You Are What You...Have?

What makes us human?

A capacity for language? Reason? Creativity? An ability to experience love, appreciate beauty, discern, relate? Our genes? A soul?

Last month Catholic bishops in the UK stated, in response to the creation of chimeras, "at the very least, embryos with a preponderance of human genes should be assumed to be embryonic human beings and should be treated accordingly."

What's a "preponderance?"

90%? 75%? 55%?

Do I get to be considered human if only 51% of my genes are human? And if not, does that mean I get to kiss my rights goodbye?

***

One of the most memorable surgical cases for which I helped provide anesthesia as a resident was a case involving robotic surgery. I anesthetized, placed an epidural in, and watched over a little boy whose uterus was being removed. Yes, boy, and yes, uterus.

There are many conditions in which people who are genetically male appear female and vice versa. There have been stories and papers about attempts to raise these individuals according to their outward appearance, with painful consequences for those who felt strongly that they were the gender opposite of that in which they were being raised.

Is our identity how we feel about ourselves? Is it based on our genes? Clearly how we LOOK is an unreliable indicator. Reminds me of my recent wonderings about racial identity...and artistic validity, for that matter...

And if we are not just our genes, or just our feelings, or our physical manifestations, or predictably shaped by environmental influences, then again, how do we decide who we are, and who decides?

Brief Oboe Update

Yes, I've been practicing even on vacation. It's hard to find a good time and place in a hotel, but I managed to practice every other day last week, and a little more this week at our cabin.

Jesu, Joy of Man's Desiring is actually getting a little faster. I now have recognizable trouble spots I can work on amid more fluent runs, instead of every measure being one messy trouble spot.

I can sight read most things I like out of our church hymnal - D and G major better than E flat or F# minor, not surprisingly.

I can play Gabriel's Oboe all the way through.

But I'm unhappy! Why? Because I sound like !$^&*@#!!

No, it's not my reed. No, it's not my trusty little student oboe. It's ME. If Mr. Kolyenkov from the play You Can't Take It With You were my teacher, he'd be pulling my husband aside and saying, "Confidentially, she stinks." I feel like my whole family thinks it sounds awful but they just feel sorry for me and don't say anything. *Sigh*

I won't have another lesson with Kyoko till August. Then I have to go on this trip with my husband's family...then what? Should I just keep taking lessons even though I feel like I'm gonna sound like stink for the rest of my life? Poor Kyoko...

Racist Cookies? (a follow-up to yesterday's post)

I remember these cookies (image used by permission). In 1999 the Philippine government protested their name and the reference to them as "brown on the outside and white on the inside." I've also seen a petition on the net against purchasing or eating them, though it should be noted that not everyone takes immediate offense at the name.

I understand the protest, but I also think Filipinos need to examine their attitudes toward "white-ness." Skin-whitening cosmetic products are disturbingly popular in the Philippines, and many people openly speak of a fair complexion and European/Western features as beauty ideals. I don't know the answer to this, but do the exaggerated Caucasian features in Japanese animation stem from similar attitudes?

And then there's that other touchy / forbidden topic: why has the Asian female/Caucasian male couple become almost cliché? (There are numerous internet reflections on this phenomenon.) I am part of the trend. I remember how violated I felt when an Asian-American man in my residency program saw a picture of my kids and then questioned my reasons for marrying my husband, implying that his white skin trumped any other reasons I might have fallen in love with him, like his values, his compassion, his intelligence, and his good character.

I was horrified but not surprised when, on my husband's first visit to the Philippines (we were not yet married at the time), a matriarch in my family exclaimed in English, upon meeting him: "A foreigner!" Then, in Spanish "Va mejorar la raza" - [if you marry him,] he'll improve our race. What an ignorant thing to say - and the worst part about it is if it had been pointed out to her as such, she probably would have said, "Why? I'm just speaking the truth." Good thing my husband was well-educated about colonial history, post-colonial culture, and the related social issues, thanks to his studies and travel experiences.

So, are we proud of our "ethnic identity," or do we envy another? Did we express outrage at Filipinos cookies out of self-respect, or does the name bother us (or not bother us) because for some Filipinos, it actually contains a grain of truth? Sometimes there can be a fine line betwee self-love and self-loathing. I think the major problems with the cookie name are its use of skin color as a way to categorize people and its failure to represent Filipinos in general in a meaningful way. But I also think there's still a lot of ambivalence in our country around these identity issues. One commentator notes:

"I remember it being reported in the press, one person saying she (as a Filipina herself) thought there was nothing wrong with [the cookie name] since, (she was of the opinion), most Filipinos wish they had been born white anyway (!) Of course, many others did and do not hold such a view.

"But one wonders why anyone would say in the first place that any Asian would wish to have been ‘born white’. Is it a reference to culture or simply to the standard of living associated with the 1st (read: white) world? I think it is true to say that Filipinos are viewed by some other Asians as being more westernised than them, particularly with regard to American influences. And often this is viewed as something negative."

This commentator hypothesizes that a desire for "white" culture or living standards lies at the root of white-envy, but I thinks it's simpler: looking white, for whatever reason, seems to have been an advantage in the world. So in several countries, not just the Philippines, people buy creams or lotions to rub onto their skin to lighten it. What I don't understand is why racism of this kind - not just the perceived inferiority of non-whites by white people, but also the perceived superiority of whites by non-whites - exists and persists.

Patriotism, Identity, "Race," and Other Constructs

Most people unfamiliar with a book I'm reading this summer might think from its protagonists' names, Juan Crisóstomo Ibarra and María Clara de los Santos, that it's a Latin American novel. But it's actually what Penguin Classics calls "the great novel of the Philippines": Noli Me Tangere, written in Spanish by José Rizal. The novel contributed to a greater awareness of national identity in the Philippines, eventually leading to a revolt against colonial Spain.

José Rizal is revered as our national hero, a patriot who died in the name of freedom from oppression. I don't know that I would face such a fate with courage or acceptance. I have often wondered if I could, but I have also wondered, is it really fair to extol patriotism as a virtue when sometimes people who are born in one country can develop a deep love for another?

Spain first colonized the Philippines in 1565. The Spaniards ruled over the Philippines for over 330 years - longer than their rule over Venezuela, Colombia, Ecuador, Argentina, Chile, or Mexico. We are geographically Asian, but in my opinion we are culturally "latino." In the Philippines one can find good paella as well as good spring rolls. Our Spanish surnames and colonial churches remind visitors more of places in the aforementioned Central and South American countries than of other South East Asian locales.

The Philippines declared independence from Spain on June 12, 1898, but this declaration was recognized neither by Spain nor by the United States, which paid 20 million dollars for possession of the archipelago. Spain ceded the Philippines, Guam, and Puerto Rico to the U.S. with terms delineated in the controversial Treaty of Paris. My great-great-grandfather (pictured right) had a seat in the U.S. Congress for a time during our period as an American territory. Philippine independence was finally recognized by the U.S. on July 4, 1946.

I've been thinking about these chapters in Philippine and American history today. I celebrated July 4 in the company of Filipino colleagues and friends but served a decidedly American barbecue - hamburgers, hot dogs, pulled pork sandwiches, cole slaw, s'mores for dessert. I've been in the U.S. since I was a child. I feel very "American," but I also feel at home among other Filipinos and still speak our native language (though not as well as I should). It was my third language at home. English was my second, Spanish my first. My cousins and I may have been among the last Filipinos, as a generation, to learn (or at least hear) Spanish at home. Over the last couple of decades even English has taken a back seat, to our nation's detriment, in my opinion; we had at one time been fully bilingual, but a resurgence of nationalism in recent years has led to some misguided educational changes, including the decline of English usage.

I don't "feel" Asian at all, whatever feeling Asian might be. I hope African Americans won't mind my saying that I feel it would be as valid to call me a Spanish Filipina as it is to call African Americans African American. The ancestral distance is about the same, and in terms of personal affinity it would be a closer approximation of the identity I feel on the inside. On the outside, though, I look Asian - more Asian than other Filipinos, even, because I also have Chinese ancestry. In the Philippines because I have fair skin I am considered more "white" than most Filipinos, those that colonial Spain would have labeled as "indios." This has complicated social implications over there which have in the past been a challenge for me. I'm not white in the U.S., but I'm white in the Philippines. So, in fact, "whiteness" is relative - it's defined by the observer; it has more to do with who's categorizing me than who I really am.

That said, there are Caucasian (as in, blond, blue-eyed) Filipinos and many whose Spanish ancestry still expresses itself. My grandmother's sister has very light eyes, either blue or green. My daughter's are hazel - green in some light, with hints of my brown. She cannot "pass for Asian" at all and had to forego the idea of being cast as a kid in The King and I. My son has a pretty Caucasian phenotype too. Sometimes I still get funny (puzzled) looks from people when I introduce myself as their mother.

So what "race" box should they, or I, check off on those forms that have a race box? How can I explain to them the existence of the race box, when I don't believe in the existence of race as a biological entity - only as a socially determined, historic entity (a useless, destructive one at that)? What becomes of our identity when we look like one "race" but feel a greater kinship with another? Why do human beings judge one another and draw conclusions based on appearance?

No easy questions, or answers, this July 4.

Who's Afraid of the Big, Bad...Resident?

Today was supposedly the worst day this year to have to go to the hospital. July 1 is typically the first day of the training year for all residents and medical students across the United States, though there are a few programs that start their year in the last week of June. I imagine that most people who know this and have a negative attitude about medical trainees look upon hospital admissions in the month of July with a mixture of dread and disdain.

There have been various writings, from The Underwear Drawer, a blog by anesthesia resident and talented humorist Michelle Au, to an article in The New Yorker by Atul Gawande, about doctors who, with some guilt over the hypocrisy of it, request the most senior person available to attend to their loved ones. I've had a different response. Yes, I want the best care for my family, always, and of course I wouldn't want my young children to be poked endlessly by novices who couldn't get a blood draw or an IV. But when I was an intern and someone asked me where I would take my children if they needed medical care, I immediately named the hospital where I was training, even though I knew residents did all the legwork. I knew my colleagues at the time, and I knew they were unswervingly meticulous about evaluating their patients thoroughly and competently.

And when I was an anesthesia resident and needed to bring my son to the E.R. at Children's for stitches, the senior pediatric resident there, who knew I was an anesthesia resident, asked me if I wanted the attending physician to do the stitches, to which I replied, "No way, I want you to do it." I knew he had been doing procedures day in, day out for the last three years while his attending physician looked on, made suggestions, and signed the chart. So in some sense I was doing the same thing Drs. Au and Gawande wrote about doing, and asking for the most experienced, competent clinician to take care of my son. But I didn't automatically decide that the pediatric E.R. resident was inadequate to the task, like so many people do, a priori.

Having been on both sides of things, I think residents are misunderstood and too little respected. Residents are M.D.'s - doctors - which means they have more knowledge than the average citizen about medical matters. Their education as residents is for acquiring sound judgment and comfort with procedures in a particular specialty - the kind of judgment that can only come from experience. Fellows are those who undertake a subspecialty after completing residency in a specialty. Attendings (short for attending physicians) are done with training.

Someone commenting on Dr. Au's blog compared being approached by residents to being "accosted by idiots." I could go on for a long time about people who make sweeping generalizations about groups (i.e., prejudiced people), but suffice it to say, I found this statement completely offensive in its attitude and content, and unfair to the many resident physicians in this country who provide outstanding care for their patients.

Of course no one wants to be a pin cushion for people learning to start IV's the first week of July, and right now the only way to learn is to practice. As a resident I did let my students start IVs on me, and I wasn't mean or whiny when they missed. The path to perfection is woefully through many hills and valleys of imperfection. And people forget, it's not always a problem with the person performing the procedure. I've seen cardiac anesthesiologists struggle with IVs after decades of doing them expertly. Some people do have terrible, terrible veins. Just like airways. Even the best laryngoscopist encounters that pulse-increasing, difficult airway once in a while.

Personally, and I've written this before, I think simulators are the way to go for certain elements in medical education, like procedures and group dynamics. Repetitive action by muscles makes those muscles and muscle-brain connections more capable. Ask any musician. Of course, in medicine there has to be a STUDY to prove something even that obvious, and those studies exist. They show, of course, that simulation of procedures increases competence at performing those procedures. What a shocker. (Kind of like that study that showed that sleep deprivation - a recognized form of torture, I might add - diminishes the quality of care provided by the sleep-deprived clinician {typically, an exhausted resident}. Like, DUH.) The one simulator I've been dissatisfied with is the intubating mannikin. Intubating that thing is NOT like intubating a human being at ALL.

Sometimes I play a game in my head that involves finishing the sentence: "There are two types of people in the world..." By now I have a long list, which I may post some time, but tonight my mental entry is, There are two types of people in the world: those who respond to students with understanding and patience, and those who respond to them with frustration or contempt. The former probably make better teachers, at least from the students' perspective, in terms of "making connections" with or "reaching" students. I've found that the medical world is littered with many examples of the latter - perhaps because responding the first way takes some genuine humility and a spirit poised for compassion. But there's hope - after all, it's called the practice of medicine.

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:

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.