Tag Archives: Culture

Helping to Decode a New Language

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She wrote the number “8” smoothly. Months prior, it would have taken her five tries to get it. She was close to remembering all the colors of her home country’s flag. She wrote her name and birthday without issue – things she hadn’t yet learned when we started working together. Her English vocabulary was expanding. She understood simple words and phrases I said often during our classes together. Perhaps the progress was slow, but she was learning English and how to write.

For the past year I’ve taught English to a new American. I’ve taught English as a second language before, on multiple occasions, but she was my first student who couldn’t read or write. She was also my first student who couldn’t speak Spanish fluently. The lack of Spanish mattered since it was the only language I spoke other than English. She and I had no language in common, but we came together over her desire to learn English and my hope to teach her English. We came together over her desire to learn how to read and write and my belief that such knowledge is a human right.

Before she and I started working together, I’d never taught someone the alphabet or how to write. I found it interesting how her writing progressed just like children’s writing does. At first, her letters and numbers were large and sloppy. With time the shapes of the letters and numbers became more precise and smaller. At first, her spacing was off – she frequently ran out of room on our little whiteboard halfway through a word. Now, word spacing is seldom a challenge for her.

She impressed me with her focus and hard work. It was apparent she studied between our weekly classes. She studied English despite running a household and raising four children – three of whom were in middle school or younger. While helping her learn important things, like her birthday so she could fill out forms, I discovered we were born the same year.

Our life journeys have been different despite sharing a birthday year. Yet, our paths intersected over English. I wish that we could communicate better. I want to learn more about her. I want to hear her thoughts about the world. Perhaps, someday, we’ll be able to have such a conversation.

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.

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.

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.

Space

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I often think about space, specifically taking up/claiming space. My most conscious ponderings about space are while I’m running in the park near my house. I’ve observed that people are more likely to step aside for a male runner than me, a female runner. It’s so blatant that when my husband and I are running or walking together we strategically put him on the outside because people move over for him and not me. It’s an annoyance. I’ve started to run strong and serious. I’ve learned that a confident stride and a squared shoulder do help remind people that women also deserve to run without stride interruptions.

Guarding my lane while running is a newer claim of space for me. The first time I claimed space was changing how I sat. Changing my sitting stance was a project that took the better part of my twenties. For some reason women in my culture are taught to sit small and closed. I’ve found that sitting small is counterproductive. It has (perhaps) made it easier for males to harass me on public transportation and (definitely) made it easier for my colleagues in healthcare to ignore me. These days I try to sit large and open, just like my culture teaches their boys to sit. I don’t take the inside seat on the train/bus (that’s more for safety as I’ve learned the hard way) and I take up my whole seat even when it’s wider than I am broad. If there’s a seat at the table in a conference room, I take it. Which brings me to medicine, my most recent occupation (both meanings of occupation, wink, wink).

I have a very distinct memory from medical school related to being a female in medicine. I was mid-sentence presenting my section of a group presentation when a male member of my team cut me off, talked over me, and started his section of the presentation without letting me finish. It was so rude that several females in the class texted me in solidarity. The experience made me think about why seats at the table are not enough on their own. Seats must be claimed and, sometimes, defended.

Being a first-year resident brought with it a whole host of interesting space claiming challenges, many simply related to being a new doctor and some related to being a female physician. Filling the role of physician involved learning how to defend and explain my medical decisions, striving to take the high road and set boundaries when other members of my interdisciplinary team did not, and observing how physicians I admired conducted their doctoring and led their teams so I could model their techniques.

The challenge of being a new doctor exists for all new doctors. But filling the role of a female physician comes with its own occupational hazards. Here are some concrete examples from the past year of times I was reminded that I was female while at work:

  • I frequently must remind my patients that I am not their nurse — a challenge that my male counterparts don’t have.
  • My name is gender neutral, so nurses often think I’m male when communicating electronically with me before they meet me in person. (We have a secure chat in our electronic health record system that we use in the hospital). It is interesting to see how nurses’ tones change after they discover I’m female when they originally thought I was male. At times the tone change is dramatic and frustrating because I get more pushback as a female than as a male physician.
  • I have been lectured by a male supervising doctor about what clothes a doctor should wear. The lecture was somewhat confusing given that all the female residents wear exactly what all the male residents wear… scrubs of similar fits, styles, and colors. I doubt any male resident teams have been subject to such a lecture, but my all-female resident team was.
  • Several times I have found myself uncomfortable on rounds (that time of day when you talk about all your patients with the supervising doctor) because the male supervising doctor was very good at looking at my chest but never made eye contact.

The above situations illustrate that there are additional features of the medical terrain that female physicians must navigate that their male counterparts don’t experience.

As my second year of residency approaches (starts July 1), I’ll soon find myself no longer a first-year resident. In my second year of residency, I’ll start to be a team leader and I won’t be the new kid on the block anymore. I’m excited about this next step in my training. I feel ready to take on the challenge knowing I’ve learned a ton already and have a ton more to learn as a physician. I continue to have much opportunity for growth on my journey to lead with humility and excellence. As I wait for my second year to begin, I’m curious what the phase of “senior resident” (my title during my second and third (last) years in residency) will be like and the space challenges it will present. All adventures have space challenges however they present themselves in different ways.

Code Status

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“Would you want us to do compressions if your heart were to stop?” I asked.  

“Of course!” the patient said.

“Would you want a breathing tube if you needed help breathing?” I asked.

“Yes, do everything you can,” the patient said.

“Ok, we call that ‘full code.’ If your heart were to stop, we will do what we can to bring you back,” I said.

“To my surprise, I recently learned that there are people who don’t want that,” the patient said.

“Correct,” I said. It was a busy day and given that the patient’s personal goals regarding code status were quite clear I avoided further discussion. 

~

Code status is the first decision people make regarding their goals of care. “Code” is medical slang for a heart attack (which is when the heart stops causing death). “Goals of care” is an umbrella title for the objectives patients have when they interact with the health system. Goals of care exist because patient autonomy is a key ethical principle in medicine. “Patient autonomy” is the idea that patients have the right to information about their care options (the risks and benefits of all the options) and have the right to decline any medical intervention they wish even if declining can result in a sooner death. 

We always ask code status when patients are admitted to the hospital so that we know what the patient would want if the unexpected happens. There are 3 code status options:

  • “Full code” means that a person would like compressions and a breathing tube if their heart stops.
  • “DNR/otherwise full interventions” means a person does not want compressions if their heart stops but would want other interventions (like a breathing tube) if they needed them for some other reason.
  • “DNR/DNI” means that a person does not want compressions or a breathing tube at any time.

Unlike what the patient above believed, picking a code status is not an easy decision for many individuals. There are zillions of reasons why one’s heart might stop; the likelihood increases the older a person gets and the more medical problems they have. There are also multiple situations that might cause young, healthy people to code. A common trajectory (but by no means the only one) for code status is that young people choose to be full code and as people get older (like in their 70s or older) and/or sicker they decide to change to DNR/DNI. If a person doesn’t pick a code status, the default is always full code.

If you ever find yourself in the situation where you are very old and frail and/or very sick your medical team might encourage you to consider changing your code status from full code to DNR/DNI. Some individuals and families are against the idea of DNR/DNI and that is their right. However, let me explain why your healthcare team might recommend DNR/DNI and why the decision is more delicate than it might first appear.

When someone codes it means that their heart stopped; they are dead. The chance of coming back to life after someone’s heart stops is zero if nothing is done. If efforts are made to restart their heart (like compressions, possible shocks, possible breathing tube) then they might come back to life or they might remain dead. The chance of coming back to life if something is done depends on many, many factors. And, even if we can get someone’s heart to restart after it stops, we can’t guarantee that the person will wake up or have brain function again. Medicine is imperfect; we can “save life” and “prolong life” but the nature of that life ranges from fully functional to a vegetative state (dependent on a ventilator and unable to communicate).

The likelihood of someone fully recovering from a code after we get them back depends on how strong and healthy they were before their heart stopped and the reason they coded. It also depends on how long it took us to restart their heart. For example, returning to normal function after coding is more likely in an otherwise healthy person who coded because they had an abnormal heart rhythm and whose heart restarted rapidly after initiating compressions. A full recovery is less likely in a person who has multiple medical conditions and required an hour of compressions before their heart restarted.

Compressions and post-code recovery are invasive medical interventions. For example, compressions often cause rib fractures. Many people require at least several days with a breathing tube and on a ventilator after their heart restarts. This is why, as you may have noticed in the above code status options, there is no option to have compressions without accepting a breathing tube (while you can have the reverse). The reasoning is that there is no point in doing compressions if a person does not want the interventions required to keep them alive after we restart their heart.

An important reason that people choose DNR/DNI over full code is because they believe their chance of surviving and returning to a functional state after a code is low. Often people who choose to stay full code no matter how sick they are do so because they believe any life is worth living. To complicate matters further, a person (or their appointed medical decision maker) can change their code status at any time. The fluidity of code status is why we ask code status every time a person comes to the hospital. Like most things in medicine, there is no “one-size-fits-all” for code status. Choosing a code status is a very personal decision with no right or wrong answer. The decision often depends on an individual’s values about life, beliefs about what happens after death, and baseline state of health.

How Strange to Be Unable to Name a Daffodil

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“We saw daffodils!” I said. My voice sang with an enthusiasm that only such a definitive sign of spring could coax from me on such a rainy, gray afternoon in February. My co-resident looked at me blankly. The importance of a daffodil passing through their genius brain just as the medical terminology doctors like to use pass through patients’ ears – jargon without meaning, hardly in and definitely right out. “You know, it’s one of the first flowers of spring. I saw it in the park.  They’re yellow…” I gave up and the conversation moved on to other topics.

Doctors are more diverse than we once were, but our makeup doesn’t come close to mirroring the population we serve. My visible profile is common in the medical world – white (always very common) and female (slightly more females are entering medicine than males these days). Yet my unseen profile, my story before medicine and path to medical school, is unusual for a doctor.

Sometimes I’m reminded of my different background when it’s easier for me to relate to patients than my colleagues who come from medical families and have never known what it is like to not know what “coronary artery disease” and “hypercoagulability” mean. Other times I’m reminded of my different background when it’s easier for me to understand the social determinants of health such as why someone might not have transportation to appointments and why medications might not be worth the monthly bill to a specific individual. Where I grew up if you didn’t have a car you went nowhere; further, I solely used public transportation for most of my 20s. I’ve also run a tight budget most of my life which has given me a lot of practice deciding where my money will and won’t go.

It’s not just my economic background that makes me different from many of my co-residents (though I’ve come to realize more with each passing year that economic background is a mountain that dominates world view). The nuances of my difference from many of my colleagues present themselves at unexpected times such as on slow days when making small talk with co-residents and supervising physicians.

I grew up in a world where medicine was minimally understood, mysterious, and (perhaps) feared. The distance of medicine was partially possible because my family was healthy and required minimal medical care; it was also who we were. Our lack of medical knowledge did not mean, however, a lack of knowledge. For my colleagues who have known the medicine way of life since childhood as they watched their parents (many doctors and some nurses) come and go from work, the hospital system is familiar and almost second nature. I didn’t grow up knowing the hospital. Yet, I know other things that are part of who I was, am, and will be.

For example, I know the birds, trees, and plants of my childhood and I’m learning the ones of my new home in Virginia. I know how to grow plants indoors or in a garden because I grew up in a culture where we all knew how to tend plants. In a similar way, I don’t believe cows are cute because I’ve been almost late to school chasing them after they got out of the fence. I know how to stack 6 cords of wood in a day, use power tools and wood tools, and change my car tires because these are skills that were necessary in the world where I grew up. I notice architectural details, complementary colors, and other design elements because these were some of the themes of my childhood.

Being an older resident with a different background and careers prior to medicine is isolating at times. A small portion of my co-residents can relate or are interested in where I’ve been before medical school. I’ve become accustomed to this. My life extends beyond the hospital. I have family and friends who understand the nonmedical aspects of my life just as my co-residents understand the Doctorhood Quest in a way non-physicians can’t.

I have so much to learn about medicine from my co-residents and supervising physicians regardless of whether they understand any aspect of my life outside of residency. But, on days such as when I find a resident who can’t name a daffodil, I’m torn between amusement and sadness. In my world it’s ridiculous to be unable to name one of the most common spring flowers in the US. The realization that there may be many doctors who can’t name a daffodil reminds me just how different we all are. It also reassures me that there is much I can teach my co-residents too. And, perhaps more importantly, it reminds me how much physicians can learn from our patients and non-doctor colleagues if we find time to listen.

My Hero List Grew by One That Night

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It was early during residency. I was still adjusting to primary care clinic which included learning how the computer system worked. I still didn’t have home access to the electronic medical records so I couldn’t review my patients ahead of their appointments. I also couldn’t write my patient notes at home. All my patients were new to me. Between the challenge of learning new patients and the computer system, I fell behind in clinic one day.

My patient appointments stacked up like logs against a dam before it bursts. And, with my appointments running behind and my slowness with the computer system, the notes I had to write for each patient appointment were pushed to the end of the day.  My last appointment ended an hour late because it started an hour late.

There I was, already after closing time and just starting to fight the computer system to write my notes as fast as I could. Everyone else in the clinic had left an hour or so earlier. I was hungry because I hadn’t thought I’d need to bring dinner.  I’d already eaten breakfast and lunch at the clinic. I was startled when I heard someone in the hall. The janitor walked by my office, “Late night?” he asked pausing outside my open office door.

“Yeah. I’m new here and I’m still slow with the computer,” I said.

“And they just left you?” he asked.

“It’s okay. Hopefully my notes will be done soon,” I said.

“Well, thanks for your work,” he said.

Hours passed. One note at a time, like small footsteps, my pile of remaining work dwindled. The janitor stopped by my door again. “I got you these. It’s not much but it’s all I could find,” he said. He handed me a bag of BBQ potato chips and a mini-Fanta orange soda.

“Thank you so much! You’re so kind,” I said. I was too tired to be giddy but in better circumstances I would have been gleeful for the snacks.

“Have a good night. Hope you can leave soon,” he said and walked away, back to his own work.  

I don’t think he’ll ever know how much he saved me that night. When I was finally done with my work and as I walked through the empty clinic and then the empty parking lot to my car, I thought about how much I appreciated the janitor. I’ve often thought it odd that society focuses so much on big names and money. In my experience, heroes are always humble strangers acting out of kindness and with no motive or expectation of recognition.  

That night I was reminded that all it takes is pausing to offer a little help to transform a person’s night. The janitor clearly had already ingrained that knowledge into his existence. And like the heroes who came before him, I added the janitor to my life’s hall of fame as I walked to my car to drive home. My hall of fame isn’t a hall of fame like those for baseball players but, to me, it’s a lot more important. And, in case you’re wondering, I’ve never had a more delicious bag of chips and can of soda.

This Is How I Started Residency

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Starting residency was like a flash flood. Beginning from the first day, I was overtaken with more work than I knew what to do with. As a new doctor in a new healthcare system, I found myself equally challenged by creating care plans for my patients (like deciding which medications to prescribe them) and implementing the plans my supervising doctors and I devised (like ordering medications in the computer system). I completed tasks more slowly than I imagined possible. My patients were well cared for because I was part of a team, but my work hours lengthened in a way that the saying “burn the candle on both ends” was created to describe.

All of us headed to residency (regardless of specialty) are warned that it will be challenging. Each person experiences different challenges and different low points. Residency is hard for everyone because the hours are long and there’s a lot to learn. So, when my work hours exploded like water through a broken dam, I wasn’t surprised. I was surprised by how my program responded.

As my hours lengthened to a point where I was exhausted and just barely surviving, my chief residents stepped in to help me develop ways to become more efficient. Senior residents observed me throughout a shift and offered advice on how I could streamline my workflow. People on my team and other teams helped take some tasks off my plate so I could focus on learning the computer system better and on writing patient care notes quicker. I was given a little extra time off to catch up on sleep because I was on track to work far more hours than permitted by the national governing body that oversees US residency programs.

At first the extra help and attention made me feel like a failure. I tried to keep my spirits up because I’ve struggled to overcome big obstacles before; I always learned more from those experiences than I did from experiences where I didn’t struggle. Similarly, past experiences have shown me that it’s okay to accept help. Still, I wondered if I was going to learn enough or as quickly as I should if people helped me more than some of my peers. I wondered if I’d get better at being a doctor.

On my extra time off I reviewed my senior residents’ feedback. I reorganized my view of the electronic health record system to make it easier to access all the information I knew was important. I took time to recharge. When I returned to work, I was still a new doctor. I hadn’t changed much from the days prior. Yet, I found myself checking things off my to-do list without the help I’d required before my recharge day. With a little more sleep behind me, I was able to see how much I’d learned in my previous days of working – something I hadn’t noticed when I was exhausted.

As I reflect on my first two weeks of residency, I don’t look at them fondly. I do think that I’m a tiny bit better at being a doctor now than I was two weeks ago. I appreciate my past self for prioritizing a work culture of support and collaboration when applying to residency. I know that there are many hard days to come before residency is over. However, my experience during these first weeks made me confident that I will be able to overcome future hard patches when they come – not completely alone, instead, with a program supporting me as I find my path forward. Feeling like my residency program genuinely wants to help me become the best physician I can be gives me confidence in the residency training process and makes me excited for who I’ll become by the end of it.

This is how I started residency. The future will tell how I end residency.