delirium has nothing to do with medicine. Delirium is most successfully prevented by having family/friends at bedside. Patients who have frequent family/friend visits (ideally daily for multiple hours) while in the hospital are less likely to develop delirium. The reason family/friends are so important is that they are familiar faces. They can help patients keep track of night and day. Family/friends help keep patients’ minds engaged in conversation, games, and other shared activities. Engaging the mind helps keep it from getting lost in delirium.

In the US, it is fascinating how many patients don’t have family members or friends visit while they’re in the hospital. There are many reasons for this, but two important ones are the American focus on independence and our geographic distance from relatives. Many Americans can’t help that they live hours from their family (and even their friends). But, in an era of electronic connectivity, don’t forget that your loved ones need you. Try a voice or video call. Call or visit even if your loved one says they’re fine. Your support might be the reason your loved one remembers their name the entire time they’re in the hospital. And that, though seemingly small, might make a world of difference in their recovery.

Is It Luck? Is It Privilege? Or Is It Something Else?

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She was in my thoughts more than I expected for how little time we’d spent together. She and I crossed paths while I was volunteering for a local organization. We were born the same year. Yet, she was born in Afghanistan and I in the US. She can’t read any language, as she reminded me, women are not allowed to attend school in her country. As a US physician, I’m among the most educated in the world. She has multiple children. I have none. We do not speak any common languages. Despite the differences, I noticed a few commonalities between us beyond our birth year. We are both married. We are both women. We both drink tea.

Soon after meeting her, I read updates in The Economist about the Taliban. Summarized, the Taliban issued more limitations on women in Afghanistan. It is so difficult to be a woman in Afghanistan that the EU has made being a woman from Afghanistan a criterion for asylum – no other qualifications necessary. 

Yet the horrors that I’ve heard about Afghanistan and the complex interconnected history of the US and Afghanistan are not how I want to know this Afghan woman. Life has taught me that the stories the media tell are not the stories of individuals. The negative thoughts and the sadness I have about how different my life is from this Afghan woman I know originate in my biases and my ignorance of her.

I do not know enough to guess what she thinks or feels about her history and her future. I do not know her story while living in Afghanistan. I do not know her story of coming to the US. I do not know what she thinks of her life in the US.

We were born the same year. Was it luck, privilege, or something else that I was born in the US and she in Afghanistan? How can one compare two lives so different? What does she think about when she has a quiet moment? What does she dream of? What does she enjoy? What makes her happy?

I interact with many people who have different backgrounds and cultures. But this woman and I seem even more different than most people I encounter. The Peace Corps taught me that difference is not better or worse just different. It also taught me that what I believed to be laws of humanity were theories – theories with counter theories, and most importantly, not proven to be true or correct. I know this Afghan woman and I have more in common than I can see now while also acknowledging that our views of the world are likely as different as views can be.

As I write this post, I wonder if I will ever have the chance to learn more about her. I hope so. I have grown most profoundly when given the opportunity to learn about new cultures and about new people. It is the diversity of humans that makes us so remarkable. And while I imagine her story is one marred with sadness, I know she has things she is proud of, moments of joy worth remembering, and stories of success. I hope that someday she can choose which stories and things I know about her, rather than my limited knowledge of her culture fabricating a story of her. Reality, I’ve found, is always sadder and more beautiful than imagined worlds.

I’m grateful that being born in the US allowed me to become a doctor and choose my own path. I hope that the US is as generous to her, whatever her hopes and dreams upon coming here are. The future is one we are each molding in our own way. Be it luck, privilege, or something else clearing the path.

Meeting in a Common Place

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Over dinner with a non-medical friend they said, “Even though I will inevitably have a heart attack [in relation to their love of ice cream], I’d rather enjoy a short life than live a long miserable life.” They brought this up even though I hadn’t made any comments about health during our meal. I’ve noticed that since becoming a physician family and friends make comments like this about their lifestyle with a frequency that surprises me. It seems that they feel guilty or defensive because they think I might be judging or evaluating the healthfulness of the life they lead. 

Perhaps more important than highlighting that I don’t judge my friends’ lifestyles just because I’m a physician is pointing out that in my role as a physician, I also do not judge my patients’ lifestyles. Society likes to use guilt to control people and create hierarchies of worse and better. Many health and physical attributes have been used to define people as better and worse. The list of such attributes is long; several common examples are weight, cholesterol level, blood sugar level, and brain functioning. Despite this societal tendency, guilt and creating arbitrary lists of good and bad don’t help achieve health, so they are not part of my practice as a physician.  

My job, especially as a primary care physician, is not to make my patients feel guilty or inferior. My job is to help my patients increase their chance of living a long, healthy life. Health is defined, in my mind, as a physical and mental state where a person can do the things they want to do with as little suffering as possible. My goal is to help my patients avoid suffering, illness, and pain from medical conditions and physical injury. Especially in the primary care setting, I provide my patients with recommendations to optimize their health. But my recommendations are recommendations – they are not law, and they are nonbinding.

Science continues to investigate what the optimal lifestyle is to ensure that one avoids illness and lives a long time. Yet, while we know many things, we don’t know what the perfect lifestyle is. Further, research can not account for the complexity of human experience. It is absurd to think that all people can live the same lifestyle. Individuals have different access to resources, different preferences, different priorities, and different realities. There is simply no universal fit for lifestyle.

When I discuss lifestyle with my patients my goal is not to make them start a different life. My goal is to identify reasonable adjustments that have a high chance of improving their health. For example, I might ask a patient about their typical diet. As I learn about their diet, I might offer education tailored to specific goals – such as reducing salt to help control blood pressure, strategies to ensure a stable weight or weight loss, or adjustments to prevent diabetes. I try to identify realistic adjustments because unrealistic suggestions are not likely to happen (by definition). For example, some of my patients only eat out. In those cases, rather than telling them they need to start cooking, I ask about the menus at the restaurants where they frequently eat and offer suggestions to optimize their health based on the menu choices they have. I might ask patients about exercise, tobacco, alcohol, drugs, sleep, stress, and any number of other things. The process remains the same for each: 1) Where is the patient now? 2) Is there some optimization that can be done? 3) What are the small steps and adjustments that can help my patient reach that optimization?

As a physician I meet my patients where they are in terms of their health goals and health situation. I see our relationship as a partnership where I’m an expert and they are advice seekers. Just as people hire financial advisors as experts and planners for their personal finance, physicians are experts and planners for lifelong health. As a physician I relay what research has shown is important for health; help my patients make decisions about specific medications, procedures, and tests; and form a plan for how my patients might optimize their health.

To my friend who thinks everyone who eats ice cream will have a heart attack – that simply isn’t the case. To my friend who thinks a heart attack is trivial – I’ve met hundreds of people who have had heart attacks and even those who survived were changed forever. So, in a general sense my response is, why not consider a middle ground where one can have ice cream and not have a heart attack? Curious how to do that? Consult your primary care doctor; she’s an expert in health and you hired her to help you reach your health goals.

Reading the Crystal Ball I Don’t Have

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“Will I make it until then?” the patient asked. They were referring to the cancer treatment which was their only chance at long-term survival. Their cancer was everywhere yet, likely, treatable and maybe curable…but only if they got treatment. Their social situation created roadblocks. To be approved for chemotherapy in our medical system they had many hoops yet to jump through and hills to climb.

“I don’t know. I hope so,” I said. My answer was genuine.

The patient signed. They closed their eyes for a long blink. They looked down. They slumped in their chair. Their stuffiness (from lymph nodes so large it was hard for them to breathe) made their breathing loud. The room felt small.

“You’re strong. You’re a fighter. You told me recently you wanted to do everything you could to beat this. We are trying to get you there,” I said. These were truths but they didn’t mean much.

This post could easily be about the inequities of our healthcare system. This patient was a victim of those inequities. But whether everything is going right or going wrong, the truth remains that neither I nor any physician know the future. We have probabilities and expert opinions to guide us. We have previous similar patient cases and the risks/benefits of medications and other treatments to consider.  But as much information as we have, we do not have a crystal ball that tells us exactly what is to come. We make educated guesses which are often right but also have a higher-than-desired chance of being wrong.

What is to come, the outcome, is exactly what my patients want to know. And, if I were in my patients’ shoes, that is what I’d like to know too. When thinking about my patients’ futures, I try to balance hope with reality which (for me) manifests as honesty. If I’m worried, I say so. If I’m confident in their chance, I say so. And, if I’m unsure then I will explain the contrary things I’m considering and why I’m undecided.

I didn’t know if the above patient would make it to chemotherapy. The oncologists (cancer doctors) were not offering this patient treatment when the patient and I had the above conversation. The oncologists felt that the patient had too many other things going on to start chemotherapy. Chemotherapy is hard to endure. One must be physically strong to survive it. One also requires lots of social support.

“We are trying to get you treatment. Remember the next steps we talked about?” I reviewed the follow up appointments and things lined up for the patient before they saw the oncologists.

The patient nodded. They looked out the window. “I’ve been here [the hospital] so long,” they said. They’d been in the hospital for about 6 weeks.

“I know,” I said. “You still have a long road ahead.”

I wish there was a crystal ball like in fantasy books that would reveal my patient’s futures. But part of life is not knowing exactly where it’s going. Part of being a physician is becoming comfortable with uncertainty. Perhaps that’s one reason why physicians study for so many years. Day by day my predictions about my patients’ futures are more informed and more often correct. But, on the opposite end of the spectrum, even the most seasoned physician is sometimes wrong about a patient’s future.

When the patient and I had the above conversation, their survival was unlikely but possible. The sliver of hope that remained is why I reminded the patient that they had told me they wanted to fight their cancer. That is also why, when the prediction is tragic and my patients say they believe in miracles, I say “I hope you’re right.” No physician wants their sad-outcome predictions to come true. Yet, we are obligated to provide our best guess even if it is bad news. As physicians we also plan for all the likely outcomes.

While I reminded the patient of their desire to fight, I also reminded them that if things changed there was an alternative option called “comfort care*.” I reminded them that they could change their mind about their goals at any time. I reminded them that we (their care team) were here to help them on their journey regardless of where it led them.

The only certainty about my patients’ futures is that their care team will be there no matter what. And while patients’ care teams change with work shifts and specialty, the purpose remains the same: to help as the unknown unfolds. Being a physician hasn’t given me a crystal ball to see the future. But being a physician has given me hope. While there are illnesses no human body can overcome, the body is incredibly resilient. Further, the human soul is a force of bravery and grace even when faced with insurmountable challenge. And when I witness these human strengths, my faith in life is renewed.  

*Comfort care is end of life care where the focus is treating symptoms rather than prolonging life. For example, if a patient has anxiety, then we will treat it; or if they have pain, we will treat it. Comfort care is offered to patients who have conditions that will kill them and either there is no treatment or the patient declines treatment. In comfort care we don’t treat chronic conditions such as high blood pressure or diabetes because the focus is to make the patient’s remaining time as comfortable as possible rather than trying to make them live as long as possible. Comfort care is the type of care that people receive in hospice. Hospice is end-of-life care for people whose life expectancy is 6 months or less. Comfort care is not about hastening death, but it is possible that people will die sooner on comfort care than with traditional care because the goal is no longer to cure illness.

The Last Stop on the Bus Line

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I looked out the window. I’d been here before, almost 2 years previously, it was the end of the bus line. Arriving here meant I’d taken the wrong bus. There were several buses with the same number that had overlapping routes but ended in different places. The last time I’d caught this wrong bus was shortly after I moved to my Peace Corps volunteer site in Paraguay. At that time, I was still learning my community and Paraguayan culture. The first time I ended up at this bus line end, I wasn’t sure how I’d get home. The uncertainty made my heart beat faster. I asked the bus driver for directions; he had been able to help. It took several hours but I ended up home, unharmed though slightly frustrated I’d mixed up the buses.

I’d learned so much since I first visited this bus depot accidentally. Since then, Emboscada, Paraguay had become my home. Emboscada was, perhaps, the first place I’d ever lived where I was certain it was home. As the days that added up to the previous two years had unfolded, I’d found a community and made friends. I’d been a schoolteacher and connected with youth over music, English, and dreams. In my Paraguayan community, older friends had died, younger friends had married, and I’d been to parties and celebrations of every variety and magnitude you can imagine.

I looked out the window and I laughed. I was an expert, yet I still took the wrong bus and didn’t realize it until I arrived here at this bus depot. In a few short months I’d leave Paraguay. I’d say “goodbye” to the home I’d found and created. I’d return to my native country and start the Doctorhood Quest. I laughed because arriving at this bus depot wasn’t scary like it had been the first time I ended up here. I knew it would take a few hours to catch the right bus and travel to the bus stop in front of my house. I’d arrive home eventually. My little Paraguayan house would be waiting for me.

This event was about 8 years ago, yet I’ve found myself thinking about it a lot recently. I’ve been reminded of it because I recently turned a page in the Doctorhood Quest that is like what I was turning in my Peace Corps service at that time. I feel settled in my role as a resident physician. I feel comfortable with what kind of doctor I am. I am happy with what I’ve accomplished and look forward to my future goals. I had similar sentiments about my Peace Corps service while I waited for the right bus to pick me up at that last bus stop.

It might seem premature to have such contented feelings about residency. But I know that the remaining 20ish months of residency will be over soon. I have so much to learn in those remaining months. Yet I know I will learn what needs to be learned. For the first time in my journey of becoming a physician, I’m confident that I’m where I need to be. I know how to get home even when I take a wrong turn.

Being an expert isn’t about always catching the right bus, it’s about knowing how to find your way home when you catch the wrong one. It’s about being calm even when things are unexpected. It’s about embracing the journey. It’s about laughing at yourself because experiences that make you grow and challenge you also put you in ridiculous situations.

How ridiculous is it to take the wrong bus after having taken the right one 100s of times? “Quite ridiculous” is the answer. But mistakes are what make us human. We learn from mistakes, even if the lesson is simply a reminder to laugh at ourselves. Life is serious, but not so serious that we can’t appreciate its absurd moments.

Stand Up for Yourself Sister

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“Stand up for yourself sister…because if you don’t stand up, no one will.” This was the theme of my thoughts as I walked home recently. I’d learned this lesson over a series of experiences, most significantly the Peace Corps and the 20ish jobs I had before medical school. It’s a skill improved with the help of pivotal women throughout my younger years who showed me how to advocate for myself (not just others). And it’s a skill I’m always improving.

Medical school forced me to practice standing up for myself over, and over, and over again. Medicine isn’t designed to be kind to its trainees. The journey to doctorhood is fraught with unpleasantries. A self-aware and self-confident person can minimize these annoyances if she chooses to face them and address them as they arise.

“Stand up for yourself sister” had popped into my mind after chatting with a younger co-resident who described several instances where she was asked to do work that wasn’t her responsibility by senior trainees and didn’t feel comfortable saying “no.” These instances were like the time in medical school when I found one of my classmates in the hospital hours after her work was done because a resident asked her to do a non-medical errand (meaning it was a personal favor and had nothing to do with the student’s learning). The student had also not felt comfortable saying “no.”

In both of the above cases, if the junior trainee has said “no” to their superiors they would have been in the right and may have prevented their time from being wasted. Further, both cases were examples of misconduct by the senior trainees as defined by the governing bodies that oversee medical trainees. Because of the hierarchy of medicine there are clear guidelines of conduct designed to protect junior trainees from abuse by senior trainees and physicians. The above cases were not reported to governing bodies.

Weird and questionable situations arise all the time. What I’ve learned is that being confident to say “no” is important. It is possible that there will be ramifications when one says “no,” but if one is in the right it is often worth the risk. Further, reporting unreasonable requests to the governing powers in our institutions is another form of self-advocacy that has the added benefit of helping to prevent others from being put in similar situations in the future. I don’t think it was coincidence that the two above examples happened to female trainees.

America calls itself “land of the free and home of the brave.” I find this tagline misleading. One reason is the different way many fractions of America raise their women and men. Even in a place that screams equality as its core value, many American sub-cultures (including my own) teach their boys to be confident, embrace conflict, ask for things, and demand better. At the same time, these sub-cultures (including my own) teach their girls to be cute, create harmony, strive for pleasantness, advocate for others (especially the weak), and be tactful. The lessons we teach girls are fine except they don’t cultivate the skills girls need to stand up for themselves the way the lessons we teach boys do.

American women from these subcultures are then at a disadvantage in many situations including when they negotiate employment contracts, ask for promotions, and define boundaries in relationships. Of course, many girls and women learn to negotiate and advocate for themselves anyway. But, what I’ve noticed, is that these skills aren’t default from culture in America like they are for men. Many of the women I know who stand up for themselves are self-learned after facing challenges or inequitable treatment next to men. A lucky subset of women are great self-advocates because other women took the time to teach them (despite American culture) in the hope of sparing them some frustration.

There are women who never find a way to feel comfortable standing up for themselves. I feel for these women because I know what it is like to be averse to conflict and scared to speak up. I know what it’s like because that is the default American subculture from which I come. But, like I told my co-resident, we can learn new skills and grow our personalities if we choose to do so.

I’m thankful I invested in cultivating my ability to self-advocate. American women are often amazing advocates for others (such as their children, their parents, their patients, their friends, and many other groups) while being uncomfortable advocating for their own needs. But, advocating for oneself is just as important as advocating for others. There is no reason to believe self-advocacy is a fixed ability or a trait only man can have. Even as I write this, I’m still not as good at self-advocacy as my husband is. Thankfully, I have many years left to practice… You better believe I’m striving for self-advocacy excellence.

35 for 35

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My white hair is coming in faster than ever, but it hasn’t brightened my dark hair yet. It’s only a matter of time before the salt-and-pepper sets in – a signal to the world of the wisdom I’ve gathered. I’ll miss my dark hair when it goes, but I’ll embrace my wise look when it arrives.

When I turned 25, I posted 25 goals for 25. Below I’ve reviewed them, annotated, refreshed, and added to create a new 35 for 35 goals list.

Key:

  • Italic font: the 25 goals I had at 25-years-old
  • Crossed out: 25-years-old goal that I completed
  • Regular font: annotation
  • Bold font: my goals at 35-years-old

35 for 35, listed in no particular order:

  1. Ask for it. Done. REPLACE WITH: Finesse effective negotiation skills. Remember to apply these skills not just when negotiating for others but also when negotiating for myself.
  2. Initiate: Don’t expect someone else to do it. Done. CARRY FORWARD: Initiate: Don’t expect someone else to do it.
  3. Look for opportunities to be helpful. Done. REPLACE WITH: Advocate for underserved and marginalized populations represented within the patient population I serve.
  4. Focus on living in the moment. Note the positive things. Done. CARRY FORWARD: Live in the moment. Note the positive things.
  5. Take time to be thankful. Done. CARRY FORWARD: Take time to be thankful.
  6. Get my novel ready for review. I did this then I threw it out. I have other novel ideas for the future should I wish to pursue that kind of writing again someday. REPLACE WITH: Create a home to call my own. By age 45 that home should include a plot of land.
  7. Rock the GRE. Done plus the MCAT, all my med school exams, STEP 1, STEP 2, and STEP 3. REPLACE WITH: Pass my Internal Medicine board exam on the first try.
  8. Be diligent about journaling. I journaled throughout my time in Paraguay. I lost the habit after I returned to the US until I started residency. I’ve been journaling at least weekly almost since I started residency. UPDATE TO: Journal using daily short snippets and weekly 1-pagers.
  9. Read more. >> I read a lot of medical writing. UPDATE TO: Read more fiction and nonmedical writing.
  10. Focus on health: Eat less sugar. Control portions. >> This is still a goal and a challenge. CARRY FORWARD: Eat less sugar and control portions.
  11. Exercise every day. >> I’ve learned that exercising every day is not necessary or realistic. Exercise is, however, essential for health. Anything related to health is especially hard during residency. My current hypothesis is that residency shortens one’s life expectancy. I’m trying to dampen residency’s effect on me. I’m also trying to be healthy in general. UPDATE TO: Exercise multiple times weekly such that I feel healthy and strong.
  12. Publish consistently on Connecting the Dots. Rocking it. Hit 10 years blogging in 2023. So far, my blog has documented my entire Peace Corps service, my premedical studies and getting into medical school, medical school, and now it’s recording my thoughts as I chip away at residency. CARRY FORWARD: Publish consistently on Connecting the Dots.
  13. Learn Guaraní. >> I know some phrases, never did become fluent. Learned the important words for me. If I return to live in Paraguay I will reactivate this goal. REPLACE WITH: Stay current on the latest medical information relevant to my practice as a physician. Review uncommon and complex topics periodically to keep them on my differential and understanding.
  14. Become fluent in Castellano. >> I made great strides while in Paraguay. I’ve used so much energy to learn medicine since I returned to the US that I’ve lost some of my Spanish. UPDATE TO: Practice and study Spanish to achieve better fluency with a focus on medical Spanish.
  15. Stay in touch with my US network. Now I have an international network which evolves and changes like all living things do. REPLACE WITH: Create more opportunities to connect with family and friends.
  16. Reach out to friends in Paraguay; don’t always go it alone. Done. Remember that time I lost my key in Paraguay? I didn’t have water and needed a shower in Paraguay? Got an upset stomach and asked my Paraguayan friends for the right herb to sooth my stomach? REPLACE WITH: Get involved in several activities/organizations to diversify how I spend my time and to meet like-minded people.
  17. Hone patience. Done. REPLACE WITH: Work on calm, clarity, and patience in the setting of becoming a better teacher of medicine.
  18. Smile more. Done. REPLACE WITH: Take at least one international vacation yearly. Travel abroad as much as is possible.
  19. Learn biology, chemistry, and math. Done. I also learned medicine. REPLACE WITH: Learn to identify more local plants, trees, and birds.
  20. Make listening to podcasts part of my routine. >> I like this idea, but I don’t think it will ever happen given how I live my life. REPLACE WITH: Learn about herbal medicine and explore what role alternative medicines play in helping my patients achieve their health goals.
  21. Solidify a positive self-image. Done. Seems like forever since this was a challenge. REPLACE WITH: Push myself to learn about people who are different than me to expand my horizons and to understand others better.
  22. Listen to understand, not to respond. Done. CARRY FORWARD: Listen to understand, not to respond.
  23. Share more. Done. REPLACE WITH: Protect time to be quiet and reflect.
  24. Let the little things go. Done. CARRY FORWARD: Let the little things go.
  25. Ask more questions. Done. REPLACE WITH: Remain curious. When things become routine remember to be curious about new ways, new views, and new opportunities.
  26. Explore every national park in the US.
  27. Hike the length of Chile (chunking it is fine, though it’d be cool to do it in one go).
  28. Hike the PCT (chunking it is fine).
  29. Visit every state in the US. A visit is defined as: at least 24 hours with 3 meals, one night stay, and at least one activity other than travel.
  30. Explore every country in Central and South America that is reasonably safe for US citizens to visit.
  31. Start traveling to countries in Asia and Africa.
  32. Retrace Darwin’s path on the Beagle.
  33. Cultivate my nuclear family – which will metamorphose as time unfolds.
  34. Attain financial independence by age 55.
  35. Stay open to opportunities in my career. Push myself. Be brave enough to change and adjust as my goals and priorities evolve.

Heat Wave and Other Environmental Concerns

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A co-resident of mine recently gave a presentation on how global climate change is impacting health at one of our residency educational sessions. As someone who grew up in a Vermont family who thinks a lot about the environment, it was a basic talk. Basic as it was, the presentation was effective in starting a conversation about the health impacts of climate at my residency program.

In their wrap-up, the presenter mentioned that there isn’t much we can do as individuals about climate change because it is a systemic problem. As I left the presentation a different co-resident mentioned how they didn’t see the relevance between the presentation and our work in medicine. These comments reminded me of an interaction with yet another co-resident I’d had the year before – when that resident mentioned that they “don’t believe in recycling” when I was talking about recycling and compost programs in Richmond, VA.

This presentation on global climate change came right after a heat spell that broke summer temperature records across the US. In one week, my 3-person team admitted 2 patients for illnesses related to heat exposure. In the post-presentation discussion, my colleagues who work with adults and children mentioned how they can guess a child’s home zip code based on how bad their asthma is. Per those residents, since the bus depots moved to certain neighborhoods to “clean up” the center of the city the children in bus depot zip codes now have frequent asthma exacerbations.

Like most terrible things, the dangers of climate change are overwhelming. To slow the process and fix the problem does require global systemic change and political dedication. But, as Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”

As a child my mom told me stories of how when she was a kid there was trash everywhere on the side of the road. And, while we still see trash on the side of the road, it’s improved a lot since her childhood. This shift occurred partly because individuals stopped throwing so much trash out their windows and dumping trash on the roadside and partly because we established systems to clean up trash. So, the less-roadside-trash-effort was a combination of individual effort and system change.

 “Green Up Day” in Vermont is a concrete example of combining individual and systemic effort to reduce roadside trash. Green Up Day is a yearly event in spring when Vermonters go out with trash bags and collect trash along the roads around their property. The trash bags are put in piles on the roadside and the towns pick up the bags. Because of Green Up Day, Vermont enters summer with minimal litter on the roadsides. Vermont is a state of natural beauty – their ability to keep their state beautiful fuels tourism and protects the land Vermonters love.

Slowing, stopping, and reversing global climate change is a lot more complicated than simple trash management. But the only way to address complex problems is to break them down into pieces. Below is a list of some things we can do on an individual level to help. The below list isn’t exhaustive, revolutionary, or original. BUT it’s a list of things I’ve been able to do despite being a medical resident with a terribly busy schedule, not having much physical or mental reserve, and abiding by a relatively tight budget. I share it with you because I disagree with my co-resident that we can’t do much on an individual level. Think about what could happen if the >144,000 medical residents in the US did these things. Think of what could change if even half of the >300 million people in the US did these things. And think what could happen if we each also demanded environmental responsibility from our networks, cooperations, and politicians.

  • Recycle. Even if you don’t have home recycling collection. Take the time to drop it off at a recycling center.
  • Compost. This can be organized compost or home compost. For example, Richmond has city-operated composed bins throughout the city – there’s even one at the public library. If you own property, you can set up a composed bin or pile of your own.
  • Limit your use of single-use cups and utensils. I bring my bamboo utensils, travel mug, and water bottle to work every day to minimize my use of single use items.
  • Use soaps, laundry detergent, dish soap, shampoos, and conditioners that come in paper containers. You can get bars or powdered soap. BlueLand sells soap tablets that dissolve to make foam hand soap if you don’t like bar soap for hand washing.
  • Get spices from bulk pins or in glass bottles to minimize all the small plastic bottles spices come in.
  • Use reusable bags when shopping, including vegetable bags. Remind your cashiers that you brought bags if they aren’t used to reusable bags yet.
  • Say “no” to plastic bags on your take-out food. Instead, use a reusable bag or no bag at all.
  • Buy things in paper, metal, or glass contains whenever possible. Avoid plastic containers as much as possible.
  • Re-use plastic bags. They’re easy to wash; I promise.
  • Make sure your sponges aren’t made of plastic. Even mainstream grocery stores sell compostable sponges.
  • Walk or bike to work as much as possible.
  • Don’t idle your car when stopped. If it’s hot, just get out of it and go stand in the shade. If it’s cold, stand and wiggle.
  • Think carefully before using single-use equipment at work and at home.
  • Turn off your lights when you leave the room, or you don’t need them.
  • Limit your AC use to what you need. Turn off your AC when you leave.
  • Change your lightbulbs to energy-efficient bulbs. LED bulbs are cheap these days.
  • Use reusable batteries and rechargeable gadgets rather the single use ones when you can.
  • Use paper party decorations rather than plastic ones. I think about sad turtles when I see balloons. I don’t expect you to have the same reaction, but paper streamers are just as cool as balloons and better for the environment.

Want more ideas about what you can do to help slow global climate change? Check out the United Nations’ page on “Actions for a Healthy Plant” at https://www.un.org/en/actnow/ten-actions. Another good page with ideas for individuals can be found at the Milken Institute School of Public Health at the George Washington University: https://onlinepublichealth.gwu.edu/how-to-reduce-climate-change.