Learning to See

Before I moved to me latest city, the people I talked to about the city during my travels through medical school rotations didn’t have anything good to say about it. One person said there weren’t any good food. Others said there wasn’t much to do. When I moved here, someone went as far as to tell me it was dangerous. And, while I listened carefully because I knew little about the city myself, I had a suspicion they were wrong.

When I was a child, I learned to see the trees and birds around me. I learned to name them. I could tell a white pine from a red pine or a sugar maple from a red maple. I could tell you the sound of the chickadee and the hermit thrush. I knew the difference between a red wing blackbird and an oriole or a bluebird and an indigo bunting. This type of seeing was the outcome of growing up in the middle of nowhere while surrounded by women who knew these things and shared them with me.

Early on, I learned to tell the difference between real wood and fake wood. I could identify sloppy joints and beautifully joined boards. I judged furniture and house finishings based on their joints. I could tell you how sheetrock differed from plaster. I understood these things because my father had taught me to notice them. My mom taught me to see colors and how they might be paired. I still notice boldly paired colors and they bring me joy regardless of if I find them in a painting or on someone’s clothes.

As a I grew, I learned to name the flowers in people’s gardens because I worked in a greenhouse. I was trained to tell the difference between a rose and a lily, for example. My parents taught me to notice architecture. What makes a classic New England home look as such and how that differs from an adobe house. I came to understand what a well-built house is.

When I moved to DC, I learned how to see a street for what it was. A pathway to somewhere. I learned how to chart my course and tell if I was safe on a particular path within moments. I learned to see the places, like underpasses, I should avoid at night and the places that were filled with architecture, trees, and flowers. I learned this out of necessity and because I have a savage passion for walking and walking and walking.

When I moved to Paraguay, I learned to see what someone was trying to say because I couldn’t always understand their words. I learned to see if they were lying, or friendly, or joking. I learned to see why some people might follow God. I started to understand why life in Paraguay is different from life in the United States. And I learned to see that difference as both beautiful and challenging.

In medical school I’ve spent years learning to see exactly what a normal breath is and how stretchy skin should be. I’ve learned to see how the heart and abdomen are when all is well and what an infection looks like. I’ve learned to understand almost every part of the body and to see when it is healthy.

All this learning about how to see I carry with me always. And, when I moved to my latest home, I applied my seeing to understand what this city was. I learned that there is a lot to say about Danbury. I found the trails (there are numerous) where I can run and walk among the trees, birds, and flowers. I’ve noted the buildings with outstanding architecture. I found half a dozen murals with beautifully blended colors. I’m mapping out the good eateries—so far, I have a recommendation for every meal of the day plus elevenses and snacks. Much like Paraguay, Danbury is filled with people who don’t look or speak like me. But, when I took the time to observe my neighbors; it became apparent that they are a bunch of people trying to carve out a little space to work, eat, and be merry. I came to understand they were just like me in many ways. And, noticing our similarities, I understood that this city suits me. Seeing is something that takes practice. But once you learn to see you can begin to understand.

Burnt

Her hands had become so numb she could no longer administer the eyedrops that kept the pressure in her eyes from getting too high. If her eye pressure got too high, she’d go blind. So, her eye doctor said she needed surgery if she couldn’t use the eye drops. There were two surgical options. One surgery would take an hour and she’d leave the operating room able to see. One would take 3 hours and she’d leave the operating room blind, requiring 4-6 weeks of recovery before her vision would return. She was lucky because she had family who already helped her a ton because her other health conditions had made independent living hard for her. For some reason, the insurance would only cover the 3-hour surgery that would leave her blind for over a month. The holidays were coming up. The family members that took care of her had kids. She refused to make them care for her while she was blind over the holidays. She postponed the surgery. Would she go blind before she could get her surgery? Is this the healthcare system we want?

~

The patient wasn’t COVID vaccinated. “What will you do to treat me if I get COVID?” she asked. I thought about the patient a resident had told me about. That patient had been dependent on family for care. His family didn’t vaccinate him. He got COVID. He came to the emergency room with trouble breathing and then went to the intensive care unit. He lived on the intensive care unit for a year. Eventually, his healthcare team cut a hole in his neck to put a breathing tube in because he needed it. They did everything they could to keep him alive. The resident said when the patient first came to the emergency room, he was a happy, funny soul. The patient lost his happiness slowly during the year he fought to breath. After a year of an entire hospital trying keep him alive, he died. When exactly did avoiding sickness fall out of favor? Do you ask what firefighters will do if you set fire to your house or do you make a concerted effort to not catch your house on fire knowing that firefighters will do their best to stop a fire if it occurs but are limited because fires are destructive and destroy houses and the people who try to stop them?

~

The patient asked, “Why are so many doctors retiring?” I wondered how he didn’t know the answer to that question already. It seems so obvious. Then, I realized he was not a medical student. Being a medical student is to have a front row seat for observing the current state of healthcare. What had I seen? Why did it seem perfectly logical to me that so many people were retiring from healthcare even as I was striving to make it my career?

Not just doctors and nurses, but everyone in healthcare seems to be retiring…

We report our COVID cases. Our COVID test rates. Our COVID survival rates after hospital admission. Our COVID deaths. Who was there to perform those tests, to care for those people when they came to the hospital, and to close the curtain when the ventilator wasn’t needed anymore? Healthcare workers. But, they were also there for all the other things too. The heart attacks. The stomach pain. The broken bones. The cancer. The normal healthcare screenings. They were there when people looked for help with their depression and their anxiety. Healthcare workers’ hours increased. They worked the job of two, three, four, and five people because the hospital was short-staffed before the pandemic hit. Again, healthcare workers were already working long hours and doing the work of several workers before COVID came. Then healthcare workers got sick. And the ones left standing worked for their sick colleagues, worked for themselves, and worked for the staff who were missing before the pandemic came. Wages stayed the same.

Housing and food got expensive for everyone, including healthcare workers. Healthcare workers missed the same performances, social events, and restaurants that everyone else was missing. Life got more expensive because everything including industry was disrupted by COVID. Healthcare wages stayed the same. Healthcare workers got sick. Sick leave was used up. Shifts were harder because healthcare was short staffed and there were more patients than before. And the patients were dying. And insurance didn’t want to pay for the treatments that patients needed, not that that was new, but it remained disheartening. And there was the need to wear masks at work. And to put on goggles and gowns and for healthcare workers to take extra time to protect themselves from infection. There was the risk of bringing COVID home after working in healthcare. Wages stayed the same.

People got sick. And healthcare workers got tired. Wages stayed the same. Hours were long. Vacations couldn’t be taken like they used to be taken. And just like their patients, healthcare workers got sick, tired, depressed, and anxious. Staff shortages increased in the hospitals and clinics.

People denied that COVID was real. People invented vaccines that helped prevent COVID infection. People refused to get vaccinated. People complained about wearing masks. People got tired of social distancing. People got sick. The intensive care unit was full. The psychiatric ward was full. The cardiac ward was full. Alcohol use disorder, diabetes, high blood pressure, and all the other medical conditions that always exist marched on because they don’t stop during a pandemic. Healthcare workers shouldered the workload of several workers each because some of their colleagues had left, some had died, and some were sick. Wages stayed the same.

In such an avalanche, how long would you have waited to change careers? For many, the answer was between 1 and 2 years.

~

There is always hope and healthcare has been grounded in hope since the beginning. But as a student so excited to become a physician I know that change must happen if hope is to materialize into lives saved. And for my sake and all the people who might need the hospital or a clinic in the coming years, let’s not make it take a healthcare collapse before we seriously consider how we might improve and restructure our healthcare system. I’d very much like some seasoned healthcare workers who are not completed burnt at my side when I start practicing as an independent physician because experience is gold in medicine. I’d also really like to have enough staff to care for patients without having to burn myself and burn my colleagues with the weight of too many lives in each of our two hands.

One Example of Sexism in the Operating Room

Often enough to be considered a pattern, the men in the operating room chose to discuss the annoyance of the hospital’s anti-harassment yearly training videos and anti-harassment policies when I was the only female in the operating room with them or when it was just an older female nurse, them, and me. And while I also find the hospital’s anti-harassment training videos frustrating (for entirely different reasons than my male counterparts), I did not appreciate when a surgeon said he could get tips from the scenarios in the video. I did not appreciate his comment (despite his humorous tone) because the truth is that harassment doesn’t just occur in training videos. It occurs all the time and in all settings of women’s lives.

And I found it interesting that these men were complaining when most of them are fathers of daughters, and many are fathers of young daughters. And if the risks weren’t so high for me, I would have asked them the questions I pose now, “How old do you think your daughter will be when she first gets cat-called so badly she feels unsafe? How long riding public transportation will it take before she has a set of rules she follows because of the physical and verbal harassment she experienced from male passengers?” The use of “when” and not “if” is intentional.

You see, women close to me have been strangled and shoved into walls. I’ve sat by as a younger woman asked for advice from an older woman about what to do because her husband raped her every night. I’ve been called by friends in tears because they were cat-called so badly they were shaken. I’ve sat with women as they hid behind dark glasses waiting to get photos of their bruises to use in court. On my first day of one of my first jobs, my preceptor told me how to use the printer and warned me to be careful of our male boss. He left the company before I had to worry about exactly how careful I had to be. By the time I’d worked in healthcare two years, two of my female friends had been groped by male patients. I’ve only been training in the hospital as a medical student for six months and already two female physicians have taken time out of their busy schedules to have lengthy conversations about how to keep my head up and build my career despite disrespect from male colleagues and male patients.

And the reason I would ask the fathers of young daughters the questions above is because I know they love their daughters. And I know they can’t fathom that they are being exactly the type of men who will get in their daughters’ way as they reach for their dreams. And I would ask the fathers of young daughters these questions to remind them that they cannot protect their daughters from the future. And, truth be told, they will likely never know the harassment episodes of their daughters’ life. And I would ask these questions to recommend that they learn how to respect women so that they can set an example for their daughters of what it’s like to be respected. That way, when their daughters do experience disrespect, they know it is not their shortcomings but the shortcomings of the disrespectful one. In other words, it’s worse to be a daughter of a father who doesn’t know how to respect women because he sets a poor example of the male gender. And the behavior of these men in the operating room made it clear that they still had much to learn about respect despite surgeons being among the most highly educated people around. What an unsettling reality to have so many years of education and still lack competency in a basic principle like respecting all humans.

You can look up the statistics in the US for harassment and rape of women (and other demographics) if you’re curious. It’s an easy Google and the numbers are almost as bad as the news that makes the front page of the newspaper. If you want to get really dark, look up statistics related to intimate partner violence. The numbers are horrific. And the numbers always surprise me because all women are daughters and perhaps sisters, mothers, and partners. Fathers and mothers see the statistics and are inclined to tell their daughters to be careful. To not drink too much. To not wear too revealing clothing. To never set down their drink. To not walk alone at night. To not live on the first floor. To lock their windows and doors. To always go out with friends….the list goes on. But the question I always wonder when I hear these statements of warning is why don’t parents just tell and teach their sons that “no” means “no,” “stop” means “stop,” respect applies to all people regardless of genitalia, and that drunk or not you are responsible for your actions? Because all men are sons, and many are brothers, fathers, and partners. It would seem more helpful to prevent the problem of people harassing others, than react to the problem by telling the victims to avoid harassment.

I also find parents’ lectures of caution stifling because they do not address so many of the manifestations of sexism their daughters will experiences. Yes, there is the risk of rape and physical abuse. But for those women going into competitive or historically male professions many of the troubles we face as women are more subtle and persistent than acts of violence. The times we’re told we’re mean or bossy when a male counterpart with the same behavior is considered strong. The times we’re ignored, spoken over, interrupted, and discredited despite consistently being correct. The times (like in the operating room when men decided to complain about harassment protection for women) when we’re othered and made to feel like demanding respect isn’t a right, but a burden we place on our male counterparts. The times we’re underpromoted, underpaid, and passed over simply because we are women. The times we must dig deeper than our male counterparts not because of shortcomings but because our parents taught their daughter to be cautious and taught their sons to be bold.

And as these fathers of daughters discussed sexual harassment policies as an annoying restraint placed on them, I thought about their daughters. I knew when they’d be cat-called. I knew how long it would take on public transportation before they developed their safety rules. And I hoped for those daughters’ sake that they would have men that set an example of what it’s like to be mutually respected. It had made such a difference for me to coexist with many men who looked at me as a person and not some different creature. You see, it’s helpful to know respect is possible because at times it seems like a fictional concept. I thought about those young daughters one day standing where I was. I sent them strength. As much as I hoped the world would change in the years between us, I wasn’t sure it would because these men I stood with in the operating room would still be here. And their sons who had them as role models would be here too.

And I was once again weary, not so much because of the long hours I was spending studying or the fact that I was scoring equal or better to many of my male counterparts in medical school while also getting cat-called and navigating colleague and patient sexism, but I was weary because these men in the operating room, like so many others, stood in the way of my father’s daughter. They stood in my way because they made things more difficult for me than my brothers simply because of my genitalia. None of this was new or surprising, but it did make the hours in the operating room seem especially long. And if the operating room had been a safer place for me, I would have told these fathers the reason I didn’t like the hospital’s anti-harassment videos was because they were triggering for those of us who have been sexually harassed and spoke of a justice system that I have not found anywhere I’ve worked. And I’ve worked in many places.

Autonomy In Medicine

Set Up

I’ve been thinking of patient autonomy and the humanness of physicians a lot recently. In my short time training to be a doctor, I’ve had many experiences that have brought these topics to light. Here are a few examples:

  • An attending physician told me he usually first recommends pills to women seeking birth control because he believes that women find it reassuring to have their period every month. Odd perspective as my experience as a woman is that some women find periods reassuring and many find them annoying. Odd perspective as my short time in his clinic showed implant and injectable birth control methods as the most common forms of birth control requested and used by patients. Odd perspective as research has shown LARC (which include implants and IUDs and NOT birth control pills) have greatly decreased unwanted pregnancies because they’ve removed the mishaps of having to remember to take a pill every day. Medicine is complex. It requires both keeping up with research and checking your personal beliefs at the door. The approach I’ve seen most physician take when discussing birth control is to outline the different available birth control options so patients can decide themselves which is best for them.  
  • I overheard an attending physician talking to a resident physician about a D&C they did recently. A D&C is a procedure that can either be used to end a pregnancy early on or clear a miscarriage that occurred early in pregnancy. The patient these physicians were discussing had the procedure to end pregnancy. The resident physician stated that she thought the patient was looking for validation from the attending physician for choosing to have the procedure. The attending physician shrugged. I (medical student) asked what the attending physician had told the patient. The attending physician said, “She doesn’t need to give me a reason for the D&C. I told her she doesn’t need to give me a reason to terminate the pregnancy.” I found this statement to be a powerful example of approaching medicine without imposing personal beliefs on a patient.
  • An attending physician walked out of a patient room and told me the patient’s problem was that she was naïve. This was his reaction to the patient (a pregnant woman) planning to visit friends/family in another city while in the third trimester of her pregnancy. The patient had gained too much weight during pregnancy. She also had high blood pressure at this appointment. When asked the patient described improving her diet. The physician laughed at her when she described eating salad. In self-defense, the patient then described eating very healthy-sounding salads. The patient’s trip would delay the follow up blood pressure reading the physician wanted by two days. The physician did not explain why he was concerned about hypertension specifically in the last weeks of pregnancy. I wondered why he didn’t recommend that the patient monitor her blood pressures with a home blood pressure cuff and bring in a log of her blood pressures when she was able to schedule her next appointment. It seemed the risk of delaying a blood pressure reading in the clinic by two days might be outweighed by the benefit of social support during the final weeks of pregnancy. I questioned the choice of “naïve” as his diagnosis. Why should she know about preeclampsia if he didn’t tell her? Naïve is a loaded term and isn’t one I’d be quick to use to describe a pregnant and uninsured woman with friends/family in multiple cities. Medicine is a team sport. Patients are the captains and physicians are the coaches. It’s important to remember that the patient is part of the team and that while they don’t bring medical knowledge, they do bring life knowledge.
  • The patient told the attending physician that they stopped their antipsychotic medications. The physician recommended that the patient continue taking their medications. The patient refused. The attending and the patient came up with a plan to watch for warning signs that the patient’s psychosis was returning. The patient continued to attend group therapy even though they stopped their medications. This allowed the group therapist to send a community crew out to the patient’s home to check on the patient when that patient showed psychotic behavior at the online group therapy session. The patient did not self-identify that their psychosis was returning. However, because they continued to attend group sessions they were still connected to care and were brought to the emergency room before their psychosis led to self-harm. I found this case an excellent example of a physician respecting autonomy while also trying to prevent serious health outcomes for her patient.

Reflection

Medical school, residency, and being a physician teach us to solve complex problems. They teach us the complexities of the human body and how to cure diseases and treat symptoms. They teach us to think critically and sift through data efficiently. They provide us with guidelines and treatment recommendations. But, medical school, residency, and practicing medicine don’t and can’t teach us the complexity of each patient. They can’t give us the ability to foresee the future or understand patients’ life goals better than patients do themselves. And, despite our great knowledge as physicians, we can’t (and will never) have all the answers. Despite extensive training, medical research, and detailed guidelines medicine is still decided by humans (yes, physicians are just humans) and is (therefore) based partly on intuition, experience, and practiced guessing.

In medicine we are fixated on being right. Our goal is to reduce suffering, cure disease, and help patients navigate illness. And while as doctors we strive to cure, as humans we know that life can be more complex than curing. As humans we know life is paired with death. As humans we know not all questions have an answer and not all problems have a solution (at least yet). And as humans we know that health, sickness, healing, recovery, pain, and death are individual experiences that share commonalities across individuals but (ultimately) are unique experiences that each person endures differently.

In my short time in the hospital, I’ve already observed patients losing their autonomy. I’ve seen patients’ wishes ignored and explanations of why skipped or glossed over. I’ve seen us (medical experts) angered when patients don’t follow all our recommendations, insulted when we’re asked why, and forceful that our way is the only right way. And I’ve seen patients suffer. I’ve seen patients suffer taking our recommendations and I’ve seen them suffer when they refused our recommendations. And while suffering seems to be a part of some points in all lives, it also seems that sometimes in addition to our patients suffering we (physicians) push our patients to accept a treatment plan that is discordant with their values and life goals. It seems sometimes that we add to suffering by piling on shame or judgement.

In medical school, in residency, and as physicians we are taught to find the truth and to be right and to be directive. We are taught to recommend the best medicine has to offer. Yet, the best options based on evidence are not always the best option for an individual patient. And even if they seem right, the best options are not foolproof. The best options are based on probabilities, percentages of effectiveness and likelihood of reducing disease or preventing further harm. Probabilities are helpful, but they are not certainties.   

I’ve been thinking of medical recommendations and patient autonomy and the humanness of doctors because medicine can be hierarchical. It can be rigid with the attending physician setting the law; a mix of other players like nurses, medical students, and resident physicians in the middle; and the patient disempowered.

There are more cases than I presented above that I’ve experience which illustrated the complexities of patient autonomy and the humanness of doctors. Medical school is a whirlwind of learning. What I’ve come to discover, however, is that all the learning isn’t strictly medical. I’m also learning how I’d like to conduct myself when I’m an independently practicing physician, the ethics of medicine, and the challenges of working in a field where the outcome is dependent on the efforts of all team members.

As I reflect on the hierarchy and the complexity of medicine, if I could hold one piece of advice for myself as my training continues it would be to ensure my understanding of medicine is excellent while also remembering that patients are autonomous individuals. This advice reminds me that my job is ultimately to help people navigate the complexities of health and illness. This advice acknowledges that patients can say “no” and that the “why” is just as important as the “right answer.” This advice helps me to remember that my patients and I are a team. And just as I can decline or refer a patient to another physician if I am not comfortable with a patient’s request, my patient can also decline my recommendations or seek the medical expertise of another.

The COVID-19 Vaccine: Celebration and Differences

Repost of a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original (split into 2 posts) here and here.

My partner and I both work in healthcare and had the opportunity to get our COVID-19 vaccines months ago. Never in the past would I have expected to await a vaccine with such anticipation and feel such gratitude upon receiving it. Among the many other social and scientific features COVID has brought to the forefront of our attention—one, at least for me, is a renewed appreciation for all the vaccines we have previously developed. To think that we can stop smallpox and polio is a relief. But, also, COVID is a reminder of all the diseases that have escaped vaccines to prevent them. HIV comes to mind.

My friends and family in the US are in various stages of COVID vaccine completion. The variance is largely because of their age, profession, and which state they live in. What is reassuring to me is that for my US community the debate is not whether to get the vaccine but, rather, when.

The conversation about the vaccine is very different for my Paraguayan friends. I have not experienced vaccine fear among the Paraguayans I’ve known—which is to say their access to the COVID vaccine is not limited by personal belief but rather distribution.

I connected with all my friends in Paraguay on Easter, an important holiday in a predominately catholic country. I was excited to hear about their celebrations. In Paraguay, the week leading up to Easter is called Semana Santa (Saints Week) and is especially important. It is a time of sharing chipa (a traditional food that’s like a hard cheese biscuit) and enjoying the company of family and friends. Visiting has been limited this year because of continued concern for COVID, but my friends still report making chipa and enjoying the company of family.

When the topic of COVID came up, one of my friends said, “Estamos acá en la lucha, en Paraguay no hay vacuna, a nosotros es imposible recibir la vacuna…primero tiene que ser por las personas saludes, por los militares… y después recién por nosotros, dicen que van a inmunizarnos, pero no sé…por nosotros acá nuestra lucha es esperar la vacuna y quedar en casa. (We are struggling here, in Paraguay there is no vaccine, it is impossible for us to get the vaccine…first it must be for healthcare workers, for military personal…and then, after, for us. They say they’re going to vaccinate us, but I don’t know. Here our struggle is to wait for the vaccine and stay home.)”

This friend has been studying online since the pandemic began. She hopes to someday work in healthcare, but she is not able to go to the hospital to continue her clinical training for fear of catching COVID. One of her uncles was hospitalized for 15 days for COVID (he is doing well and made in home for Easter). Many of her family members caught COVID this March, but only the one uncle ended up in the hospital.

One of the things that continues to strike me about my Paraguayan friends is an unwavering optimistic outlook even though COVID-19 vaccination in just beginning in their country. My friend’s comment, “Here our struggle is to wait for the vaccine and stay home” struck me. She said it in a matter-of-fact tone that did NOT hint at frustration but, rather, exuded unwavering patience.  In thinking about my friends in Paraguay, I began to wonder if the closeness of families (not just emotionally but geographically) is a protective factor against feelings of isolation I’ve heard from many of my US friends. My friends in Paraguay either live with their parents and extended family or on the same block as them; compare this to my friends in the US whose families are spread out across distant states. This comparison reminded me that even though this pandemic has touched lives across the globe our shared experience is also a highly personal experience shaped not only by our uniqueness as individuals but also by the culture of the society in which each of us live. 

How I Came to Discover That Pronouns Are Like Ants

On my first day of medical school they handed us our badges and had a table full of pronoun ribbons (so, she/her, he/him, they/them) that we could stick to the bottom of our badges. There was a strange pressure to take the ribbons and they were briefly explained, but the whole thing felt forced, abrupt, and confusing. In those overwhelming hours of my first day of medical school, the pronoun thing felt like an attack and was unexpected. I didn’t know that several schools across the country were making moves to include pronouns in name tags and email signatures until I picked up my badge that day.

I had no interest in walking around with “she/her” pasted on my badge. Those are the pronouns I use, but why should I walk around with them on my badge? I also didn’t like the ribbons themselves. They were impractical. They stuck to the bottom of my badge, making it longer and heavier. I was concerned that this extra volume and mass would make my badge more likely to hit me in the face when I was doing compressions. Also, the fabric couldn’t be cleaned with an alcohol wipe like the rest of my plastic badge. It’s important to sanitize things in healthcare.

I decided to not add the ribbon to my badge. But, the idea of pronouns stayed with me. It bothered me. It bothered me that I was uncomfortable by the idea of wearing my pronoun. Why was it uncomfortable to me? Why had some people said we all should wear pronouns? I decided I needed to find answers to those questions.

I would come to learn that pronouns are an important topic because there are people who are either given the wrong one by society and/or who don’t identify as a he or a she and, instead, identify as a they. Using the wrong pronoun is a form of misgendering (assigning someone the wrong gender) and often can be considered a microaggression against that person. Many of the people who use “they” pronouns consider themselves nonbinary, which means that on the spectrum of male to female they don’t fall on one extreme. These groups of people, those that use pronouns that weren’t assigned to them by their parents, often endure others using the wrong pronoun. The idea behind having everyone declare their pronoun was to normalize talking about pronouns and to reduce our tendency to assume we know other people’s gender identities simply by looking at them. All the above made sense to me. I also thought we all should be able to use whatever pronoun we want. But, for some mysterious reason, I was still hesitant to add pronouns to my name badge.

I talked about the pronoun label with some friends. I talk about it with some people I love who are part of the LGBTQ+ community. I thought about the patients I had worked with when I worked in the emergency department and on the ambulance. I thought about the patients who were always called the wrong pronoun. I thought about how thankful they were when I asked about their pronoun or used the right one. I thought about how awful I felt to have someone be thankful that a did something as basic as use a pronoun correctly. Pronouns are pretty basic grammatical elements. But, of course, using the right pronoun isn’t about grammar, it’s about respecting people’s identities…but I’m getting ahead of myself.

Time went on. I put my pronouns on my badge and then I ripped them off again. I kept thinking. What kind of message would wearing a pronoun send? Could I back up and live up to that message?

For all of this year I didn’t include a pronoun on my badge or my email signature. But, my pronoun abstinence wasn’t passive. I kept thinking and observing. A resident with a pronoun pin (not a ribbon) on his badge came and talked to one of my classes. I liked the pin way more than the ribbon. My school had a guest speaker come and talk about being a trans man. His stories about navigating healthcare were unpleasant and demeaning. I’d never want similar experiences and I would never wish the emotional pain he experienced on any of my patients. Then, later in the year, I learned that someone close to me started publicly using they/them pronouns.

As I kept thinking, I realized that I’ve also spent a fair amount of time thinking about pronouns in the past. Why? Because people mess mine up all the time. Not when they see me—my born sex, presentation, gender identity, and societally assigned pronouns and gender have always matched (that means I’m cisgender)—but almost 40% of the time when correspondence is over email people get my pronoun wrong. Why? Because people don’t read carefully. My name is “Jett,” but many people read it as “Jeff.” What’s more, “Jett” is a gender-neutral name. People guess wrong often. I find it funny how many people get my gender wrong because of my name over email. It does not hurt me when people think I’m Jeff the he/him in an email. It doesn’t bother me because I know they’d correct themselves and apologize when they meet me. I know this because that has happened to me on several occasions.  

But, what if people didn’t apologize? What if people got my pronouns wrong when they talked to me, face-to-face? That is the questions I realized I needed to consider. Upon thinking, I realized I’d correct them and be annoyed. I know I am a woman. I’m proud to be a woman. Considering that I am a woman and I want others to see me as a woman too, I came to realize that it does matter to me that people use she/her pronouns when they talk about me. If everyone called me “he/him” I think it would be like a bunch of ants invading my home. One ant (one pronoun) is very little and its bite would sting but it wouldn’t cause much damage. But many ants are quite destructive and add up quickly.

If you’re like me and fit what society assigns you, you’ll never know what stress or pain it causes to be misgendered. But, I challenge you to consider how you’d feel if every time someone talked to you they called you the opposite pronoun from the one you use. That means, if you’re a she/her they called you a he/him (or vice versa). I challenge you to sit and actually think about it. How would you feel?

My last month of school this year I decided to join the pronoun presenters. I ordered she/her pins for my badge. It was $2 a pin, less than a pack of gum to fix the ribbon problem. I decided to order those pins because I know there are people out there who society continually labels with the wrong pronoun.

This country has been talking about systems used to suppress and control certain groups of people a lot lately. One of those systems is language. One of the methods to harm people is forcing them to answer to a pronoun that is not correct. I think of it this way, when someone comes to me and tells me they have a headache I do not say, “no, you have foot pain not a headache.” If I can’t know where someone hurts better than they do themselves, how can I possibly know their gender identity better than they do? How can I know better than they do their correct pronoun?

I decided to get pronouns for my badge because I work in healthcare. I think as a physician I should be a life-long learner. That doesn’t only mean I will keep up with the latest medical knowledge. It also means that I will continue to learn more about the different people who are and will be my patients. In the end, we use medicine to treat people. The key word is “people.” And the identities each person has are an important part of who they are and is, therefore, relevant to their overall health.

Now, after thinking about pronouns for a year, I still make mistakes while using they/them pronouns. I make mistakes when using pronouns that are different from what I originally assigned a person before asking what their pronouns actually are. But, I make fewer mistakes the more I practice. And I do practice. It is important to me that my patients, and anyone in my life, can be who they know they are, not who society has said they should be. So, when I wear my pronoun the message I wish to convey is that I want a society were everyone can use the pronoun that suits them whether or not it is the same pronoun their parents used for them as a baby. The idea I want to support is that each of us has to do our part to be accepting of people who are different from us. It is one thing to say that all people have a right to life, liberty, and happiness and quite another to create systems that support that and to act as if all people have those rights. Getting pronouns right is one tiny thing each of us can do to start to change our biased language system. Remember, the thing about ants is that their power comes from numbers not size.

Tipping point?

“I’m glad they hired an American,” the woman checking out at the CVS said to me. To my right and left were my friends and colleagues working other registers. That customer had no idea where I was from or where they were from. I was the only white cashier that day.

“What is wrong?” I asked.

“He swore at me and called me slow,” my colleague said. I had served that customer 100s of times. He was rude, but he had never talked to me that way. I was white and my colleague was not.

“I told her she should pick someone else. I ask her why she couldn’t pick a lighter man, so they could have lighter babies,” my friend said to me.

“Is he white?” a friend asked when I was talking about a professor that I was struggling with because his course was unorganized. That was her second question. Her first was the professor’s name.

Above are several times when I had to think about race publicly.

  • What would you do in each scenario?
  • Have you experienced similar situations?
  • How would you approach a situation like these in the future?

The first one, in that CVS, haunts me. Why? Because I was silent. I was so surprised by the comment that I didn’t know what to say. I have often wished that I could go back and tell that woman I was not American. Just to see her reaction. I wish I had complemented my friends for their hard work in front of that woman. I wish I had said something, almost anything, to let that women know I disagreed. But wishing doesn’t change anything.

Every encounter since that one in CVS I’ve said something. My response has never been perfect. Questions and comments about race always surprise me. They shouldn’t, but they do. I review these types of interactions many times after they are done. Most of my responses were weak, but with each one I get better at saying racism is wrong. With each one, I get better saying that I do not believe people should be judged based on the color of their skin.

~

George Floyd was murdered by a cop. He died of asphyxia because a cop knelt on his neck and prevented him from breathing. George Floyd was not the first black person killed by cops. His murder was brutal but not unlike many previous violent acts against people of color in the US. After George Floyd’s murder, people took to the streets in large numbers. Cities across the US are protesting.  

We cannot know the future. But, perhaps, we can make sure that when today becomes history we are not still fighting the exact same fight. Today we find ourselves listing the names of the dead, the hurt, the pushed down because of their skin color. And though the list is too long to complete, many of us have not considered acting until now.

Why is George Floyd’s death the tipping point? Why are we acting now? Why not before? We may never know.

We may feel guilt for inaction in the past. That guilt will remain. But, let’s not feel guilty years from today because of now. Guilt does not fix problems. Actions fix problems.

The most important question each of us must ask ourselves today is: What am I going to do from this point on?

Protesting is one thing. It’s important but it will not, alone, change the status quo. We must do more.

Here are some things I’m already doing/starting. Join me. Or, make your own plan.

Immediate:

  • Protest or donate to bail out funds and organizations supporting and organizing protests.

Ongoing:

  • Vote.
  • Donate to organizations that fight for justice and equality.
  • Be an advocate, get involved in politics beyond voting. I can influence politics and our country’s laws in many ways beyond casting my vote (though that’s a good way to start).
  • Hold politicians accountable.
  • Hold friends and acquaintances accountable.
  • Reflect on my interactions with people who are different from me. Identify my biases. Make and enact a plan to be better. I will make mistakes. I will get better if I continue to push myself to see my shortcomings.
  • When I see racism call it out. Stand up for others. Take the hit. Have the hard conversation.
  • Review the systems I am part of like work and school. Is there bias? How can it be eliminated? Take action to eliminate the biases I see.
  • Push myself to learn from those who are different from me. Diversity is what makes all of us stronger. Seek it out.
  • Realize it is not good enough to be kind. Learn how to be just. Strive to be empathetic. I can not fully understand another person, but I can challenge myself to hear them and see them to the best of my ability.

When do we need heroes?

In movies and books with simple plots heroes have capes and big muscles. They drive decked-out cars and never compromise their morals. They are always good. The problem is, creatures like that don’t exist.

Heroes do exist though. They just aren’t as straight forward and flashy as blockbusters make them seem. We don’t usually notice them. As the saying goes, “A job well done goes unnoticed.”

Heroes use their precious time in selfless acts. Those acts need not be large, but sometimes are. Heroes don’t seek acknowledgement. They don’t expect thanks. They are driven by something within. They are driven by a belief that the world can be better and that helping others is worth some personal loss.

Being a hero always comes with a price. The price isn’t always steep, but sometimes it is. No one is always a hero. None of us are like superman.

Everyone has opportunities to be a hero at different points throughout their life. Those who become heroes step up and take those opportunities to help others more often than they let the opportunity go untaken. Those who can’t act on those hero opportunities aren’t bad—they’re just human.

Few can dedicate most of their time to others. Life is more complicated than that. Personal need is real. That’s why it’s amazing when someone goes out of their way to help others often. Being a hero doesn’t come with a job title. Becoming X doesn’t mean you are selfless. Becoming X may afford you more opportunity than becoming Y does to be selfless. Some jobs are centered around helping others, but only doing the job well achieves that goal. The bigger point is that we all can be heroes. Regardless of what profession we do or place we live or activities we undertake, choices are made every minute of every day in terms of how we act and treat others. What makes some people exceptional on the hero scale is how often they take a loss and lend a hand.

I think it is important to be grateful for acts of kindness and service. Not just now, but always. I also think little acts pile up. It’s worth noticing small acts just as it is worth acknowledging something large like a life saved. We can always thank those who are kind. We can always strive to be kinder. Times like these, when so many folks are sick, make it easier to notice how others are sacrificing for us or our family. But, truth be told, people are heroes every day. Just like someone could use our help always.

The circumstance of COVID19 remind us that we can make a difference in other’s lives. But, the need for heroes will not end with COVID19, just as it did not begin there. COVID19 has given us a window to view our inner strength. It has made us pause and observed those around us. I think hard times renewed our reverence for helping. Let’s keep the value of others sacred long past when the pandemic fizzles. Because, when the pandemic ends, all of life’s other troubles will continue.

Today I’m Grateful

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

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

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

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

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

True Love

Not so long ago in the ED, I was helping a patient in one of the acute care beds. Through the curtain that divided the room I was in from the next patient room, I heard someone reading out loud. Where the reading was coming from, a post-retirement man was the patient and his wife was with him.

I saw through a gap in the curtain that the wife was happily reading a book to her husband. Her voice rose and fell with the emphasis of someone who had read aloud many times. Her voice mixed with the sound of her husband’s snoring. When she stopped reading, he stopped snoring and became restless. Sometimes she paused and looked at him. She’d smile and then continue reading before he fully awoke.

The sleeping husband and reading wife seemed so content and peaceful despite being in the middle of the ED on a day when people around them were having their worst days. The husband could have been very sick too but, unlike many of our patients waiting to be seen, he wasn’t sitting alone staring into space as he waited.

That woman reading to her husband was the clearest example I’d seen of true love in months. We see a lot of couples and families come through the ED every day. Accompanying a sick loved one often brings out the caring side of people, however there was something about the calm, closeness of those two (sleeping and reading) that highlighted the strength of their connection. I was reminded, for the millionth time, that it’s the little things that add up to indomitable forces.