Saturday, June 30, 2007

A Few Things You Should Almost Never Say to People

"Are You NUTS?!"
When I told people I was going to embark on medical school with a ten-month-old in tow, I got various versions of, "Are you friggin' NUTS?!" in response. See, I think you should only ask that question of someone who's about to jump off one of these (visited today at the Lake Placid Olympic Ski Area):




"We Think Your Child Might Be Retarded." [sic]
When I was four or five my kindergarten teacher expressed some concern to my mother that I might be developmentally delayed. After premature birth at 32 weeks in the early '70's, this wasn't out of the question, but when my mom asked why she suspected a problem, the teacher reported that I couldn't seem to pay attention and often looked blank.

"What are you teaching them?"
"Oh, the shapes and colors-"
"She already knows those."
"How to count to ten-"
"She can count to a hundred."
"The ABC's..."
"She's been reading the New York Times to us for weeks. Look, is there anything else?"

I don't think the meeting ended too well. Just for documentation my mom brought me to Clark Air Base to get psychometrically evaluated by the Americans. Everything checked out reasonably well. She put me in a different school.


"You'll Never Amount to Anything."

Sometimes I think conventional measures of ability and the tendency to judge people based on personality do little justice to the capabilities and gifts people actually have. I came across a wonderful letter to Stanford pre-meds by Michael McCullough, M.D., that I wish were required reading for ALL high school, college, and med school students and teachers. In it he reminds us: "Albert Einstein, Bill Gates, Winston Churchill, Thomas Edison, and Mother Teresa all had something in common: they didn't do well in school. Take home point: Don't rely on a grade point average to prop up your sense of self." We so often define our worth by our successes; it's high time we redefined success!

My favorite example of the school-"failure"-yet-genius is the story of Australian make-up artist Ann Maree Hurley. She kept telling people when she was growing up that she was going to be a make-up artist, and the best response she ever got was, "That's nice, dear." She failed her last year of high school and struggled through Wodonga Catholic College. But she persevered with her true love and has now worked as a make-up artist on all three Pirates of the Caribbean films. To that I say, you go, girl.

Oboist Caroline Plamondon posted a story on the Oboe BBoard relating how her school band teacher discouraged her from trying the oboe, because she was "too shy," then later tried to persuade her mother not to allow her to audition for the Montreal Conservatoire and two other colleges: "He called my mom and told her it would be a good thing if she discouraged me from entering those schools, because I didn't have any chance of getting in, let alone becoming a professional musician. Well, I got in to the 3 schools, chose the Conservatoire, studied there for 6 years before changing schools to obtain my Master's degree." SO THERE! Way to go, Caroline Plamondon!
***
When I was applying for pediatric residencies (before my anesthesia days) the chairman of pediatrics told me that Children's Hospital in Boston would be a "reach" and I shouldn't bother. In many ways he was quite right and the advice was practical. A couple of years later, after I had fallen in love with anesthesiology and switched my career track, I couldn't help laughing at the whole episode when I found myself practicing medicine at, guess where, the O.R.'s at Children's Hospital. The only way to know if you can reach something is to stretch for it.

This was the same chairman who, during my internship, after listening to me explain the molecular mechanism of hyperkalemic periodic paralysis, asked me in front of a roomful of pediatric interns and residency applicants to draw a diagram of the mechanism on the board. After a split-second silence, I said, "Sure" and walked up to the board and drew it. Then I left that program and started my anesthesia career.

But that's when learning became grueling.

During my first year in anesthesia residency I took an early leave-of-absence to help my husband and children move to the Boston area, and the day I returned, with my "skill set" still nonexistent (how I hate that phrase), or embryonic at best after only two weeks on the job, the attending physician I was working with sniped at me all day with insults before finally saying, "Maybe you shouldn't be doing anesthesia." When I looked at him in disbelief that a teacher could be so un-helpful to a trainee, not to mention in pain at being disparaged all day, he just emphasized, "Yeah. Maybe you shouldn't."

His labeling of me haunted me in various ways throughout my training, and despite some genuine teachers, like my residency program director, who were willing to judge me for the good progress I made and the expertise I attained by the time our training ended, there were still those who didn't have the capacity to look past that prejudicial incident and my early struggles during that challenging first year. Thankfully they weren't able to discourage me from taking good care of my patients - from the Peruvian child at Children's who put his arms around my waist and thanked me the day after I had to intubate him awake with a fiberoptic device, to the elderly Korean gentleman who spoke no English but conveyed his thanks with a squeeze of my hand. It was in these unseen, uncredited moments that I felt I was truly a physician my program could be proud of.

To the teachers who actually TAUGHT, I send out a heartfelt thank you, for bringing me to this successful place:

Thursday, June 28, 2007

Composition and Decomposition

I remember being afraid as I stood in line waiting to enter the anatomy lab for the first time in medical school. What I can't remember is why. Dead bodies can't hurt us. Practically speaking, we can't really hurt them any more either. But I was scared. I was nervous about entering a room and seeing dead human beings everywhere.

But I needn't have been. The most beloved professor of anatomy at my school, Matthew Pravetz, made sure to teach us from the start that we could not approach our cadaver, our "first patient," as he reminded us, without deep reverence in our attitude, demeanor, behavior, and indeed in our hearts. Dr. Pravetz, also a Franciscan priest, brought the gifts of his spirituality into his work, and ours, without imposing any kind of religiosity on us. Every time he gave a lecture or demonstration, you could see his sense of wonder at the way every sinew and vessel in the body had developed; his love of the human body and faith in its sacredness permeated the course and set us off on the right foot toward becoming true physicians. That's a good teacher for you.

The following year, when it was our turn to help the new first-year students take that first step into the anatomy lab, I was stunned to find myself breaking out of my usual timidity and lack of self-confidence, carried away by my own excitement about anatomy and growing love of medicine. I remember trying to pass on some of what I'd learned, touching a cadaver's thorax and explaining what its "barrel chest" might have signified about lung disease in life, laying their hands on the chest so they could feel for themselves and no longer be afraid, as I had been. The medical school chaplain was there, standing by just to support us all, and later he took me aside and said, "Good teaching in there."

I can still see my cadaver clearly in my mind, down to the graceful loop made by her recurrent laryngeal nerve after we dissected it free from the other tissues in her neck. Some of my other fond memories of the anatomy lab are spottier, though I remember my three wonderful lab partners vividly. I remember a guy once had an itch on his nose but his gloved hands had just been handling the cadaver, so in desperation (and apologetically) he rubbed the tip of his nose on the shoulder of my scrub shirt as I walked by. I remember being alone late at night with my cadaver studying for an anatomy exam and being startled when a light turned on at the opposite end of the lab, followed to my great relief by a friendly classmate's voice saying, "It's just me!" I remember having no child care for one of my anatomy oral exams and handing of my then-one-year-old daughter to the group ahead of us as they came out of their oral so I could go in with my lab partners and take mine.

It was so great to come out of that exam and find my little girl waiting in the lobby with my kind-hearted classmates. A new, fresh little life, bright and sunny, just beginning her journey.

***

I started thinking about the ubiquity of decay today because of mushrooms. We spent the afternoon at the Adirondacks' natural history museum, The Wild Center, a small but beautiful museum in Tupper Lake, NY. Despite the fact that I have almost completely shed the "doctor" part of my identity during this vacation, I was happy to see this defibrillator situated halfway through one of their nature trails:




You'd think the highlight for me would have been the adorable river otters, or the natural history hands-on cabinet, or the live kestrel presentation, but no, the highlight for me was...the mushroom exhibit. I didn't know there were 1.5 million species of fungus in the world (compared to 4,630 mammals). I had no idea that oyster mushrooms are predatory. But I did know that morels are DELICIOUS as well as mysterious.

***

Speaking of morels, I have to give vent to the foodie in me and rave about the dinner we had last night at our amazing hotel. My husband and I have been trying for weeks to celebrate our anniversary with a nice dinner, and last night we had our chance: the Narnia movie was showing in the hotel's small movie theater, and our kids were more than happy to be dropped off while we had our romantic dinner for two. We were done with it in time to see the last battle scene with them - perfect!

I had some delectable morel risotto with a perfectly prepared halibut garnished with a frizzled wild leek and some small carrots, paired with a delicious Sheldrake sauvignon blanc. My husband had lamb. For dessert I had a strawberry "shortcake" assembled from candied ginger scones, whipped cream, and strawberries with sorbet and a dark-and-white chocolate stick on the side. YUM.

Yesterday the New York Times featured a story about a chef , Rebecca Charles, who was fighting for her recipes and restaurant design to be recognized as her intellectual property. I don't know much about the case, but I do think it's time for creativity with food to have its due. Creativity and composition balance out ever-present decomposition and the relentless law of entropy, and the necessity for all life to fall into the cycle of decay and renewal.

In a couple of billion years our sun will explode and take all of our achievements with it - human language, writing, architectural treasures like Chartres cathedral and the great bridges of the world, chemical engineering, great musical works, art, painting, inventions, medical technology, spiritual insights, movies and shows, all lessons and artifacts, not to mention relationships and unique individuals...unless we find a way not to lose these by then. For now, our creativity is what we have as evidence of our vitality and witness to our preciousness. Creativity in the kitchen included!

***

This recipe for Morel Risotto is courtesy of Phillip J. Speciale and quoted from www.thegreatmorel.com/recipes.html:

Ingredients
1 cup of small dried morel mushrooms, reconstituted and cut in quarters
1 medium sized yellow onion, chopped
2 cloves of garlic, chopped
4 Tbls of butter
6 cups of chicken stock
1/2 cup of Marsala wine
2 and 1/2 cups of arborio rice
1/2 cups of freshly grated parmesan cheese
1/4 tsp salt
1/4 tsp of freshly ground black pepper

Preparation
Pour broth in a medium size saucepan and heat to a simmer. In a slightly larger saucepan add the butter and sauté the garlic and onions for about 1 minute. Add rice and mix well coating the rice with the butter. Stir in the wine until it has evaporated. Stir in mushrooms. Add broth 2 cup at a time and stir until broth has been absorbed. Repeat until all the broth is used. When rice is tender mix in parmesan cheese.

Tuesday, June 26, 2007

Codes

Code #1: Rondeau's Journal


One of my favorite books when I was in grade school was a book about secret codes and ciphers called How to Keep a Secret. Not only the act but also the idea of writing fascinated me - that our thoughts could be made visible on the page, with symbols. Ciphers had special allure because you could put those thoughts out into the world, then conceal them again - how intriguing!

The reason I mention this is because codes and ciphers came up in conversation during our visit to the wonderful Adirondack Museum, probably one of the nicest museum experiences we've had as a family. It's a bit like the Shelburne Museum in Vermont, with lots of historic memorabilia and artifacts related to human labor and achievement, beautifully displayed, but more compactly laid out than at Shelburne, with more focused exhibits.

There was an interesting replica of pages from the journal of Adirondack hermit Noah John Rondeau, who wrote his journal in cipher, sparking a conversation between my family and me about writing for oneself only, and why someone might do that. Ultimately we may write most genuinely when we write for no audience other than ourselves...but to block access so actively seems to counteract the sharing process I associate with writing, although of course I've also discussed writing as tilling the garden of one's own mind, a way to shape and develop one's thought processes...

Code #2: The "Sliver" (a true medical code situation, potentially, if I ever saw one!)

Elsewhere at the museum I was amused to find a charming cottage that had been the dwelling of the doctor "on-call" at a place called Camp Cedars. If only all call-rooms could be so quaintly appointed! Other highlights included a walk-through rail car, the carriage Theodore Roosevelt rode at breakneck speed after McKinley was shot and Roosevelt got the news he was president, a picnic lunch with a view of Blue Mountain Lake, and an exhibit on loggers, which being a fan of log homes I found especially valuable. I was startled by this depiction of an injured logger receiving general anesthesia to remove a "sliver":


Not something I want to see rolling into my O.R.!

Code #3: Oral History, Unspoken History, and Codes of Conduct

After visiting the Martyrs' Shrine yesterday we spent the night at the Mohawk Indian Bed and Breakfast, also known as Kanatsiohareke ("ga-NAH-jo-ha-LAY-gay"), meaning "place of the clean pot" after a basin formation in a nearby stream. The lovely Mohawk woman who runs the place, Emily Tarbell, is the seventh of seventeen children (!), and a great story-teller. She cooked us a hearty country breakfast during which a man named Rob stopped by just to tell a delightful story about a runaway 800-lb bull he was trying to transport. It was beautiful to hear little bits and pieces of the Mohawk language in the conversation, and luxurious to be able to talk and eat without watching the clock. I would so love this slower pace, rich in human contact and story-telling.

I couldn't help but wonder, all these centuries later, if there is still some tension and pain between the Mohawk and other area residents. As much as I cherish the life of René Goupil and his companions, and admire how they demonstrate real growth in their anthropological understanding (as shown in the writings of Jean de Brebeuf for the Jesuit Relations), I am not oblivious to the fact that they came as outsiders, albeit with good but in many ways misguided intentions, and basically contributed to the loss of a native culture and people, the Huron. Nor do I have any romantic, uni-dimensional notions of native tribes in the 17th century as placid tree-huggers; from what I've read and heard, they had deep spirituality and reverence for their world, but they were also plenty violent with prisoners of war and committed atrocities that might turn the stomachs of the most battle-scarred warriors today. Nothing is simple, and over 350 years later this holds true. There was plenty of both heroism and guilt to go around. But the fact is, Europeans and their descendants claimed for themselves an unjust portion and are still enjoying the fruits of that claim today.

I find myself caught between two sympathies - my admiration for Jesuit faith and work ethic, with special affection for René, and my admiration for native peoples and desire to learn from their wisdom. Meeting Emily was a real blessing, a bridge. I cherish the connections we've made, in our minds and hearts and with others, stemming from our encounter.

Music and Silence

Monday, July 25, 2007:

We’re on VACATION!!!

We set off westward found ourselves near the Massachusetts-New York border by lunch time, so we had a home-packed lunch of sandwiches and strawberries at Tanglewood, right in front of the Hawthorne Cottage. What a great start – a picnic in a place permeated with music and literature, my favorites!

***

In the car on the way to New York I was so pleased when my daughter asked, “Is this Holst?” and started humming along to Jupiter. I also played a mix of violin selections, some of which included Joshua Bell in belated honor of his busking experience.

I always think of Perlman when I hear the Mendelssohn concerto and of Gil Shaham when I hear Sarasate’s Zigeunerweisen. Thoughts of Perlman made me recall Youtube footage of a master class he taught in Russia. What a great “bedside manner!” He was supportive of his students, acknowledged them as musicians without being condescending, and offered corrections in a way that was so clearly meant to help the musician be the best he or she could be. Watching one of Heifetz’s master classes (the clip I saw is no longer up) gave me a totally different feeling – intimidated, threatened, disdained, like my hard work and efforts would cause the guy nothing but exasperation. It was like reliving residency all over again. He’s such an unbelievable technical wonder, though.

I believe teaching should come from a love of what is being taught and a desire to transmit that love to one’s students, and with it the commitment to strive for excellence. I believe in respecting students, whatever their abilities or background, and in approaching them with an attitude that says, “I believe you can learn this, and it’s my job to help you do that, and it’s okay if you have a hard time with it at first.” No condescension, put-downs, scorn, resentment, or rage when something is not known or understood or immediately done well by the student. In other words, the opposite of most medical education, at least in my experience.

I hope when I teach I come across more like Perlman.

***

We spent the afternoon at the Shrine of the North American Martyrs in Auriesville, NY – a peaceful place with a gigantic round church surrounded by meadows and trees. It was a personal pilgrimage of sorts for me – the patron saint of anesthetists, St. René Goupil, died there after being tortured for weeks with his fellow-captives. I was surprised that a place with such a sad and violent history should have such tranquility about it. My husband and children were very supportive of my desire to visit this place, “where Mommy’s special saint died.” Our favorite part of the visit as a family walking down the ravine where René was killed by two natives and later buried, in an unknown location, by his friend St. Isaac Jogues. Posted for visitors to read on the trail down were excerpts of Jogues’s first-hand account of René’s death. It was an indescribably peaceful walk, despite the tragic story, and at the bottom the trail suddenly opened up into a beautiful clearing, where we spent several minutes just enjoying the sacred atmosphere of the place. It was strange to think part of him was still physically there, somewhere in that clearing, and wonderful to enjoy the silence of the place. It’s not often any of us has a chance to enter into some quiet contemplation on our own, much less as a family, so this moment of tranquility and renewal was like a drink of water in the desert.




___________________________________________________________

Addendum, July 11, 2007:

Found this description from a reflection by William McNichols, S.J.: "Walking down the pathway into the ravine at Auriesville where it is said René was murdered, one knows why pilgrims come especially to the ravine, and will always come there. For it is in the ravine that one senses something of God - some touch, some peace, some blessing. This place does not attract the sensation seeker, looking for the morbid or the macabre. Rather, one finds that the earth there, sown in red seeds, has brought forth a verdant, shimmering landscape Pope Pius XII called 'Nature's Reliquary.' " Jesuit Bulletin. Fall 1984. p.12-14.

Saturday, June 23, 2007

On Seeing and Being Seen: a meditation on the social psychology of medical intervention

I thought Bill Clinton's graduation advice to make sure you really see the person next to you was good.

I thought the failure of people to notice Joshua Bell playing at the Lafayette Metro Station was bad.

But there's worse.

What's worse is people NOTICING something notable, but ignoring it.

And worst of all is when failure to see, or act on, a noticeable crisis costs a life. It was one of this week's buzz stories in the O.R.: the death of Edith Rodriguez.

Edith Isabel Rodriguez went to the E.R. at Martin Luther King, Jr. Hospital in L.A. - also known as King-Harbor and formerly known as King/Drew - doubled over with abdominal pain. According to the Associated Press, "It was at least her third visit to Martin Luther King Jr.-Harbor Hospital in as many days. 'You have already been seen, and there is nothing we can do,' a nurse told her.”

This kind of situation can put any doctor or nurse in a tough spot. A patient presenting with a history like this is usually either afflicted with an ill-defined medical problem, sometimes chronically, often more than one, and typically difficult to relieve completely, OR...the patient is in SERIOUS TROUBLE.

Jonathan Larson, composer of the famous Pulitzer Prize and Tony Award-winning musical Rent, got sent home when more than one emergency department failed to diagnose the cause of his chest pain and nausea: aortic dissection, which killed him the day before Rent opened.

Sometimes it can be a tough call, but I think when someone goes from abdominal pain to vomiting blood, it's usually a clue that something really BAD might be going on, depending on the nature of the vomitus and the amount of blood present, and I have to wonder what the thought process was in that emergency department. I admit I don't know all the details, and hindsight after someone codes and dies is certainly 20/20, so I am in no way trying to point the finger here. I'm just wondering, like everyone else, what happened, and how could it have happened?

Edith Rodriguez's story has by now been publicized widely in the media. The articles I saw were on MSN and the L.A. Times, but I was struck most by the CNN video on glumbert.com. It relates how Ms. Rodriguez lay on the floor vomiting blood, and somehow got help from NO ONE except a couple of individuals who tried to call 911 for an ambulance to take her to ANOTHER hospital. From the video and the articles I read, I've reconstructed part of the transcript of these calls here:

First call, 1:43 a.m.:
Caller: My wife is dying and the nurses don't want to help her.
Dispatcher: Okay, what do you mean she’s dying? What’s wrong with her?
Caller: She’s vomiting blood
Dispatcher: Okay, and why aren’t they helping her?
Caller: They’re watching her...uh...they're watching her there, and they’re just not doing anything. They’re just watching her.

Second call, from a different person, 1:51 a.m.:
Dispatcher: What’s your emergency?
Caller: It’s a lady on the ground here at the emergency room at Martin Luther King.
Dispatcher: Well, what do you want me to do for you, ma’am?
Caller: Send an ambulance out here to take her somewhere where she can get medical help.
Dispatcher: Okay, you’re at the hospital, ma’am, you have to contact them.
Caller: They have a problem, they won’t help her.
Dispatcher: Well, you know, they’re the medical professionals, okay? You’re already at the hospital. This line is for emergency purposes only. 911 is used for emergency purposes only.
Caller: This IS an emergency!
Dispatcher: It’s not an emergency. It is NOT an emergency, ma’am.
Caller: It is!
Dispatcher: It is not an emergency.
Caller: You have to see how they’re treating her.
Dispatcher: Okay, well, that’s not a criminal thing. You understand what I’m saying? We handle-
Caller: Excuse me, if this woman all out dies, what you mean there ain’t a criminal thing?

The call did not end well. The dispatcher insisted again that the situation was not an emergency and offered the caller a business number if she was displeased with what was going on. Just before 2 a.m. the caller said, "May God strike you too for acting the way you just acted." The dispatcher's reply: "No. Negative ma'am, you're the one." He has since received "written counseling" for the way he handled the call.

Edith Rodriguez was pronounced dead at 2:17 a.m.

Zev Yaroslavsky, LA County Supervisor, was flabbergasted at the security video of the incident. He said it was even worse than the audio tapes. “Not one person out of a couple of dozen, including citizens and staff and doctors and nurses…[They] didn’t lift a finger to help her. They just ignored her. Even the janitors who were cleaning up the vomit from around the woman who was on the floor did a very elegant job of cleaning up the vomit but didn’t do a thing to help her. It was just indescribable.”

With her writhing on the floor in pain, vomiting blood, and her loved ones begging for help, how could someone NOT have assessed the need for some intervention? If nothing else, isn't that what emergency departments DO?

Now, I know about the Bystander Effect. I've heard of Darley and Latané's social psychology experiments demonstrating the failure of people to help others in a crisis if other people are also present. I've read about the terrifying case of Kitty Genovese, who was stabbed, raped, and killed over the course of half an hour even though 38 witnesses heard her desperate cries. I've even been a cautious bystander myself.

When I was walking back to my hotel from dinner with an anesthesiologist friend of mine (we were in D.C. about to take our oral boards, actually), we noticed a pair of human legs protruding from the bottom of the potted plant decorating the entrance of her hotel. We came upon a man passed out on the sidewalk, his head and neck cocked to a rather concerning angle. There was already someone palpating the carotid for a pulse (correctly, we observed), and we didn't want to contribute to a "too many cooks spoil the soup" situation, so we lingered in case our help was needed but stood quietly in the background. I did go into the lobby and try to get the hotel management to bring out any first aid or medical equipment they might have had, but they just stared at me blankly and said 911 had already been called. I insisted that someone go and retrieve the stuff anyway, and one of the employees went, but I didn't see him again. Anyway, the paramedics arrived and packed the guy up, and my friend and I saw that they needed no interference from us. But I should hope we would both have asserted ourselves immediately if the situation had really called for it.

What bothers me about the Edith Rodriguez case is that I could easily have been one of the bystanders in that hospital lobby and contributed to her death, although I can't say for sure what my reaction would have been without knowing all the details of the actual situation. We all want to think we would have been the different ones, the types who would have said "no" to the authority figure in the Milgram experiment and refused to apply the electric shocks to the subject, the types who would have called for help in Darley and Latané's experiment when the stranger started seizing. We all imagine we would have bent down in concern toward Edith Rodriguez and at least tried to figure out what was going on, if not offer actual assistance. I think I would have done this, I hope I would have...but I also think deep down we all know that it's easy for ANYONE to be swept into the middle of an inert crowd and stay there dumbly looking on.

Edith Rodriguez's brother, Eddie Sanchez, made this poignant comment on the glumbert video: “You go there to get help, and nothing happens, like…You get ignored like if you’re nobody.” How many times have I failed to SEE my patients, or unwittingly treated them as if they were "nobody?" I cringe to think that I may have done the very same, albeit without the fatal consequences. Or, even if I paid adequate attention to a patient, what if I made the wrong judgment about how to manage the patient's problem, out of a reluctance to admit, "Yes, we have a disaster, and it's right in front of our eyes?"

I pray every day for the ability and courage to make the right calls. A couple of weeks ago our friend who's a flight attendant was describing a flight during which a passenger was found doubled-over in his seat. She announced the need for a physician and said it took a long time for one to come forward. I understand that - the daunting sense of responsibility often competes with the desire to serve and relieve suffering. As it turns out, the physician who did examine the man also told our friend that the captain had to land the plane immediately because the man was in acute heart failure. I think that was a very brave doctor in there. That's a heck of a call to make, diverting a flight filled with passengers to save one life on the suspicion of a life-threatening condition NOT confirmed by the technological aids we get so used to relying on in hospitals. I spiritually bow my forehead to the ground in respect and admiration and pray I never have to make a call like that. Although, what's worse - being wrong about the heart failure, and causing an inconvenience, or being right but lacking the confidence to make the move, thus costing a life? I guess the answer's pretty unambiguous.

I've alluded to the training we got in our medical simulator during residency. I am not allowed to comment specifically on our training scenarios or on people's actions within them, but I think I can make some general remarks on the experience. While the medical aspects of those scenarios were useful, I think a key element in teaching crisis management of any kind is a rehearsal and discussion of group behavioral dynamics. We did bring up and discuss issues like those raised by the Edith Rodriguez story. What makes us blind to another's needs? What makes us ignore data that's right in front of us, or help that's offered? How can we best structure a group's interactions so that efforts to provide help are focused and organized?

One take-home message I valued was that there should always be an "event manager" - one who's NOT involved in DOING tasks, but rather is WATCHING everything that's going on, processing it, and determining what steps are needed next. But of course, in the real world, this role separation is difficult, and often it's not possible to delegate. Or, people are reluctant to step forward to claim the role.

My heart goes out to Edith Rodriguez's loved ones. We in the medical profession failed them, egregiously. The only personal offering I can make at this point is a commitment not to rest smugly in the position of critic and judge, thinking, "Well, I would have seen her there, and I would have done something. I'm not blind." Sure I am. Or can be. And it makes me think twice about an old, familiar New Testament quote from a blunt, rather ticked-off Jesus:

Jesus said, "If you were blind, you would not be guilty of sin; but since you say, 'We see,' your sin remains." (John 9:41)

All I can honestly say is I would LIKE to think I would have treated the situation differently. But I cannot say that I would surely have been immune to group blindness or inertia. I think we need to learn to acknowledge our blind spots and make a promise to all patients, "We don't always see well, but we will always work to see better. Always."

Friday, June 22, 2007

Have You Hugged Your Anesthesiologist Today?

That’s it. I’ve had it. I’ve read yet another piece of writing that demonstrates a complete lack of understanding of what anesthesiology is and entails, and I need to vent.

So allow me to lower the mysterious drapes for a moment and let you into my world.





No one gets up one day and says, “I want to be an anesthesiologist when I grow up.” I wanted to be a ballerina, or a bookstore-café owner, or an artist of some kind – someone who was required to pay close attention to the world, take real notice of it, and take creative and compassionate action. But I am neither a ballerina nor a bookseller. I am an anesthesiologist.

Frequently people ask me a version of “What on earth made you choose that?” I try to explain that I love the way anatomy and physiology come alive moment-to-moment in daily practice. Or I try the concrete approach and admit that I actually enjoy placing intravenous lines and breathing tubes. The response I get is usually a glassy-eyed “Uh-huh” or, occasionally, a nose-wrinkling “Eew.” If the conversation progresses beyond “eew,” the more people talk to me about what they think I do – that is, if they think I actually do anything in the first place – the more bewildered I get over how difficult it is to convey to others an understanding of my work.

One time I visited a patient the day before her planned surgery. After I explained what she could expect, she exchanged a few words with her family in her native language. They clearly assumed I couldn’t understand them. An older woman instructed my patient not to bother asking me too many questions, saying, “She’s just an anesthesiologist; what do they know?”

After years of annoyance at many people’s assumptions that I was not a physician because of my gender or my young appearance, this remark – not the first I’d heard along those lines – made me take stock. I realized that not even other physicians understand what we anesthesiologists do, sitting back there in our little cockpits behind some blue drapes (“the blood/brain barrier”), periodically looking up at large machines but appearing otherwise idle. One doctor asked me once, “You have to take an oral exam? For anesthesia? Is there enough material in anesthesiology for an oral exam?” Considering the profound suffering the ordeal of the orals caused me, and causes many anesthesiologists, I felt like shaking the guy by the hair – except he didn’t have any. If other doctors don’t get it, how could I hope to find anything but murkiness and misunderstanding in the perceptions of non-doctors?

I did a little experiment. I constructed a detailed questionnaire about what kind of physician people would want to come to their rescue if they collapsed in a public place. No one wrote down that they would be glad if an anesthesiologist were around.

I figured out about four broad, wide-spread misconceptions about anesthesiologists:
-we are not doctors
-what we do is easy
-we don’t establish rapport with our patients
-if anything goes wrong, “it’s Anesthesia’s fault.”

Then I realized something else: because people have absolutely no idea what to imagine about our work, they decide to make stuff up. It’s amazing.

People react to the mysterious in one of three ways: with fear, with fabrication, or with efforts to deepen their understanding. The fear I see daily. The fabrication – well, let’s just say if I hear one more person declare that all I do is put people to sleep, then sit next to my anesthesia machine and—what? Daydream? Wait for the patient to wake up? Twiddle my thumbs?—that will be one person too many. But that is what people say.

I have heard more times than I can count, “Well, all you do is knock people out. How hard can that be?” My hairdresser asked me when we first met, “So, once you put the patient to sleep, do you leave the room since your job is done?” Excuse me? My job is done? Then who did he think was keeping the patient alive while the surgeon was mucking around with his vital organs and causing all sorts of dangerous disturbances to his vital signs? Who was going to make judgments about what was specifically appropriate for that patient’s particular brand of heart defect, or lung disease, or neurologic abnormality? And then there’s my personal favorite: “You mean, anesthesia for appendicitis is different from anesthesia for heart surgery?” Hmm. 1-inch abdominal incision versus sawing through a person's chest. Yes, it's different.

My husband once tried to mollify my irritation by pointing out that people just couldn’t be expected to know about anesthesia. “Do you know what a machinist does? Or a gaffer?” To which I replied, “Of course not. I have no idea. But I don’t assume that their jobs are easy, and I don’t presume that their work can be summed up by one simple task.” Even my lawyer husband had to admit I had a point. “Well,” he said, “what DO you do, and what do you want people to know about it?”

I don’t think of myself as a doctor whose function is to induce sleep. My primary function is to resuscitate those who need resuscitating. Yes, about 1% of what we do does involve calculating the appropriate dose of the appropriate drug, drawing it up into a syringe, and injecting it into the veins of people who would like to avoid feeling pain or hearing unfamiliar noises during surgery. But I spend most of my energy making sure that I can bring them back. Designing an anesthetic is a thoughtful act. My resuscitation of my patients often begins the night before I meet them, when I am going over safety plans in my head.

Most of my training, in fact, was focused on becoming an expert at resuscitation in its various forms – reviving patients who were dead or near death; intubating those who could not breathe; rehydrating the dehydrated; unparalyzing those I had paralyzed chemically for surgical purposes; awakening the unconscious with judicious use of anesthetic drugs and gases; creating pain relief and anti-nausea regimens for the afflicted; and making sure failing heads, hearts, or lungs functioned well enough to ensure survival of a given surgical procedure.

Late in my training, I realized our level of expertise when I asked a resident in a different specialty – one whose members also take pride in their resuscitation skills – how many intubations she had done after two years. I was expecting to hear perhaps half of my quota of about 1200. “I’ve logged about 84,” she replied. And this was the physician-type people wanted nearby if they collapsed in a public place and needed a breathing tube to stay alive.

Anesthesia affects consciousness, blood pressure, heart rate, respiration, and a whole host of other body processes. If I am not there to watch over you, that first injection can harm you. And that’s just the first step. I should be breathing for you if you stop (and you will), administering fluids when your surgeon nicks a “bleeder,” and giving you the medications you need to wake up safely and comfortably. This can mean a lot of scurrying around, checking, and readjusting within the confines of my “cockpit.” Is the IV running too fast? Is the machine blowing in enough air with each breath? How’s the urine output? Oh, they’re closing – should I turn the gas down now, or will he take a while? Is that heart rate a little too high for his aortic or mitral valve problem? Did I give the drug to slow it down? Let me dive down under the drape to make sure his eyes are still protected…This is all behind-the-scenes, largely unacknowledged work, but it makes even the tiniest task a meaningful act, and I love that about my job.

And that’s just in the O.R.

I've written elsewhere about my E.R. and I.C.U. intubations, but I haven’t even addressed the expertise anesthesiologists bring to laboring women, not only in placing and ensuring the safety of epidurals for labor and spinals for C-section at any given moment, day or night, but also in caring for mothers when childbirth becomes dangerous. On occasion help is needed for an alarmingly sluggish newborn, and yes, we are useful for that too. The code that made my heart beat the fastest was when “Anesthesia, Stat” was paged overhead to the labor and delivery suite and I realized the person coding wasn’t one of the moms, but rather a minutes-old newborn. The family practice attending physician handed over the laryngoscope he was holding, and I intubated the baby so we could bring her oxygen saturation back up to liveable.

Many people have assumed that their limited understanding of our profession reflects a limited scope of medical practice on our part. Assumptions can be unfortunate, but I prefer to focus on the things that keep me coming back to the O.R. despite people’s colossal lack of awareness about what I try to do for them. I know what you’re thinking: it’s gotta be the paycheck, right? Never mind that childcare costs and six-digit educational loans eat up half of it. Sure, the pay is good, but it’s good because of what we are capable of doing for people, and the amount of sweat and tears it took to acquire and prove those capabilities. This is not a job you can commit to just for the pay and be truly happy. It’s too hard.

Nor can anesthesiologists be motivated simply by glamour and prestige – there’s too much ignorance about anesthesiology to allow for either. For me, real job satisfaction has to rest on tenacity, self-respect, humility, kindness, and happiness with the work itself. The big pay-off, in my mind, lies in my relationships with my patients, whom I may meet only briefly but during intensely significant moments in their lives, when they may need the most comfort. All the scientific gobbledygook that goes into the practice of anesthesiology has a chance to get sifted and transformed into a true human connection, into resuscitation that goes well beyond the needs of the body.

It’s my hope that someday, when a person collapses in the bookstore-café that I don’t own, or in the opera house in which I’m not dancing (or playing the oboe!), and an anesthesiologist responds, it will be common knowledge that the professional responding to the situation is providing expert care in the truest sense of the phrase.

Thursday, June 21, 2007

Writing, Reed-ing, and a List of the Week

When my eighth grade English teacher, Mrs. Riederer, asked us to keep a journal, she changed my life. To each of us she passed out a super-sized version of those black marbled composition books you get at the drug store, and she said we could write about anything, any time, without worrying about spelling mistakes, criticisms from her, grammar corrections, or anything like that. How liberating!

Along with the journals she handed out a page or two of suggested topics and questions, single-spaced, a few of which are reproduced at the bottom of this blog. Although she asked us to write in the journal only about once a week or so, it wasn't long before I found I just had to write in it almost every day. It became almost a meditative practice, like a liturgy of the hours, a physical act making incarnate the process I was going through, of becoming the person I was to become. I found that this daily writing, poured onto the page, was doing its work within, carving out the shape of my mind and filling in cracks and crevices, sculpting my intellect and my character day by day. Writing made me notice and pay attention - to my own life, my world, my own formation in that context.

When I look back on the entries now, I am profoundly embarrassed by my florid style as a thirteen-year old, and probably the best writing advice for me would have been what the father in A River Runs Through It said: "Half as long." But in a way having time and space in which to express myself without worrying about rules, style, or perfection gave me the freedom to cultivate greater mental agility, a better eye, a more versatile voice. Writing and thought are intimately connected and feed one another. I am convinced that cognitive (and, often, spiritual) development can be greatly enriched when people use writing as a tool for learning. Teachers should use it more.

Of course, I also believe in discipline and rigor in the writing process. Playing has its place, but exercise, revision, and just plain work are crucial. That terse comment from A River Runs Through It is still good advice for me today (no, the irony of this post's length is not lost on me!), along with Zinsser's incomparable work, On Writing Well, which is perhaps the best writer's guide I know. Among writers' reflections on the writing process, though, my favorites are Anne Lamott's Bird by Bird and Julia Cameron's The Right to Write. The latter contains so many inspiring, beautifully articulated passages about why we can and should embrace "the writing life."

"Daily writing," she reflects on p.150, "writing simply for the sake of writing, is like keeping a pot of soup on the back of the stove; it is always there, always ready to be tasted, always ready to be added to, always nourishing, savory, life-sustaining. Like soup, your daily writing doesn't have to be fancy. A few simple ingredients are enough."

Among my favorite lines, though, are these from pp. 50-51: "Valuing our experience...is the act of paying active witness to ourselves and to our world. Such witness is an act of dignity, an act that recognizes that life is essentially a sacred transaction of which we know only the shadow, not the shape...Writing is an act of self-cherishing."

I was crushed when a good friend of mine during residency heard me start a sentence with the words, "As a writer, I..." and said cynically, "Oh, you're not a writer," as if to say, you're not a "real" writer. Obviously I'm still preoccupied with this question of artistic validity. I was hurt not because the casual remark "put me in my place" - I don't think he intended that - but rather because I felt he was assaulting my self-concept. I realized that writing wasn't just an activity for me but something like an internal organ - a very real part of me. I wanted "being a writer" to be, not what I am, but who I am.

I have not danced ballet or modern dance seriously in years, but I still feel I can truthfully start a sentence with, "As a dancer, I..." Even if I never dance again, I think, I will still think of myself as a dancer. It's in my soul. Writing's in there too, and now, I think, being a musician. They're intertwined. Perhaps music is what started it all; music inside me has emerged as dance or as writing because those have been the instruments I've had so far (ok, piano too). I'm hoping I'll eventually find another path for this inner music, with my trusty little oboe.

***

A quote from Ralph Vaughan Williams about one of his works (4th Symphony, I think): "I don't know if I like it, by it's what I mean." What a great guide for creativity - to aim not necessarily for like-ability, but rather for genuine self-expression!

***

I went music shopping today. I bought a portable music stand and some staff paper so I could work on arranging a piano accompaniment for the Raymonda adagio. I got the same momentary pleasure I get when I go to the store to get writing supplies or at Christmas when I wrap presents for people (one of the happiest activities I can think of). I had so much fun.

Practicing is getting more multilayered. There's so much to work on! Long tones, scales, interval etudes, dynamics (which are at this point still so reed-dependent for me), breath support, the Bach and the Morricone, the smaller works I'm trying to learn (Simple Gifts and other churchy things). I can get through all of Gabriel's Oboe now, ever since Kyoko clued me into the left octave key (like, DUH!), so now I want to push past just "getting through" the notes and actually start to make some MUSIC. The Bach's gonna be a while.

***

Top 15 List of the Week (after today's O.R. conversation)(tweaked up from 10):

Attractive Leading Men in Movies Old and New

15. Viggo Mortensen in The Return of the King.
14. Bill Pullman as the president in Independence Day and the adorable brother in While You Were Sleeping.
13. Johnny Depp in Chocolat.
12. Anthony Andrews in the jail cell scene in The Scarlet Pimpernel.
11. Hugo Weaving as Elrond in The Lord of the Rings. Jeff Chandler as Cochise in Broken Arrow. Same type of concerned-father/warrior/ruler character.
10. Half the cast of King Arthur (e.g. Clive Owen / Ioan Gruffud) was eye-candy. The other half...wasn't exactly, but still enjoyable to watch.
9. Gary Sinise in anything in which his character isn't evil.
8. Antonio Banderas in The Legend of Zorro. Or in Take the Lead - whew!
7. Orlando Bloom in Kingdom of Heaven, more for the character he played than anything else.
6. Oded Fehr in The Mummy and The Mummy Returns
5. Yul Brynner in Anastasia. White shirt and guitar - 'nough said.
4. Paul Newman in Cool Hand Luke.
3. Hugh Jackman in pretty much anything.
2. Daniel Craig in Casino Royale.
1. Gregory Peck in Roman Holiday. Drool, drool, drool.

Tuesday, June 19, 2007

Today's Fortune Cookie

"Every artist was first an amateur."

(Lucky numbers: 20, 11, 31, 47, 26, 8;
baseball in Chinese: "bang-qiu")

***

I was too exhausted after today's long-ish work-day to cook, so my husband called Peking Cuisine for delivery. The crispy scallops with roasted honey-walnuts hit the spot.

The fortune cookie fortune was uncanny and brought to mind a recurring question in my mind: when is a writer a "real" writer or a musician a "real" musician? Can one be an artist by virtue of how one views the world, and the inner disposition with which one lives life - what Flannery O'Connor called "the habit of being"- or, does the nature of the work produced (good/bad, published/unpublished, finished/unfinished) figure into the definition too? (This is sounding vaguely like the justification-by-faith versus value-of-good-works dialogue among Christian churches...interesting...)

Monday, June 18, 2007

Lesson 7

Good lesson today! I'm improving! Kyoko will be leaving for the Colorado Music Festival, so I won't have another lesson till August. We crammed a lot of material in - long tones, little etudes from the method book, a teensy bit of repertoire, reed adjustments. One of my favorite moments was when she connected for me the anatomy/physiology of wind production with the physics of the oboe - and explained the greater breath support needed to counter the loss of wind velocity for notes played further down the length of the instrument. The doctor in me thought, This, I get!

She gave me one of her reeds as a summer gift, and it's the best one I have so far. And she gave me homework: Jesu, Joy of Man's Desiring. I'm going to have to work on my breathing for that one! One of my other favorite moments of the lesson was at the end, when, after talking about Bach for a bit, we started humming Sleepers Awake together and couldn't bring ourselves to stop. Bach has a way of reeling you in...

I've figured out why, for me, oboe is harder than piano. I need to recruit more of me to play the oboe - lungs, abdominal muscles, and oropharyngeal muscles in addition to arms and hands. When I hit a key on a piano, a sound is guaranteed; not so on the oboe. And notes on the piano keyboard are spatially arranged in ascending/descending order, logically. On the oboe there's definitely more jumping around that's not always intuitive. On the plus side, with the oboe we only have to worry about one note at a time...but I think it's harder to make that note sound "just right."

I've listened to more oboe music now and have come to the conclusion that pieces written specifically for the oboe are often less appealing than oboe parts written within larger orchestral works. That said, I have to admit I can't seem to go a day without hearing at least the first movement of Vaughan Williams' Concerto for Oboe and Strings, the second movement of Saint-Saens' Sonata for Oboe and Piano, and little snippets of Albinoni's and Marcello's concertos. I've also found some shorter works by Henri Sauget and Fernando Sor that I really like.

Yesterday my daughter had a piano recital and did beautifully. I don't know how she can be so relaxed about them. That's probably WHY she does well. I have been plagued by terrible stage fright in more than one area of my life and I've already told my oboe teacher I can't possibly EVER do a recital. At most maybe I'll play at church someday. Maybe. Years from now.

***

At work my colleagues and I take turns providing anesthesia for patients undergoing elecroconvulsive therapy (ECT). Today it was my turn. It's not like it is on One Flew Over the Cuckoo's Nest; it's a pity that it's such a demonized procedure. For some people it's literally the difference between life and death. Again I face the marvels and mysteries of the human brain and its workings during my day-to-day tasks at work...and participate in both altering and protecting it. This is always in the back of my mind during ECT's, which are some of the shortest procedures for which we provide anesthesia: the fact that the psychiatrist and I really have to take care of our patient's brain and concentrate every effort on helping it heal. And of course I'm also preoccupied with the airway, the cardiovascular system, the musculoskeletal responses...

Found this on Panda Bear's blog, and it made my day: "I’ve seen an Emergency Medicine Chief resident and a Medicine chief resident both fail to get an airway which the anesthesia junior resident put in while still half-asleep." At last! Someone who gets what our expertise consists of! Someday I'm going to have to vent about how little people seem to understand my specialty - even other doctors. Right now, though, this little anesthesioboist is bushed. Lights out.

Sunday, June 17, 2007

Three Men and a Ghost Story


Happy Father's Day to the wonderful fathers in my life:



My own, who, besides being a brilliant scholar, historian, and writer, is a loving person, a gentle advisor, and a loyal friend, always there with an ear to listen, a question that shows you he cares about what you're saying, or a kind word when needed;







My children's, who has never shied away from taking part in the day-to-day scut work of parenthood, the open-hearted delight of playing with the kids' toys (whether or not the kids are actually around), or the challenge of being their closest teacher;









and my husband's, a true Renaissance man, who has the gift of making people feel welcome, not alienated, and whose help you can ask with almost anything - an academic paper on Malraux, building an addition to your house, emergency child care, multilingual music, dinner on the fly, furniture-building...



These are what I call REAL MEN.

What's a real man?

This morning as I was making quiche for Father's Day brunch I played with the idea of calling today's post, "Real men do eat quiche, change diapers, cry at sad movies, and love faithfully." That about sums it up for me.

Real men use their minds as well as their muscles. They are turned on, not turned off, by a partner's intelligence and talent. They have the courage to have integrity. They fight for human rights, in ways large or small, and teach that kind of honor to those around them. They work hard. They're not shallow. Real men have a sense of wonder and reverence as well as a sense of humor. Real men show respect and kindness and don't use hate or jealousy as an excuse to exert control or act with violence or cruelty. Real men are free of the needy arrogance of living for others' adulation, for material or social gain, or for self-seeking pleasure or self-glorification. Real men aren't afraid to be gracious and aren't embarrassed by the need to keep learning; in fact , they seek that kind of growth every day. Today such men deserve to be celebrated!

***

My mother grew up without her father. He died (of TB, we think) when she was 10 months old and her mother was 24 - the age I was when I got married. Young.

But when my mother was 3, or so the story goes, he came to visit her.

I love a good ghost story. So do most Filipinos, and they also enjoy believing in them, without all the usual rationalist excuses or attempts to come up with "natural explanations." People in my country see spirits and don't think twice about it. No one diagnoses the seers with mental problems or tries to come up with some DSM-IV category like, "transient, culturally-induced psychosis." It's an accepted phenomenon. One of the people in our family who has this gift of sight is a practicing physician who graduated at or near the top of her class. Intelligent, talented, rational, emotionally stable.

As was my mother's mother, in her time one of the most cherished professors of history at the University of the Philippines. She was sharp, and she knew her stuff. She lectured entirely without notes or prompts of any kind. She saw her dead husband, years after his death, once or twice, and once even had a conversation with him, then never again.

It happened like this. She was inside the house doing some work while my mother was in the yard. She had the window open to keep an eye and ear on her little daughter, who was playing with a ball. All of a sudden she heard the little girl laughing delightedly and saying, "Throw it! Throw it!" Alarmed that a stranger might have come upon them, she quickly looked out the window...and saw her husband playing with their child. Her husband who had died three years before.

I loved hearing this story growing up, and I used to ask all the older women in my mom's family to tell it again and again. My own grandmother, a very private person, would just smile sweetly and nod when I asked her questions but as I recall she said very little about the incident. Someone once told me that she confronted him about why he kept returning, and with what seems to have been characteristic cheek - I can almost see the twinkle in his eye - he replied that if suitors could visit her (which they were doing), so could he. My grandmother was quiet but strong of purpose. There was work to be done and life to be lived; she wanted peace for her husband, herself, and her daughter. She put an end to her suitors' visits, and thus to my grandfather's visits as well.

American psychiatrists would have a field day with a story like this. They would dismiss it as a grief or guilt apparition, a psychotic illness, depression with hallucinations, or what-have-you. My Filipino relatives and I keep it simple. My grandmother saw the spirit of my dead grandfather for a little while; that's all. No different from the occasional visitors my uncle, or cousin, or a family friend sees, benevolently taking in the goings-on in our family home.


The day my other grandfather died of a cardiac event in the hospital, my nanny says she saw him bending over my crib in the nursery at home. I guess Filipino dead just LIKE to visit their little ones. I chalk it up to a father's love, a grandfather's affection, the possibility that even the death of the body doesn't extinguish that energy completely.




Saturday, June 16, 2007

Memories, Dreams, Memories

First thing's first: Happy Anniversary, honey! 11 years, not too shabby.

I have to admit I was a little taken aback by the June 4 This I Believe essay on NPR, which described a fine line between settling for and accepting a "good enough" marriage. The author sounds practical, down-to-earth, sensible, but I also thought, if she hopes for certain things in her marriage, why not ask? She writes,

"My husband is not my best friend. He doesn't complete me. In fact, he can be a self-absorbed jerk...On the other hand, he doesn't beat or emotionally abuse me. He doesn't drink or chase other women. He's a good provider. So I'm sticking with him...

"...yes, I'm settling. Sure, I wish my husband would kiss me more often, tell me he loves me every day, and get as excited about my accomplishments as I do. Emptying the dishwasher without being asked and giving me unsolicited foot massages wouldn't hurt, either.

"All that would be nice, but it's not necessary. I'm happy with my husband who, despite his flaws, is a caring father, capable of acts of stunning generosity and fiercely protective of his family. Thinking about him may not set me on fire as it used to, but after 17 years and two kids, our love is still warm."

I guess I have to be enormously thankful. My husband, in addition to all the amazing qualities I wrote about in my Gabriel's Oboe post, is generous with his affections, compliments me and verbalizes his love every day, gets excited when I'm excited about something I've done or gotten interested in, is a supportive partner and devoted father, does more than his share of housework, is noble and compassionate in his work and his attitude to others, does volunteer to give massages, and is indeed my best friend in the world as well as a shameless flirt with me after more than a decade.

I've heard other folks tell me, "Oh, it's so nice that he still tells you you're beautiful (I'm not, actually, but he tells me I am). Mine never compliments me," or "When you two look at each other, the room still disappears," or my personal favorite, my daughter saying, "Marriage is life's great happiness." And when I asked her where she got that idea, she answered matter-of-factly, "You two." I wish I could impart some secret ingredient or piece of advice to her for when her time comes. The things that come to mind about why we "work" are, we make each other laugh; we can cry together too; we learn from each other; we hug each other often; and we pray together. Oh yes, and when we fight, we make up. That always helps. And we try to accept (sometimes even cherish) each other's imperfections (many, in my case, poor guy). I guess that's the same point the NPR essayist was driving at: "happily ever after" comes with a healthy dose of patience, humility, and acceptance. But I don't think "settling" is necessary or something to encourage. Maybe it's all just semantics?

I hope my children have blessed relationships in which their preciousness is SEEN, recognized, and truly, deeply loved.

***


Today's the last day of the IDRS conference. Wish I could have gone this year, even if I can barely play two notes on an oboe! The above photo is of the Fossati table at the conference, I think (got it from the Fossati Paris website). *Sigh*

I DREAM of getting a Fossati E30...We're supposed to go visit my husband's relatives in France this summer, but I'm too embarrassed to walk into the Fossati atelier as a flaming beginner and ask to try one. Their company philosophy sounds so supportive of all levels of musicianship, but I mean, you can just imagine - I walk in there and start HONKIN' around on their BEAUTIFUL, superbly crafted instruments...wouldn't they want to rescue the poor oboes out of my hands and boot me out of the store? That's if they can stop rolling their eyes long enough... :)

When we bought our lovely little upright piano for our daughter, going to the piano store was FUN. It was at the top of a three-story walk-up in an old building. There was a workshop area with piano parts in one corner of the place that looked like an "exhibit for the anatomy of a piano." Neat! My father and I walked in and just started playing. He did some Beethoven, I think, and I pulled out the old Mozart concerto, and we had a blast! "Oh, this one's out of tune, that one's too bright and plinky, but this one's JUST right." You just get a feel for the instrument, a comfortable feeling like coming home and putting on something cozy that fits perfectly, and you hear a sound that's true to what you have to express, and you know you've found it. But I can't go and do that at FOSSATI. Wish I could bring Kyoko along!

***

I am on call all weekend again. Bummer.

***

Blogging here at the hospital after an embouchure-destroying practice session in our little lounge. I must be doing something wrong. I am sputtering more now than I used to. My lips got so pooped out after only 45 min. that I had to stop. I guess that's better than my former 20 min., but still, I feel like such a WEAKLING!

Have been idly leafing through magazines on a lunch break. Another reminder to be thankful for anonymity (and for the freedom to leaf through magazines in the first place). I was just perusing an article about the Princes of Wales and thinking back to Princess Diana's tragic death. I remember clearly the moment I heard it on the news. I was pregnant with my daughter and unable to sleep. I went to the living room to watch a little TV late at night, and there it was.

This made me think of that famous recurring question, "Where were you when such-and-such happened?" I started to make a list (as is my wont):

Event (occurrence or report of occurrence) & where I was at the time:

9/11: visiting Mount Sinai medical school in New York City as a 4th-year medical student, on a rotation through their genetics clinic

Death of Princess Diana: in my living room watching very late night news

O.J. Simpson verdict: coming out of the T station at Harvard Square

Shuttle Challenger explosion: being interviewed for a scholarship at what would be my high school

Pope John Paul II shot by Mehmet Ali Agca: at home; my mom said I cried (I was 9).

Thursday, June 14, 2007

Pie It's Not; or, Two Steps Forward, One Step Back

Why, oh why, just when we seem to be making progress, do we suddenly BOMB?

Yesterday's oboe lesson was so WEAK. I don't know what happened. I've been practicing DAILY. Scales, long tones, method book, and, dare I say it, "repertoire," embryonic though the latter may be. Practices have been going ok, with only a few bumps in the road due to fatigue, lack of technique, lack of know-how, what-have-you. Yesterday I was not fatigued. I was not nervous. I was having fun. 'My teacher was good-natured and laid back, as usual. And I just BOMBED. Couldn't even get through D major. Tone was horrible. Took 10 minutes of back-tracking and re-warming-up to regain my "sound." I was totally inconsistent. I kept making mistakes. I sputtered. What is UP with that?

I have a neurobiological theory, of course. I think when we learn a new skill and begin to practice it, our brains start rearranging little functions and electrical discharge patterns. Neurons adjust to new bursts of neurotransmitter, new connections. But I think there's a shifty phase when they're not quite comfortable with their new assignments. In the building process, with the "scaffolding still up" and some exposed parts here and there, I think some misfirings occur, and we have one of those dreaded bad days that supposedly everybody has. [Speaking of building: even during last week's barn-raising there was a major snafu that needed some re-working to resolve: the center post was actually off-center, so one of the major spans came up short!] I think eventually the activity patterns become established and coordinated, more orchestral, and the brain itself acquires new architectural elements, like a cathedral with a new wing. I guess I need to remember that every work-in-progress has to pass through major imperfections & ups & downs to get to a "more perfect" place.

If only it really were easy as pie. My family is very appreciative of my apple pie. My son calls it "Paradise Pie" because he says eating it is like being in paradise. When he was asked in school last November to write down instructions for how to make a turkey dinner, he wrote on his paper, "My family doesn't like turkey. We have ham and chicken at Thanksgiving." So his teacher asked him to make a list of instructions for any Thanksgiving dish, and he wrote,

How to Make a Pie.
Get 7 apples.
Bake a pie.
Eat it.

Love it! Wish I could apply that to music: pick up oboe, blow through reed, play music. Simple, right? If only!

And it's not like I can use an "oboe simulator" to learn. In medicine some of the best learning experiences I had were at our residency program's medical simulator. We could practice managing some pretty hair-raising scenarios and social psychology quandaries in the sim. I think it's the wave of the future for medical education and crisis management training. But to make music, I can't imagine there being an effective equivalent. The only way to be a musician is to keep TRYING to be a musician. I get so embarrassed when loving family members call me a "musician" - I feel so unworthy of the word right now!

Tonight I could only practice for a short time because it was close to the kids' bedtime by the time I got started. My son came up the stairs because he heard my scales. I said sheepishly, apologetically, that I wasn't that good. Like the supportive son that he is, he said, "I think you are, and you practice every day, so that makes you good." Sweet boy! My daughter soon joined us, and likewise said encouraging things that had more to do with her affection for her mother than her mother's abilities, but hey, no complaints here.

At the end of yesterday's lesson I asked Kyoko to play a portion of the Raymonda adagio I love, which I had transcribed clumsily onto some music paper a couple of nights before. I don't think I've ever heard it sound so beautiful. Wow. She has the perfect, rich tone and gentle vibrato for the piece. It sounded so gorgeous I could barely breathe. *Sigh* Something to aspire to...

Wednesday, June 13, 2007

Meet Selah, Hear Bell

My son brought home this print entitled "My Clever Creature," which he made at school. I love it.

He doesn't realize it, but it looks just like Selah. Selah is a little character that I imagine popping up to ask me questions about my world whenever something astounds me about people, or makes me shake my head in disbelief. I am too old to have an imaginary friend, but lately my mind has conjured little Selah up quite frequently, usually in the car during my long-ish commute, when listening to NPR becomes a quick education on all sorts of issues from around the world.

Lest it seem the stress has finally made me crack, let me affirm that this little guy is completely imaginary, a character in a little mental game I play that could be entitled something like, "How to Explain Earthlings to a Visitor from Another World." I used to think of him as a "Little Yoda," but his English was too good.

I named him after the Hebrew word that recurs among the psalms calling listeners or readers to pause and reflect. Selah is not of this world, and the questions he asks about our world do make me stop and think.

In the past when Selah has materialized in my mind, he has asked things like,

  • What is race?
  • If medicine is the profession of compassion, why is it so riddled with disdain?
  • Why do people believe in God?
  • Why don't people believe in God?
  • Why have you had two female presidents in the Philippines but none in the United States?
  • Why do people hate each other? Why can't they respect each other more?
  • Why are people so afraid of differences?
  • Why are athletes and entertainers paid more than school teachers?
The thing that made me shake my head in both wonder and disbelief today was an old article from the Washington Post detailing virtuoso violinist Joshua Bell's experience as a busker at the L'Enfant Plaza Metro Station. Thanks, by the way, go to Elaine Fine and L. Lee Lowe for passing this story along. I found this project astonishing as a social psychology experiment as well as a philosophical study about the arts and artistic talent.

Joshua Bell, who commands ticket sales upwards of $100 per person per concert, agreed to play at the metro station at rush hour as a "street musician" and to let cameras roll to see what would happen. So there he was, a world-class and world-famous violinist playing Bach's "Chaconne" from the Partita No. 2 in D Minor on a three-and-a-half million dollar Stradivarius. What happened?

What happened was, Joshua Bell was ignored. He was playing for FREE right in front of them, and most people rushed on by with not so much as a glance his way. No one paid any attention. No one, that is, except for the occasional child who passed by, being pulled along by a rushing parent or caregiver. And a handful of adults, maybe three or four.

After reading this article, I played "what would an alien visitor think?" and in my mind Selah and I went back and forth as follows:

Selah: Are human beings deaf and blind?
Me: Um, no, we're not. Really.
Selah: Can people feel wonder?
Me: Of course.
Selah: Do they like good and beautiful things?
Me: Absolutely.
Selah: Do they notice good and beautiful things?
Me: Not always.
Selah: Why not?
Me: Hmmm.

The article's author, Gene Weingarten, wrote (and I really hope it's okay to include this here):

"It was all videotaped by a hidden camera. You can play the recording once or 15 times, and it never gets any easier to watch. Try speeding it up, and it becomes one of those herky-jerky World War I-era silent newsreels. The people scurry by in comical little hops and starts, cups of coffee in their hands, cellphones at their ears, ID tags slapping at their bellies, a grim danse macabre to indifference, inertia and the dingy, gray rush of modernity.

"Even at this accelerated pace, though, the fiddler's movements remain fluid and graceful; he seems so apart from his audience -- unseen, unheard, otherworldly -- that you find yourself thinking that he's not really there. A ghost.

"Only then do you see it: He is the one who is real. They are the ghosts."

This piece made me think longer and harder than I have in a long time. Then I put in some violin music and just listened.

***

I have since read SawLady's and Elaine Fine's responses to the Bell Busking Bust, and I am relieved there's more to the story than the "spin" placed on it by the Post. Thanks to these talented and experienced musicians for teaching me more about the art of busking, and helping me reflect on things like approach to one's art, expectation, and context!

I do still think people should at least have LOOKED UP once or twice and acknowledged the musician's fine efforts, though...I mean, it was Joshua BELL...

Makes me wonder how often I walk by people and never see them. Bill Clinton recently gave a graduation speech about noticing the guy next to you on the street. I need to work on this more! Gives new meaning to the New Testament words, "You listen, but you do not hear."

Tuesday, June 12, 2007

God on the Brain; the Brain on God

When I was little I wanted to be St. Bernadette. One of my prized possessions was a worn, newsprint comic book depicting her short life - her impoverished childhood in Lourdes, her visions, her illnesses. The visions, of course, were what captivated me. To see a supernatural person, someone from heaven - wouldn't that have been the most amazing thing ever? I remember trying to find vision-friendly spots in our garden - a grotto-shaped pile of rock, a hospitable arrangement of brambles. Similarly I would look for arrangements of tree branches or hedges that might make good portals to magical worlds like Narnia. Needless to say, I never had any visions, and when I was reminded that sainthood often involved suffering greatly for one's faith, I got over it.

As an adult I didn't have too hard a time letting go of some of my childhood "magical thinking" (I've happily clung to some of it - like the thought, "If I get all my resuscitation drugs ready, maybe I won't need to use them.") In high school we had a required course in scripture during which we were encouraged, as our church teaches, to undertake a contextual rather than an insistently literal interpretation of the Bible. Rather than objecting to or resisting this, as many of my classmates did, I found this approach emancipating and, in fact, spiritually enriching, opening up more truths and insights for me than I would have gleaned otherwise.

I wasn't bothered, either, when neuroscientists began to study religious experience and connected religious visions with temporal lobe epilepsy. By then I had spent time as a medical student in psych wards and, though the various disorders of the DSM-IV and the way we seem to be at the mercy of our neurotransmitters made me really question the nature of human will, I didn't necessarily connect sanity with validity. Some of the most psychotic people I saw spoke uncanny truths and had remarkable insights that the "rational" caregivers, supposedly more connected with "objective reality," didn't have.

A few months ago when our church was planning a retreat for young people who were about to get confirmed in our faith, one of the suggested activities was a "Saint Buffet": a time and space set aside for story-telling and visual exhibits about people's favorite moral heroes and heroines. During the discussion of which saintly people we might highlight, I remember saying, "Can we not do Joan of Arc?"

"Why not?" one of my team-mates asked.

"Um, because she was crazy?" I replied, hoping she would hear my tone as affectionate and not disrespectful. Then, fearing that the other folks in the group who didn't know me well, and didn't realize the deep love I had for our faith and many of its elements, might not realize I was NOT trying to be irreverent, I dug myself deeper by saying, "Don't get me wrong, she was an amazing person, but she was psychotic. Or, she had temporal lobe seizures." Thankfully, people seemed willing to chalk this up to me having to interpret everything through the lens of modern medicine, and no one ejected me from the retreat-planning team.

Bishop Stephen Sykes of the University of Durham said during a BBC program, "There is a very interesting dispute at the moment about whether one can have a talent for religion and whether that is something like a musical talent which some people have and some people don't have." This relates to other issues I've often wondered about - the issue of talent in general, and creativity, and their origins / sources / relations to experience and learning. I've often heard that faith is a gift. There may now be scientific proof of that, in the observations regarding our temporal lobes and the other parts of the brain that interact to produce/interpret spiritual experiences. I do think many of the traditional saints, and people who have had profound mystical experiences, had/have highly active, perhaps unusually active, temporal lobes. Some people seem to have temporal lobes that are innately (i.e., genetically?) more "receptive" to religious experience than others'.

As someone who has to interfere with the brain a little bit every day - chemically reduce anxiety, promote indifference to painful stimuli, induce lack of consciousness, and even cause some amnesia - I am acutely aware of how neurotransmitters can be manipulated. I do it for a living! And yes, I did hear about the Johns Hopkins study that found that the psilocybin in psychedelic shrooms can act on brain receptors, induce mystical experiences, and produce positive changes in the study subjects. Clearly the brain is the gateway to human perception and thus has a great deal to do with what we consider spiritual experience. As many pieces in the emerging field of "neurotheology" have pointed out, our spirituality, in large part, is in our heads.

The thing is, I just don't mind. It wouldn't make sense for the brain NOT to show these responses. Also, I've gotten to the point, I think, where I don't feel I have to be RIGHT about everything I believe. There are some truths that lie beyond human belief, and whatever science reveals should only enrich my understanding, not destroy it.

By now neurotheology has its prominent names - Drs. Vilayanur Ramachandran, Michael Persinger, Andrew Newberg, and Matthew Alper, to name a few. Some scientists interpret the growing data about the neurobiological basis for spirituality as suggestive of God being a human construct, with the " 'God' part of the brain" being a genetically-enabled product of evolution which helps self-aware creatures cope with the knowledge of their own mortality - the fruit of Eden's tree. It's the old chicken-and-egg conundrum: did God create the brain, or did the brain create God? Some people of faith argue that God, being a smart one, would obviously create a neurobiological substrate for divine revelation - a natural, physical way for humans to perceive and interpret a relationship with the divine.

What would be really neat is if both were right and true somehow.

My understanding of neurobiology, rudimentary as it is, goes something like this: the brain is "hard-wired" to learn, all experience counts as learning, and learning creates changes in the cellular architecture, gene expression, and electrochemical interactions in the brain. Everything we experience changes our brains from moment to moment, and sometimes cumulatively those changes can be significant. Reading a book, hearing an oboe concerto that moves me, being hurt by an ex-boyfriend, playing cards with my family, practicing tendus repeatedly at the ballet barre, internalizing grammar rules in a new language, smelling roasted peanuts while walking down a Manhattan sidewalk, these all make their mark in our minds, and therefore on our bodies, because our brains are, after all, body. The idea that they are separate is illusory.

And maybe we have some evidence. Dr. Andrew Newberg's work with SPECT scans of people from various religious traditions in deep meditation showed not only increased blood flow to the temporal lobes but also decreased flow to those areas in the parietal lobes that were related to our perception of time and spatial orientation. This finding may explain what those who meditate often describe as an experience of "loss of self," a liberation from the limits of space, time, and individual personality, or a mystical union with a greater reality. I wonder if the perfusion changes were a cause or an effect? In any case, these studies lend support to the fallacious nature of thinking of mind and body as separate. Mind IS body.

This is why I love the story in Chapter 5 of the Gospel of Mark, where Jesus heals a woman of a chronic hemorrhage. I love the juxtaposition of medicine and faith in this chapter, and the way the healer, Christ, felt a transformation in his own body - the healing power draining from it, into the woman - while at the same time the woman felt the transformation in the depths of her body as the flow of blood dried up completely, all because she reached out and made a very physical, hopeful connection by touching the hem of Jesus' clothes. Both healer and healed were physically and emotionally changed by the healing. I love this story so much I wrote a poem about it. (I know -what a dork. Or, as someone who loves me a lot says, what a super-duper-dork!)

Now I gotta go to bed and give my temporal and frontal lobes a little rest.

Monday, June 11, 2007

Scales

"Down the road someone is practising scales,
The notes like little fishes vanish with a wink of tails..."
from Sunday Morning by Louis MacNeice

I was astonished to read what Patty Mitchell wrote on June 7 at Oboeinsight, about how some of her colleagues don't require their students to practice scales because they don't believe scales are important. Perhaps I haven't earned the privilege of having an opinion about this, but surprise surprise, I do have one, just as I have one about times tables (they should be committed to memory at an early age), diagramming sentences (all school kids should participate in the exercise, lest a working knowledge of English grammar, seemingly a low priority in this country, be thrust into further decline), and learning poetry by heart (go ahead, call me old fashioned).

If I've learned anything from both dance and medicine, it's that expertise which requires physical activity also requires rigorous training. Repetitive physical acts in such endeavors are neither useless nor unimportant; they are, in fact, essential, both for the muscular strength and dexterity they develop and for the discipline they instill.

Two weeks ago I couldn't get past the first measure of Gabriel's Oboe by Ennio Morricone. Yesterday morning, facing a glorious day outside my bedroom window, I surprised myself by playing through eight measures -not well, of course, but considering I couldn't even try it not too long ago, I was glad just to be playing through the notes! I have no doubt that practicing scales - again, not necessarily well, but with good intentions, at least - has made a difference and added those seven new measures. I'm going to have to start working on F minor. I tried to figure out the adagio portion of the Grand Pas Hongrois in Raymonda, and those four flats aren't exactly second nature...yet.

But boy, I have no endurance. I have no wind control, no stamina in my hand muscles; my embouchure poops out after twenty minutes; I am an oboe wimp. And a "grace note" queen. Not a great combination! :)

***

Got called to the ICU today to manage yet another God-help-me type of intubation. The procedure went fine, and when one of the family practice docs started asking me about my approach, I found myself thinking back to residency, when we residents had achieved enough seniority to get sent to places like the ICU and the E.R. by ourselves, carrying a supply bag on our shoulders, all eyes watching as we attempted to do what others had already tried to do but were unable to. I thought back to my recent call to the E.R. at one of our smaller hospitals, a community hospital in the middle of a bunch of dairy farms, where after the E.R. physicians, I was the only other person around for miles who was qualified to even attempt intubating someone. All I can say is, thank goodness for those residency runs, which gave me chance to develop an approach. Thank goodness for scales.

Saturday, June 9, 2007

Barn Raising


Last fall we bought a cabin from a lovely couple who moved to Gilmanton, New Hampshire to raise alpacas. They bought a 1756 farm house previously owned by Grace Metalious, author of the Peyton Place books. Today we visited them at their new home to help with their barn-raising.

My husband, a civil rights attorney with a yearning to be a builder, had the time of his life. It made me happy just to see even from afar how much enjoyment and satisfaction he was deriving from the work on the barn. Watching an idea become a finished product through the work of one's hands is a blessed experience, even more so when a small community of hard-working friends comes together in trust, commitment to excellence, generosity, and good will to make the dream a reality. I think participation in a barn-raising should be required for business employees, students, and physicians!

Though some women helped with the construction and one of the men helped with the cooking, for the most part we fell into stereotypical gender roles, and LIKED it that way I might add, with the men performing most of the hard labor and the women providing food and drink, keeping an eye on the children, and engaging in some warm conversations over tea or coffee. By midday the "progress" in the work-in-progress was visible.

Today's work was a true labor of love for our friend, who was building the barn for his wife's alpacas. We had the chance to visit a neighboring alpaca farm after lunch. I have found my new favorite animal. My encounter with them was such an unexpected blend of warmth and mystery. Alpacas are cute and gentle, guardedly friendly, with an adorable "humming" vocalization that is much more pleasant than bleating, baa-ing, or mooing. What surprised me, though, was an otherworldly, almost mystical aura about them. I can't explain it, but they exude something really tranquil, an almost palpable serenity. Their presence is somehow actively calming, as if they carry some of the blessing power of Macchu Picchu in their gaze. My children and I felt an immediate affection for them.



I visited one website that defined the word "cria" as an unweaned camelid baby, from an old Spanish word for "create." I seem to recall my parents calling my cousins and me "los crios" when we were kids. Creation, creativity, childlike freshness - I like the suggestion of all these in the word cria.

We spent the rest of the afternoon back at the barn raising, thankful that the predicted thunderstorms seemed to be holding off. The cloud cover and cool temperature were ideal, in fact, for construction work. Afterward the four of us drove twenty minutes home to our beloved cabin, ate a light but yummy supper of homemade pasta puttanesca, and played a rollicking game of Ouistiti, a card game passed down in my husband's family which has some similarities to Hearts and to French Tarot (but is much simpler and faster-paced than the latter). All in all a wonderful Saturday.

***

Pasta Puttanesca for Four

(How can stirring together a bunch of ingredients I don't particularly care for individually result in a sauce we enjoy so much...?!)

Ingredients:

¼ c olive oil
6 minced garlic cloves
1 huge Vidalia onion (or 2 medium regular onions), chopped
6 oz can of tomato paste + equal volume of water
1 28-oz can peeled plum tomatoes in puree
1 can medium pitted black olives (dry wt = 6oz), drained & halved
1 tin of rolled anchovy filets w/ capers, minced finely
1 3.5oz jar of capers
2-3 tsp sugar
¼ tsp salt
sprinkling of black pepper
several shakes of dried basil, oregano, & parsley

Directions:

Heat olive oil.
Sauté garlic & onion 10 min.
Add tomato paste, water, & plum tomatoes (reserving some puree).
Stir & cook 3-4 min.
Add olives, capers, dried herbs, & seasonings; heat & stir.
Add minced anchovies & some tomato puree for volume. Stir.
Adjust seasonings.
Stir & simmer till heated through.
Cook 12 oz of your favorite pasta – tricolor rotelli, penne, linguini, etc. – & serve w/ sauce (either mixed in or on the side).