Tag Archives: Change

The Social Determinants of Health

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I was walking home from a series of hard shifts. My mind slid back to the first code I ever worked. “Code” is medical slang for when you do CPR and try to get someone’s heart to start again after it stops. My first code was a trauma-code. The story was that the patient lost a literal game of Russian roulette. The injury they had from the close-range bullet was not compatible with life. But the patient was young and when their heart stopped, the doctor overseeing the case didn’t pronounce them dead right away. Their heart didn’t respond to CPR; they died.  

That code was years ago. I hadn’t thought about it too much since it happened. Medicine is full of sad stories. I was surprised that the memory of the code entered my thoughts as I walked home. I wondered why I was thinking of it. I realized quickly: I was angry.

I don’t often get angry when working in medicine. The more common emotions I have on the job are excited, interested, happy, annoyed, exhausted, and sad – sometimes within the same interaction. I’ve only been angry a few times in my ever-lengthening medical career. I wasn’t angry at my first code, so why had I thought of it when I was angry?

On that day when I remembered my first code, I had cared for a patient who was dying of advanced heart failure even though they had the unblemished skin of youth. At first it would seem my current patient and the patient who died during my first code had nothing in common except an early death. But as I thought about it, I realized that they had more in common than it seemed at first.

Both patients would die harsh deaths. The code was fast, and the heart failure would be slow. And while both patients had easily observable health conditions, I found myself wondering if they were dying of those conditions or if they were dying because they were victims of something much greater. Could their deaths have been avoided if society hadn’t pushed them down so many times in their short lives? Were they dying of disease or of the social determinants of health?

The social determinants of health are non-medical factors that influence health; they’re the social and structural realities that shape how people interact and live. The social determinants of health include access to education, food, and secure housing. They include neighborhood exposures (the positive like puppies and playgrounds and the negative like violence and drug misuse). They include skin color, first language, sex, and gender. The list goes on.

I was angry because there was nothing more I could do for the patient with heart failure, just as there had been nothing more I could do for the young patient whose heart stopped all those years ago. Society had failed them. Collectively the two patients had experienced racism, the jail system, drug use disorder, mental health struggles, unfair treatment by employers, barriers to education, and likely countless other obstacles that I did not uncover during my short interactions with them. The patient dying of heart failure was difficult. They didn’t trust the healthcare system and they were profoundly unpleasant to work with. As I learned more about their story, I came to understand that while it is never okay to be mean it is also sometimes easy to see why a person could become mean. This patient had been knocked down so many times throughout their short life that it seemed all they knew how to do was fight. And, unfortunately, they were fighting for their life. And while they had not yet acknowledged it, they were losing. Would it be months before they died? Maybe a year or two because they were young? Maybe they’d be a miracle case and live much longer. I, however, don’t count on miracles.

I was angry because I thought the healthcare system was the last part of society to fail my patient with heart failure. I (and my team) tried to build a case to make them eligible for advanced heart failure treatments, all of which have strict criteria. The criteria are strict because all advanced therapies for heart failure are complex and require incredible collaboration between the patient and their care team, otherwise they fail to work. Among the options for some patients (not all) is heart transplant which has even stricter criteria because organs are scarce. In the end, the patient I was caring for was deemed not a candidate for any advanced therapies. They were not a candidate because they showed a consistent record of disregarding medical advice and missing their follow up medical appointments and prescribed medications.

After days of long conversations with the young patient with heart failure I understood that it wasn’t just personality that drove them to fight against medical advice. It was a fear of death, a desire for independence, and a long history of mistrust built on a life of the system failing them. There were many negative social determinants of health which had worked against them their whole life. I was angry because what is done can’t be undone. Just as death cannot be stopped when it comes calling. It’s unfair when and how death calls; it’s a metaphorical game of Russian roulette.

Being angry about the social determinants of health doesn’t solve them, but sometimes being angry is a place to start. And so, on that walk home and for a little while after, I let myself be angry. Part of writing this post was sorting out why I was angry. The next step is figuring out what can be done to address the social determinants of health. They are numerous and complex so there isn’t one solution and they’re slow to change. The young patient with heart failure reminded me that while I’m focusing on learning the science of medicine right now, I can’t forget the public health and community work I did before I jumped into residency. I can’t forget because when I’m an independently working physician, my patients won’t come to me with just disease. They will come to me with life stories that influence every aspect of their medical care.

Bones on the Trail

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Each year, July 1st is the infamous day when new doctors who just graduated from medical school (called “interns”) start taking care of patients for the first time as physicians. This year I’m among these new doctors. It’ a momentous day for the interns because it’s a huge milestone and a huge transition. Some words that come to mind in anticipation of the experience are “excited,” “terrified,” “happy,” and “ready.”

I’ve been mulling over what I think about starting residency. As I’ve reflected, a story from a hike I did in New Mexico came to mind. I think it captures my mixed feelings of starting this phase of the Doctorhood Quest.

New Mexico, June, 30, 2021

My partner and I arrived at our lodging place in the late afternoon so we had just enough time for a short hike but not so much time that we could dillydally. We looked up some nearby trailheads and settled on one just down the road. We were staying in a flat valley lined by near mountains on one side and far-off mountains on the other. It was spring so even though there was no mistaking that we were deep within the New Mexico desert, the shrubs were as green as they could be. The cactuses were blooming.

We started off walking across the flat valley floor following a road through the shrubs. We stopped often to take pictures of the desert flowers that lined our path and kept a lookout for elk because there were many in the area. We laughed and joked and chatted as we often do when hiking. Our mood ranged from jolly to ecstatic. The beige and browns of the dirt and rocks contrasted against the blue sky; sage-green shrubs and cactuses; and yellows, pinks, reds, and purples of the flowers.

The road neared the bottom of the mountains and narrowed to a wide footpath. We didn’t know the trail, but we had a GPS map and a general sense of the trail’s course. We were timing ourselves to ensure we turned around with time to get back to our car before complete darkness. We knew before starting that we wouldn’t be able summit if we wanted to be home by sunset. It was our first hike together in New Mexico, the western US states, and mountain lion country.

We wanted to have fun while also exercising caution. We’d learn later that trip exactly how scary things can be in the big mountains, but that would be a lesson learned on a different hike. We were experienced hikers, but we’d primarily hiked in New England and never in the western US (except as children under our parents’ watchful eye). The short mountains of the northeast are different beasts than the giants of the US west.

As the trail narrowed, we entered the woods and left behind the shrubs and flowers of the open desert. We soon crossed a small stream. There, on the far side of the stream was an elk carcass in the middle of the trail – it was mostly skeleton, almost picked clean. We paused and became quiet. The bones were a reminder that there were big predators in these woods. We debated if we should continue and decided we would. We stayed loud and watched our surroundings more carefully than before. We were especially attentive to our timing and made sure we got back to our car before darkness fell.

We had the skills and knowledge foundation to successfully complete the hike. The difference was the terrain and responsibility/higher stakes that came with a more complex hiking environment. Hiking in new, more intense territory isn’t such a bad analogy to becoming a resident after being a student – just like with hiking, as a resident I’ll draw on previous skills and knowledge as I take on more responsibility and learn more about my craft.

They Said It Would Change Me Forever: Now Almost 10 Years Later

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I recently returned to Paraguay after 5 years away – COVID delayed my return. It’s the third time I’ve been back since finishing my Peace Corps service there. I also realized during the trip that 2024 will mark my 10-year anniversary of first arriving in Paraguay as a just-starting, excited, and (yet) terrified volunteer. What I remember most about the pre-departure materials and pre-departure orientation speakers for the Peace Corps is how often they said that my service would change me forever.  At that time, I thought their message was a bit sentimental and dramatic.

It would take 27 months for me to understand how right they were – aka it took exactly the duration of my Peace Corps service. I remember returning to the US after more than 2 years away and realizing that the person who lived in the US before (pre-Peace Corps me) didn’t exist anymore.

When I returned from Paraguay after my service, US life hit me like an overloaded moving truck. There were glorious aspects such as being able to throw toilet paper in the toilet rather than into a trash can next to it, no days without running water or power, and not having to run around to unplug everything at the start of a rainstorm in case the power surged. Yet, there were also terrible things about returning. Perhaps the worst was that I lost the community that I’d built over the years, which had become central to my life. I transitioned to a cold region of the US where few people spoke Spanish – two things that made me sad because I find joy in the sun (and its warmth) and the interesting way that Spanish captures our thoughts.

Now having had a decade to think about my Paraguayan self and my US self, I’ve come to understand how the Peace Corps in Paraguay changed me. Thinking about it, I’m not remorseful if I sound a bit sentimental and dramatic because, perhaps, I’m appropriately both of those things.

Having just graduated medical school I can say with a certain amount of pride that my Peace Corps service remains the hardest experience of my life as well as the period where I learned the most (more reflection on my medical school experience to come in future blog posts). This may be because my Peace Corps service came first so I applied what I learned from it to my medical school experience, but I suspect that the challenge the Peace Corps poses is unique and may still have outcompeted medical school even if it came second.

I should clarify that hard doesn’t mean miserable. By “hard” I mean an experience that pushed me to problem solve frequently and on the fly, find new ways to tackle obstacles because every known way didn’t work when I applied it, challenged me to revise and revisit ideas, placed me face-to-face with my own preconceived notions so that I could consider how they may not be absolute truths, forced me to define my values, and required me to look inward both to reflect and to find strength.

When I say “learned the most” I don’t mean I sat and studied all day (I did do that sometimes in medical school though). What I mean is that finding a way to navigate two second languages (Spanish and Guaraní) and to operate in a culture that wasn’t my own required unlearning, relearning, and new learning behavior, vocabulary, customs, traditions, and systems that may have been similar or completely different form my native equivalent and may (or may not) have been in line with my belief system.  

The Peace Corps in Paraguay stretched me to look at things differently. It forced me to decide what parts of myself I was willing to give up to assimilate into Paraguayan culture and what parts I would keep even if they accentuated my otherness. Living in Paraguay was a give and take between, on one hand, being open to new ideas and experiences that required flexibility because often situations were unpredictable or not completely understood and, on the other hand, defense of individual needs and goals that did not fit nicely into Paraguayan life.

The experience of navigating conflicting parts of daily life in Paraguay and shifting self are what changed me so much during my Peace Corps service. It showed me that I have multiple identities that come together to form me and how the pecking order of those identities shifts depending on the situation and the activity I’m doing. Also, the amount of self-reflection I engaged in during the Peace Corps (both as a factor of my strange schedule there and as a byproduct of living in a different culture) is what made me who I am today. No time before or after the Peace Corps (so far anyway) has given me so much time to look inward and examine who I am and how that relates to who I hope to be.

When I returned to Paraguay after 5 years away, I was struck by how much I’ve grown since I finished the Peace Corps (and last visited Paraguay). I was surprised and content that who I am today (a doctor about to start residency) is still grounded in the self I created in Paraguay starting now almost a decade ago. When they said my Peace Corps service would change me forever, they undersold exactly how much. Even now, having done and achieved many things since returning to the US, I find my mind drifting back to those days in the land of the Guaraní as a volunteer and falling back on the strategies of perseverance I developed then to help me through rough patches now. These days, I remain skeptical when someone tells me that something will change me, but I also remain humble and open to the possibility because Paraguay taught me that one experience has the capacity to change everything. 

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!   

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.

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.

Welcoming 2023

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Fog

by Carl Sandburg

The fog comes

on little cat feet.

It sits looking

over harbor and city

on silent haunches

and then moves on.

2022 was a year of achievement. I finished my last exam and clinical rotation of medical school. I applied for residency and got cool interviews. I went to my first medical conference. I got married. I re-combined houses with my husband after he graduated from nursing school and started his first nursing job. I did some of my longest hikes. I feasted frequently.

2023 will be marked by change including finishing medical school and starting residency in a place yet-to-be-determined. I started with Carl Sandburg’s “Fog” because quietness, absorption, and forward movement are the 3 themes I think will get me through the whirlwind of transitions that will unfold in the coming months.

Quietness

Life is loud whether visiting with friends and family, undertaking adventures, or working. In all pursuits, inner quietness can act as a grounding point. This year my primary goal is to cultivate my inner quietness.

Absorption

Residency is a huge leap of responsibility from medical school. It’s the first time I’ll get paid to be a physician, but with more responsibility comes a ton more to learn. In this context, I’m planning to tap my inner sponge and absorb as much knowledge as I can.

Forward Movement

Whether the days are long or short each one is a step forward. This can be difficult to remember in the moment. As I work through the joyful and unpleasant times of 2023, I hope to remember that my efforts are moving me along life’s adventure even if it’s not readily apparent how each piece fits together.

Battle at the Kitchen Sink

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Disclaimer

This is a throwback story from my Peace Corps days. I’ve been thinking a lot about Paraguay lately and decided it was time to share some of the stories I didn’t share when I lived there. I always find myself thinking about Paraguay when the weather gets cold in New England (my current home), because I miss the sun and the mango trees Paraguay reliably had year-round.

Setting

The last quarter of my 27 months in Paraguay as a Peace Corps volunteer. Which is to say, I was very comfortable. At that point, Paraguay was my home.

Battle at the Kitchen Sink

It was grapefruit season. I remember this because we had gone foraging for grapefruits. In Paraguay there’s a citrus season (there’s also a season for every fruit you love… passion fruit, avocadoes, mangos, pineapples…). The Peace Corps volunteers who came before me had shown me how to hunt for grapefruits, so it was one of the first things I showed the new Peace Corps volunteer visiting me that weekend. It was her first time traveling beyond the training community in Paraguay where all Paraguay Peace Corps volunteers in my era spent their first three months learning language, culture, and other skills they might need once they arrived in their sites (where’d they work for 2 years). She was visiting me to learn about what it was like to transition from training to working in Paraguay.

After our lesson on foraging grapefruit, I showed the visiting volunteer (just as the Paraguayans had shown me) how to peel the grapefruit properly. This involved using a knife to carefully cut the peel off in a spiral, leaving a thick layer of that bitter white stuff that hides under the colorful part of the peel. I showed her how to cut a little cone-shaped hole in the top of the grapefruit. Then, how to squeeze the whole thing and suck the juice out until the grapefruit was dry. This is how Paraguayans most frequently eat grapefruit and oranges. It is my preferred method above all methods I’ve tried.

We then had lunch. I took the dishes out to my kitchen sink, which was located outside my apartment in the back under a mango tree. I had running water (which was nice) but my kitchen sink was outside – an unfortunate location on rainy days, but perfectly fine on this day. I set the dishes in the sink and then looked around for my soap and sponge. As with all full sinks, the sponge was hard to find. I went to dig under the dishes to see if it was there. Sitting among the dishes exactly where my hand had just been when I put the dishes in the sink, was a tarantula about the size of my palm.

I don’t know your position on spiders. But, living in Paraguay I developed a set of rules for all home invaders. Spiders were included in that list and my rules for them were as follows: they received the death penalty if they were too big and in my home territory (which included my sink), if they were too close to my bed, and if they were too close to the toilet. If they did not violate any of these rules, I was willing to live peacefully together. The tarantula in my sink resoundingly violated the size rule permissible within my territory.

My heart thumbed. I didn’t know much about tarantulas, but it was the largest spider I’d seen outside of a zoo exhibit. I yelped (sound effects are always part of my life) and then promptly went to find my bottle for fighting invaders (obviously I developed rules for invaders because there were many including ants and roaches). My invader-fighting bottle was a rather short (maybe 10 inches in length) plastic bottle that was square and originally contained my favorite yogurt in Paraguay.

I banged at the tarantula as hard as I could. Of course, having never fought one before, I was jittery.

I missed.

The tarantula climbed out of the sink, plopped on the ground, and started marching toward me.

I didn’t miss the second, third, and fourth time I tried to hit it.

Luckily, the new volunteer was at the front of the house and did not witness this battle, though I told her about it promptly thereafter. All in good time. She would likely battle her own home invaders during her years in Paraguay.

Reflection

These years since I’ve returned to the US have been challenging as I plodded through pre-med classes and several jobs and now, medical school. I’ve encountered many challenging situations with people who act tough and aren’t particularly nice. Most, if not all, of these tough-acting people have never battled a tarantula. Knowing that they lack tarantula experience has put my interactions with them into perspective. Afterall, toughness is relative, like all attributes.

There are many times in medical school where I’ve thought of my Peace Corps days as reminder that the current challenge is not harder than ones I’ve encountered before. Resilience comes from knowing where you’ve been even if others don’t. It comes from applying skills you learned in the past to new scenarios in the present. Most challenges can’t be overcome with a plastic bottle weapon. But, having a plan and being ready to implement it even when surprised can be applied to almost anything.