Saturday, January 31, 2009

Chicken Soup for the Filipino Soul

One of my dearest friends recently tagged me on Facebook with that list activity that's going around - "25 Random Things About Me." Don't worry - it'll take me a while to come up with 25, so I won't be treating readers of this blog to such a list at the moment (much as I love lists). But something on her list caught my eye.

She wrote, "I wish I felt connected to a culture."

My initial reaction was, "But wait, you are! I mean, isn't everybody?"

I thought about it some more in light of my recent travels, and I realized she was voicing a longing my own daughter is beginning to feel strongly, having witnessed my comfort within my own country which, despite its being highly Westernized, still feels "foreign" to Americans but still very familiar to me.

I realized that despite some past efforts (for a number of reasons) to distance myself from certain elements of Philippine culture, I am definitely, irrevocably, and happily connected to my native culture. As one of my Filipino colleagues put it, "You still recognize the aromas when you get off the plane." That's actually literally true. The closest thing I've found here to that "Philippine" smell is the scent of a certain brand of jasmine green tea. Proust comes haunting again...

So what does it mean to me, being "connected to a culture?"

It means I speak and understand a language known only to some. And that when I'm in a crowded room of people who don't speak that language, and that language suddenly springs up in conversation somewhere in the room, my ears perk up, and I feel a sudden delight at my immediate comprehension of what's being said.

It means there are some ideas that only phrases in my own language can convey adequately - phrases I understand, and which I know would lose something in translation.

It means there are certain looks and tones and gestures that I recognize right away that convey instant meaning but which would look like undeciphered code to anyone who didn't grow up with them.

It means there are certain customs / greetings/ games / rhymes / rituals that are familiar to me, in family settings or in broader social gatherings, but unfamiliar to others.

In means I eat and enjoy certain things that can't be found elsewhere. That I miss those foods when I'm away from them, and crave them, and try to make them, to recapture the smells and tastes of a place in which I have felt a sense of belonging.

It means knowledge of music that I can hum to myself without thinking about it too much, and that someone else from my culture would recognize immediately and be able to hum with me. Perhaps it even means knowing some of the dance moves to those familiar songs.

It means having some inside jokes. Jokes that only other people connected to my culture would "get."

Words. Music. Food. Three things that define my culture to me and give me a sense of ethnic identity. I suppose it's no coincidence they're among the things I love best in the world.


In my jet lag this past week I found myself lying awake constructing a little abecedario of Filipino foods: A for adobong pusit (which I made for dinner last night), B for bagoong (two jars, right in my pantry), C for calamansi (the best citrus fruit in the world)...and on and on to L for lumpia and longganisa, M for mangoes and maja blanca...P for pancit palabok...S for sans rival...

It seems almost unthinkable that I should have spent all this time in the Philippines without a single food post (though perhaps I went a little overboard with the Filipino food posts last year - see here, here, here, and here). I crammed my suitcase full of grocery items to bring home - envelopes of dry soup, tableas of drinking chocolate, breakfast cake (bibingka) mix (which I broke out yesterday, minus the requisite banana leaves in which to bake it - see above).

People have been doing this for over a hundred years. In my research for an online family tree I'm putting together, I encountered some notes and recipes in Spanish by a Filipino woman living in Paris in the 1880's who used to host gatherings for fellow Filipinos at which she served a variety of native dishes. I can imagine the crates of sotanghon she must have asked to be loaded onto ships bound for Europe. There's no doubt food has always been one way for people to stay connected to their cultures.

And every culture seems to have its chicken soup, or at least some sort of comfort food. One of the items I brought back was some instant arroz caldo. Not as good as home-made, but not bad, either, much to my surprise.

Arroz caldo: just saying it makes my mouth water.

It's an Asian rice porridge with a Spanish name - Filipino comfort food at its best. According to this site, "Arroz Caldo is actually a Chinese congee that was adapted to the tastes of the Spanish colonial settlers who patronized Chinese restaurants in the Philippines. As the Spanish could not pronounce Chinese, they gave it a Spanish name for easy reference."

Arroz caldo. Just what the doctor ordered when you're home with a cold on a rainy day, or craving some warm home cookin' on a winter night.

Nowhere have I found a better arroz caldo than that served, believe it or not, by Philippine Airlines.* Here's a version that may not be as good as PAL's, and that lacks the traditional golden coloring given by saffron or kasubha, but that should stick to the ribs well enough:

Mince 1 small onion, 4-6 garlic cloves, and a 2-inch piece of ginger.
Saute in oil till onion is translucent and garlic is brown.
Add chicken meat in pieces (however much you want) and 2 Tbs fish sauce (or to taste) and simmer till cooked through.
Add 2 cups of Asian rice - NOT American long grain, and NOT arborio - and stir till translucent.
Add 8 cups of broth 1/2 a cup at a time and stir constantly.
When sufficiently porridge-like, just before serving, add a squirt of calamansi or key lime or lemon juice.
Garnish with 1/4 c chopped scallions, toasted garlic, and hard-boiled egg (and, if you're in the Philippines, some dilis).
And there it is: a steaming bowl of comfort from a blending of cultures in colonial times. Yum.

*in the Sampaguita Lounge, NAIA Terminal 1; the Mabuhay Lounge, NAIA Terminal 2; or on certain flights 

Tuesday, January 27, 2009

Conscientia Recta

The girl* was young, so very, very young.  Thin arms and legs, dark circles under her eyes, a surly, muscle-bound boyfriend at her side, a nervous mother who had gotten a wake-up call at two in the morning to meet them at the hospital.

The girl was bleeding a lot.  Her eyes were tired, her face pale.  

"We're sorry for what you're going through,"  the nurses said as they hooked up the IV tubing and got her settled in the O.R. bed.

The mother and boyfriend went to the waiting room with an awkward wave of farewell toward the girl.  She was alone with us, then, bleeding and exhausted, the remains of some "products of conception" not fully evacuated at the clinic she had visited earlier to end her pregnancy.

I touched her head as she lay on the operating table.  "I'll be putting an oxygen mask on you now, and I need you to take some deep breaths, okay?" She nodded.  

A few seconds passed.  Eternity in the space of a few breaths. "How are you doing?" I asked.  "I'll be giving you some medicine now that's going to make you feel really sleepy.  Just keep breathing, all right?  All the way in, all the way out.  That's it, you're doing great."  The drug went in.  Lights out.

It was over in less than ten minutes.  She awoke easily.  Then she began to cry.

"Is it over?"  she asked.

I told her we were just wheeling her to the recovery room.  She began to sob. She cried and cried and cried, so mournfully and so hard that the nurse helping me maneuver the bed started to get tears in her eyes.  I felt that sore tightening in my throat that often heralds the onset of unstoppable tears.  I swallowed and willed it away.  We couldn't all be falling apart here; it would not have been helpful or good for her, our patient.

In the recovery room she gripped my hand tightly.  I just looked in her eyes and said nothing for a few seconds.  I put my hand on her forehead and brushed back her hair.  "You're going to be okay," I said. "You're in good hands."  I looked at the recovery room nurses, who nodded their assent.

She was only sixteen.


I have been engrossed in some blog posts by PalMD who has been ranting against "conscience clauses" here, herehere, here, and here.

Here's what I think about the role of conscience in the practice of medicine.

I think an individual's highest authority is his or her own conscience - which for some includes some kind of belief in God and for some does not.  I don't believe any person should be forced to act against his or her conscience. 

I also believe respecting a patient's autonomy (and, for that matter, a person's moral sovereignty) is a supreme and unimpeachable ethical obligation.

I agree that where a patient's autonomy is foreseeably threatened by the dictates of a practitioner's conscience, that practitioner should recuse him- or herself, either by avoiding the involved medical specialty or by making provisions for prompt disclosure and speedy referral.

What I DON'T agree with or appreciate is insulting physicians for their personal beliefs, addressing them with extreme condescension, or calling them names such as "idiot" or "bigot" simply because they support conscience clauses.  They are not idiots or bigots or freaks with fringe beliefs just because they are in a minority, and to insult and utter all kinds of calumny against them for the sake of their values is to contradict the very respect for autonomy they are being asked to demonstrate and to violate the principles of freedom of belief on which this country was founded. I think telling doctors they absolutely cannot live according to their deepest convictions, and in fact should not be in medicine at all because of them, is a kind of bigotry in itself and as disrespectful of a person's highest authority as it would be to force a blood transfusion on a Jehovah's Witness.

Now, I abhorred many of the Bush policies as much as anyone who rejoiced on January 20 this year, as I did, when Barack Obama was inaugurated as potentially one of the most brilliant presidents this country will ever see.  I celebrated in the days following Inauguration, too, when Obama took prompt action to do something concretely life-affirming and just: close Guantanamo.   I am truly glad Bush's sorry, damaging administration is at an end.  But I don't believe either Bush or Obama governs the intellectual and spiritual terrain encompassed by my conscience.

I spent my childhood under martial law. Though I was shielded from its most horrifying effects, I remember what it was like to be taught that I had to be careful what I said, where I went, and when.  It felt like a violation of my natural rights as a thinking individual, even at that tender age.  I condemn any regime that attempts to control the lives and attitudes of the people it serves - whether it's a president obliterating due process, a doctor, nurse practitioner, or pharmacist tyrannically imposing a moral code on a patient, or a legislative body thrusting laws upon a particular group - women, married couples, believers, non-believers.  I think there are ways for all physicians, regardless of personal belief, to practice ethically and uphold the standard of care - again, for example, by prompt, respectful disclosure, thorough explanations of treatment possibilities, and speedy, dignified referral.  

As for my young patient who terminated her pregnancy:  I would never have refused to take care of her in the situation she was in when she arrived, no matter what led to it.  I do think of the termination of a pregnancy as the termination of a human life; I did weep inwardly with her, though she couldn't see it; and I wish she hadn't felt she had to take that painful step.  But I also don't believe I'm entitled to take away her right to make decisions about her own life according to her own conscience, any more than I believe it's anyone else's right to prevent me from living according to mine.

*The patient and events described here are a composite of several different clinical cases.

Friday, January 23, 2009

"Our Fearless, Reed-sucking Goddess of Sleep"

And the winners of the 2008 Medical Weblog Awards are...

Best Medical Weblog of 2008: KevinMD
Best New Medical Weblog: Life in The Fast Lane
Best Literary Medical Weblog: Running for My Life
Best Clinical Sciences Weblog: Clinical Correlations
Best Health Policies/Ethics Weblog: Respectful Insolence
Best Medical Technologies/Informatics Weblog: Life as a Healthcare CIO
Best Patient's Blog: Six Until Me

Congratulations to all the winners!

I'd like to thank all the wonderful readers, family members, and friends who wrote in their support here and here and who cast their votes for Notes of an Anesthesioboist (which ended up coming in second in the polls). Your words and sentiments made me feel as if I had received an award even before the voting began.

And thanks, too, to Patty of Oboeinsight and Ted of Bookeywookey for naming me for a Premio Dardos award, which "acknowledges the values that every blogger shows in his or her effort to transmit cultural, ethical, literary, and personal values every day." Thank you, Ted, for writing these kind words about this blog: "Our fearless, reed-sucking goddess of sleep shares her thoughts on her work, her reading, cooking, family life. A thoughtful, nourishing place to visit and for that I honor her." That may be the most unique compliment I have received to date!

I have found it difficult lately to follow the rules for awards such as this one - not because I don't admire the work of many, many bloggers or don't want to name others for the award, but because I feel like I end up naming the same people, or trying to name people who have already been named - but my thanks and respect go out to my fellow-bloggers, a community that has been a source of real intellectual and spiritual sustenance. You guys are great!


Tuesday, January 20, 2009

Inauguration 2009!

We were there!

We routed our trip back from the Philippines through D.C. on purpose, to try to catch some of the inauguration festivities, and we could feel the buzz as far away as San Francisco, where someone had left this giant set of foam fingers on the paper towel dispenser in an airport ladies' room:

In the airport in D.C. there was a palpable vibration of excitement in the air. People were festive and friendly, as if unable to contain the good will and hope inspired by the upcoming historic event.

When we got up this morning, though, reports of nine-degree wind chill and commuting difficulties were a little discouraging. Nor did the thought of 5000 porto-potties for 2-3 million people make me feel too enthusiastic...What did people do back in medieval or Tudor times?  Carry chamber pots around?!

We decided to venture out anyway and take our chances. We boarded the Metro a little after 9 a.m. - a much later start than that of the folks who braved the 4 a.m. opening time. The cars were packed so tightly we didn't think we'd be able to exit where we wanted to, but at Foggy Bottom people graciously moved around to let us off the train.

Our excitement mounted as we descended 23rd Street toward the Lincoln Memorial.  Once we got there cheerful greeters wished us a "Happy Inauguration" and solicited "high fives" from those of us arriving. 

The mall looked beautiful in the morning sun. 

We walked toward the Jumbotrons near the Washington Monument and found a spot to sit within the World War II Memorial which provided warmth from the sun and surprisingly effective shelter from the wind.

How the crowds cheered every time one of the Obamas appeared on the screen. How breath-taking was John Williams' Air and arrangement of Simple Gifts played by four world-class musicians (Perlman, Ma, McGill, & Montero) representing the many faces of America. And how compelling it was to hear our new president call this country to unite, uphold our integrity and values even as we defend our safety, and stand strong in the face of hardship.

The joy of the people was visible on every street corner. Exuberance on every face. Even for those who made a different choice on election day there is something immeasurably important and earth-shattering to celebrate on this day.  Everyone, regardless of ideology, should be able to rejoice in the historic significance and triumph of this proof that we at last have been able, in some measure, to move beyond the stupidities of a racist past.  This is a great and momentous day for all, not just for democrats.

I thought of the sour grapes of those who have in the past criticized our president's tremendous popularity with the people, his eloquence and ability to articulate his vision (as one conservative pundit even admitted, he has a "writer's" mind). I wonder why those same cynics and naysayers don't reflect instead on the reasons behind this man's unmistakeable magnetism rather than resenting or envying it; could it be that he's right - that hope (hope meaning forward-looking vision, not mere optimism) is a much more productive and powerful force than fear; that integrity, competence, focus, real presence, and wise restraint are much more charismatic and in-keeping with people's dreams for their leaders, their country, and themselves?

At last, a class act.

At last, some intelligence, courage, dignity, and honor in the highest position in the land.

At last, some discipline and organization of thinking and procedure.

At last, someone with the sense and vision to welcome good ideas from anyone regardless of ideology, to encourage opponents to unclench their fists, and to see that labels like "big government," "small government" "left," and "right" are too narrow to allow for the full realization of our potential as a people.

At last, a figure who will regain international respect and demand of Americans and non-Americans the very best they can give, a high standard of integrity and hard work that he expects himself to match.

At last, the model of a healthy marriage and family in the White House.

At last, an African American takes the oath of office looking out over what used to be a slave market: we have finally grown up just a little more.

At last, a true leader who is able to win admiration and respect around the world and the love of his own people - even those who do not share all of his views - and who inspires - truly inspires - people of all ages and from all walks of life to move, to be engaged, to be fueled by hope, and to work toward transformation.

Grand Rounds is Up

Check out the historic Inauguration Edition of Grand Rounds and see what the medical blogosphere came up with on the subject of making health care in this country better...

Monday, January 19, 2009

Journeying Home From Home

We're on the west coast on our way to the east coast and surprised to be so jarred at being surrounded by Americans. I guess my friends were right: you can take the girl out of the Philippines, but you can't totally erase the Filipina out of the girl!

My children are beginning to mull over their ethnic identity - my daughter especially. She FEELS very Asian and wishes she had grown up with more of her Filipino culture - especially the three languages, Tagalog, English, and Spanish, at home - but she LOOKS very Caucasian and her languages are Caucasian ones - English, French. I had the opposite experience: I grew up looking Asian but feeling very European and American.

More and more my kids are beginning to realize, I think, that their mother really did come from foreign shores and grew up speaking foreign tongues, eating foreign foods, perhaps even thinking differently about certain things from the way they are used to thinking. When we arrived in the United States and I was required as a Green Card holder to place my hands on a fingerprint analyzer and have my picture recorded by immigration as we entered, my kids were a little "weirded out": they don't think of their mother as foreign. There's enough of my home in me to make me fit in easily, still, as a native there, despite decades residing in the U.S., and seem in some instances to be a foreigner here on U.S. soil. I get rid of my Philippine accent easily, though, when we're here, so I hide my native origins well - without really meaning to hide them, really.

The other night when we stood to face the Philippine flag and sing the Philippine national anthem (which I still know by heart) before a theater performance, my daughter stood next to me with hand on heart proudly gazing at the flag, and I could feel her wishing to be more connected to her heritage. Perhaps I should have done more up to this point to pass this heritage on to her; perhaps the family stories are not enough - I should have given her the language too, the ways of thinking. I think she and I will have an interesting journey together to figure this out.

We're on our way to DC to visit some friends and maybe get in on the inauguration action. Blogging may be sporadic this week as we wrestle with jet lag once again...but I'll be in touch!

Thursday, January 15, 2009

It's Not Too Late to Vote

We'll be leaving the Philippines to go back to the U.S. in a few days, but I wanted to remind everybody about the 2008 Medical Weblog Awards -


If you think this blog is the best "literary medical blog" you've visited in the last year,


or click on the link at the upper right-hand corner.

Thanks, everyone, for your support! I deeply appreciate it.

Wednesday, January 14, 2009


Usually when tyrants are overthrown and democracy is restored to a people formerly living under martial law, there is bloodshed.

In the Philippines, blood was shed by one man: my mother's cousin, Benigno Aquino, Jr. - "Ninoy" - who was assassinated when he stepped off the plane that had brought him back home from exile.

His death became the rallying cry that united our nation and inspired the nonviolent "People Power Revolution," during which people joined hands in prayer, linked arms, and faced army tanks coming toward them. The tanks came to a halt without hurting a soul. Ferdinand Marcos was overthrown, and Benigno Aquino's widow Corazon Aquino was elected first woman president of the Philippines and inaugurated a block away from my childhood home.

Today we took our children to the Aquino Center in Tarlac so they could learn more about the family member who is considered the greatest Philippine national hero since Jose Rizal.

We learned about how he was "disappeared" by Marcos and placed in solitary confinement for years. We saw a replica of the wall on which he ticked off the days of that imprisonment, which brought him to the brink of despair. He was protected from losing his soul entirely, I think, by two things which in his restricted world were closely related: writing and prayer, the latter particularly fervent, intense, and deep.

We read his letters and poems, looked at photographs of his life and death and family, and were moved to tears at the sight of the stained clothes in which he was killed. My daughter in particular was heart-broken over the tragic story and its very real, tangible artifacts. I found myself "going medical" on her when she asked why there was so much blood on his shirt. The logic of physiology sounded so woefully useless in the context of the story behind it, but I do think it helped relieve some of her bewilderment and shock - though not much. We cried.

Over lunch I encouraged her never to take her freedom or democracy for granted and discussed with her why it's so important for her to exercise her right to vote when she comes of age. She has already been engaged in the political process and made an effort to be informed of both historic and current events. I hope both of my children always remember what a gift it is to be free, and I hope they can keep their hearts open to the courageous spirit that shone through those who came before them.

Tuesday, January 13, 2009

Grand Rounds, Vol. 5, No. 17

Grand Rounds is up at In Sickness and In Health. Check out this enjoyable edition, in which Barbara Kivowitz uses sci-fi films to introduce each batch of blog posts. Don't miss Providentia's post The Semmelweiss Mystery, a riveting piece of history and a window into the culture of the medical world and why change comes so slowly.

Monday, January 12, 2009

The Man Who Came To Dinner

The doorbell rang unexpectedly after dinner. An old family friend was there, a Spaniard who had moved to the Philippines at the age of five - someone we were delighted to see. My father invited him in, and when we realized he hadn't eaten dinner yet, we insisted he sit at the table with us to dine.

As usual there was an exchange of hilarious stories and jokes, retold by our friend in his inimitable, humorous way. Our friend is funny and kind and full of life.

At some point in the conversation my father asked, "Have you been back to Santa Ana recently?"

"Just the other day, in fact," answered our friend, "though I've avoided it for a long time. I was tortured there by the Japanese. I finally went back to find the exact place where it happened."

He said it so simply that at first I wondered if I'd heard him correctly. We were stunned by this revelation and completely riveted as he recounted, after 65 years of silence, how as a young boy of fourteen or so, during the Occupation, he was taken by a group of Japanese men who, because of his blue eyes and fair skin, insisted he was an American. They pinned his arms behind him and repeatedly used their hands to cover his mouth and nose until he passed out. Eventually they got tired of suffocating him over and over. He awoke feeling something warm all over his body and realized his torturers were urinating on him. They then threw him into the Pasig river, assuming he would drown. He swam to shore, went home, cleaned up, and never spoke of the ordeal to anyone. "¿Para qué?" he asked us rhetorically. What for?

"But you know, it's time to talk about it. I want to write about it," he said.

I hope he does. I think those who know him would be more awed than ever by his creative life, his capacity for joy and gratitude, and, despite the nightmares that cause him to cry out at night, the way he's been able to avoid getting stuck in the role of wallowing, self-pitying victim. Those who don't know him would receive the universal gift of a good story told: a new way of seeing something. And for him, perhaps the telling of this story will help a healing process that must have spanned almost his entire lifetime.


The DSM IV Criteria for Post-Traumatic Stress Disorder comprise a fairly long list of possible symptoms, but I found this summary by Dr. Frank Ochberg useful:

"PTSD is three reactions at once, all caused by an event that terrifies, horrifies or renders one helpless. The triad of disabling responses is:

-recurring intrusive recollections;
-emotional numbing and constriction of life activity; and
-a physiological shift in the fear threshold, affecting sleep, concentration, and sense of security.

...Victims of human cruelty (as opposed to victims of natural disasters) experience additional emotional difficulties which are not listed in the official diagnostic manual and are not part of PTSD. Foremost among these is shame. Although violent criminals should feel ashamed, they seldom do. Instead, the victim who has been beaten, robbed or raped is humiliated. This person has been abruptly dominated, subjugated, stripped of dignity, invaded and made, in his or her own mind, into a lower form of life."

If you or someone you know might be suffering from post-traumatic stress disorder, or are living with consequences of a traumatic event that may not fit into the diagnostic criteria for PTSD, please don't bear the burden alone. Please tell someone your story, and get help.

Sunday, January 11, 2009


The Kraken

Below the thunders of the upper deep;
Far far beneath in the abysmal sea,
His ancient, dreamless, uninvaded sleep
The Kraken sleepeth: faintest sunlights flee
About his shadowy sides; above him swell
Huge sponges of millennial growth and height;
And far away into the sickly light,
From many a wondrous grot and secret cell
Unnumber'd and enormous polypi
Winnow with giant arms the slumbering green.
There hath he lain for ages, and will lie
Battening upon huge seaworms in his sleep,
Until the latter fire shall heat the deep;
Then once by man and angels to be seen,
In roaring he shall rise and on the surface die.

-Alfred, Lord Tennyson, age 21

I am reminded of squid everywhere I go here.

There are squid for sale,

Spanish dishes featuring squid in their ink,

Asian salads in which the grilled white meat of the squid showcases the delicate flavors of tropical fruits like the pomelo, local seasonings made of sweetened citrus juice and fish sauce, ground nuts, and delicately shaved scallions, cabbages, cilantro, and lettuce (photo credit and recipe).

Then there's the priest at mass, who's a dead ringer for Squidward...(uh-oh, perhaps I should go to confession for thinking so...)

I've decided to pay tribute to this totally under-appreciated mollusk, such a star player in evolutionary, molecular, marine, and neurobiology. I'm a little late for International Cephalopod Appreciation Day, but I'm going to borrow a couple of suggestions from this festive website on how to make merry for mollusks: I'm not quite bold enough for the squid hat or the octopus tattoo, but I think the kids and I might have fun flying our very own paper squid...


I first learned about the squid's importance to neurobiology during college, where I was exposed to Hodgkin and Huxley's Nobel-prize-winning research on the squid giant axon - "NOT the giant squid axon," I can still hear the professor emphasizing, "but the squid giant axon. Don't make that mistake."

Since then we've learned even more about the workings of our own brains thanks to studies on squid and octopus brains, arguably among the "smartest" invertebrate brains out there. (Photo credit.)

Squids learn. Newborn squids learn through trial and error. Their earliest life experiences can produce lasting physical changes in their nervous systems. The lessons they learn from a young age lead to complex, adaptive behaviors that enable them to succeed as adults, with corresponding, dynamic, neural transformations that are mapped into the squid brain down to its very cells. In an article entitled "Lowly squid's behavior may yield clues to human brain" Professor William F. Gilly at Stanford's Hopkins Marine Station says,

"The simplicity of the squid's giant axon system will be advantageous in identifying the genes and chemicals involved in causing and maintaining these cellular changes - even in people. In this way, the delectable calamari may actually help unlock the secret of how our own brain cells are modified by early childhood experiences and help explain why we are who we are."

Who we are, in fact, is a species whose experience can write itself into the brain as significant chemical, cellular, genetic, and physiologic change. This implies an astounding pliancy and dynamism in the structure and function of the human brain. Cognitive neuroscientist Maryanne Wolf writes in her extraordinary book Proust and the Squid: the Story and Science of the Reading Brain,

"Computer scientists use the term 'open architecture' to describe a system that is versatile enough to change—or rearrange—to accommodate the varying demands on it. Within the constraints of our genetic legacy, our brain presents a beautiful example of open architecture. Thanks to this design, we come into the world programmed with the capacity to change what is given to us by nature, so that we can go beyond it. We are, it would seem from the start, genetically poised for breakthroughs."

This is a book that deserves a blog post of its own. Wolf traces the evolution of reading as a neurobiological entity, a human developmental attainment, and an agent of further neurodevelopmental change. The brain that could express ideas had to be able, at some point, to read; but literacy introduced its own rearrangements - a brain less dependent on memory, but more able to transmit information and ideas across vast expanses of time and distance. Wolf appears interested in and concerned about where our journey as readers and writers will take us next in this digital age, where spoken and written language may themselves be transformed, and where language inequalities - even "word poverty" - reflect the disparities between those who can "do well" in the world we have created and those who must struggle.

Every society has a Kraken or two to fear: a danger lurking beneath the surface we cross day to day, a hidden monster, or perhaps only an imagined one whose greatest menace is what we make of it in our own minds. One of the hidden threats I'd hate to see realized would be the decline of writing and reading - what Proust calls "that fruitful miracle of a communication in the midst of solitude" - and the deterioration of language skills that make our brains truly, splendidly human. So I'll repeat these magnificent lines by Tennyson, which I can't help reading (anachronistically) through the lens of medicine and evolutionary biology, and which make me want to savor language, savor words I can see and speak and rewrite and read and understand and know:

"above him swell / Huge sponges of millennial growth and height / And far away into the sickly light, / From many a wondrous grot and secret cell / Unnumber'd and enormous polypi / Winnow with giant arms the slumbering green."

Thursday, January 8, 2009

See One, Do One, Teach One

Of all the maxims that got tossed about during my medical training, the one I despised the most was "See one, do one, teach one." Everything about it annoyed me.

What I found so irritating and inherently disrespectful about it was that it exemplified so much of what I saw as the norm in medical education at the time (with a few notable exceptions): lazy teaching with an undercurrent of hazing.

Not even the biggest hotshot can do a procedure well for the first time after only seeing it once or twice, in the absence of real, hands-on tutelage (with perhaps this impressive exception). Moreover, I don't believe learners gain ANYTHING from havng to fumble through a procedure for themselves with little to no instruction. Some people argue that it helps you think for yourself, learn what not to do next time, and gain confidence. I think that's a total CROCK. Confidence comes from having been well taught and from experience.

Atul Gawande's book Complications opens with a vivid description of the first time he had to place a central line during his surgical residency. He had seen his senior resident do one, then was asked to place one himself. When his senior arrived to "supervise" the procedure Gawande and his patient had to endure the anxiety and embarrassment of her asking him, "Did you remember to check the platelets? Did you put a towel roll under the shoulder blades? Do you have the hep flush drawn up?" To which the anwers were no, no, and, uh, no.

Why couldn't she have given him a checklist of things he would need to do and have prior to the procedure, so he would KNOW? Would that have been so difficult or so terrible? No. He would have been prepared for the procedure and been perhaps more efficient and confident about it. Why couldn't she offer a little guidance while she herself was doing the procedure, and prior to his attempt? Would it have killed her to do a little teaching? Well, no, but as is so often the case during residency, she probably had a HUNDRED other things to do at the same time - just as he did - around the time he was setting up for the procedure, and she probably expected of him what had been expected of her: magical instant competence.

Many academics argue that trainees should show up knowing about a procedure already from having read about it. Again, I tell you, a crock. Try making my pie crust from me giving you a list of ingredients with some instructions. It'll never be the same as the crust you make with me showing you, talking to you, TEACHING you how to do it. And who wants to be in a plane flown by a pilot who learned how to do it by reading a manual? No thanks. I did read about EVERY SINGLE PROCEDURE I ever learned to do prior to attempting it, and no amount of reading helped me the way a teacher's attentive verbal and physical guidance did. There are just some things about the give and take of conversation, the micro-narratives contained in passing on "tricks of the trade," and the physicality of demonstration and manual adjustment that are irreplaceable.

But those things take energy, and time, and a respect for one's student, all frequently lacking in the hallowed halls of "teaching" institutions. You're supposed to show up knowing, and doing things well, and if you flub, the response is often anger. Anger at imperfections. What kind of teacher gets mad because the student has stuff to learn?

The first time an attending did a central line in front of me I asked her to talk through what she was doing so I could learn from her technique. She couldn't be bothered.

So the day before I was due to place my first central line, I brought a central line kit home, went to the home of a classmate who had already finished his cardiac anesthesia rotation, and asked him to TEACH ME how to do one, because I knew I couldn't necessarily rely on the the fellows or the attendings to do anything other than expect me to place it perfectly with confidence and without needing a lot of coaching.

My friend talked me through every step as I opened the kit and practiced...on an orange.

"Make sure your hand's in a comfortable position pulling back the plunger on the finder needle. Good, then just imagine the distal tips meeting when you put the other needle in. Okay, you got your guidewire - make sure you watch the EKG while you're threading it. Now take your scalpel, that's right, widen that a bit but have some gauze ready so you don't ooze all over the place...dilator in...dilator out - don't let go of the wire, now...pass your line over it...there you go. Central access in a citrus fruit. You're in!"

That was SO much more helpful than the chapter I had read on central line placement. My central lines went fine.

Nowadays when I teach or guide someone through a procedure I always try to talk to the student before we go to the bedside. If possible, we go through a practice run, both for the student's comfort and for me to be able to see where the student might need a little extra help. When I'm talking him or her through the actual procedure I use a LOT of encouragement and try to give corrections in a very positive way. In other words, I try to give my students the kind of learning experience I only had sporadically during my own training (assuming, that is, that they want to learn; there's nothing that makes me harder on a student than perceiving apathy from that student).

And if my students fail at something, I try to be comforting rather than dismissive or judgmental and to share my own stories of tough procedures, bloopers, and the like. I can still remember telling a deflated OB/gyn resident in the ICU after he was unable to place an arterial line under my supervision, "Ari, I spent my entire first year missing these. We'll do another, and each one will feel easier than the last. It'll come."

Well, ok, maybe not a year. But some chunk of time. A period of time spent failing, succeeding, failing, adjusting, and finally succeeding fairly consistently. Then I was able to feel comfortable teaching the procedure. Don't tell me see one, do one, teach one. It takes much more collaboration between teacher and student - in fact, it takes relationship, however momentary - to pass a lesson on; it takes respect for the act of teaching itself, and patience for each person's learning process, and ultimately a love of medicine and patient, in order to achieve real, fruitful education - from the Latin educare: to nourish, to raise.

Addendum:  Please visit Anatomy on the Beach, where Beach Bum has written an outstanding post on medical education, making  "a firm distinction between demanding excellence of students (and being hard on them when they don't live up to expectations), and emotional abuse (characterized by personal attacks that make the student feel small and the teacher big)."  

Wednesday, January 7, 2009

The Black Box: Aviation, Anesthesia, and the Debt We Owe Those Who Came Before Us

Excerpts of cockpit voice recorder transcript,
Air Florida Flight 90, January 13, 1982

Aircraft: Boeing 737-222B

Pilot: Captain Larry Wheaton, age 34
First Officer: Roger Alan Pettit, age 31

Initial complement: 74 passengers, 5 crew members
Weather: blizzard with severe icing

Portion of take-off checklist:
(Pettit): Air conditioning and pressurization?
(Wheaton): Set.
(Pettit): Engine anti-ice?
(Wheaton): Off.

15:59:24 (Control Tower): Palm 90 cleared for takeoff.
15:59:28 (Control Tower): No delay on departure if you will, traffic's two and a half out for the runway.
15:59:32 (Wheaton): Okay, your throttles.
15:59:35: [Sound of engine spool-up]
15:59:49 (Wheaton): Holler if you need the wipers.
15:59:51 (Wheaton): It's spooled. Real cold, real cold.
15:59:58 (Pettit): God, look at that thing. That don't seem right, does it? Uh, that's not right
16:00:09 (Wheaton): Yes it is, there's eighty
16:00:10 (Pettit): Naw, I don't think that's right. Ah, maybe it is.
16:00:21 (Wheaton): Hundred and twenty.
16:00:23 (Pettit): I don't know...
16:00:31 (Wheaton): Vee-one. Easy, vee-two
16:00:39: [Sound of stickshaker starts.]
16:00:41 (Control Tower): Palm 90 contact departure control.
16:00:45 (Wheaton):
Forward, forward, easy. We only want five hundred.
16:00:48 (Wheaton): Come on forward....forward, just barely climb.
16:00:59 (Wheaton): Stalling, we're falling!
16:01:00 (Pettit): Larry...We're going down, Larry....
16:01:01 (Wheaton): I know it.
16:01:01: [Sound of impact.]

The plane hit the 14th Street Bridge across the Potomac River and killed four motorists in addition to 74 on board. Only a minute and 37 seconds had passed from the time the tower cleared the plane for take-off to the time it crashed.


I don't like flying. I've been doing it almost all my life, since the age of four. But to this day as we take off in jets making that graceful upward angle I so love to watch from the ground, I think to myself, even though I can use physics to come up with the answer, "How on earth is this huge thing gonna get up and stay up?"

It's probably one of my life's greatest ironies, then, that I am an anesthesiologist by profession. Anesthesia owes a great deal to aviation for the safety measures that have now become the standard of practice, and there are several significant parallels between life in the cockpit and life behind the drape. [Click here for a great article on a play, Charlie Victor Romeo, that dramatizes this very subject and the impact it has had on medical professionals - hat tip to Transor Z for the link.]

Here are several that come to mind:

  • We (pilots and anesthesiologists) must function as part of high-performance teams with high stakes: if we mess up, people die.
  • We have to use technology with a great degree of skill and accuracy.
  • Our work environments are complex and potentially unpredictable.
  • High stress, dangerous work, fatigue, and potential disaster are ever-present issues in our line of work.
  • We value and use checklists, monitors, safety protocols known to the entire team, detailed plans, backup plans, closed-loop communication, and in-depth error analysis.
  • Take-off and landing are often considered most perilous times but we have to be prepared for turbulence in the middle as well.
As residents one of the most valuable educational experiences we had was training in a simulator. Practicing clinical responses to patient problems was useful but I think an even greater impact was made by the team-communication training we got in the sim. The "surgeon-as-captain-of-the-ship" model was rejected as outdated and, frankly, unsafe. Scrub techs, students, and circulating nurses were encouraged to ask questions and speak up in the name of patient safety, and all team members were expected to listen to one another, value each other's different skills, and combine them smoothly and efficiently.

One of the best tools we took from our simulator exercises was the "Advocacy/Inquiry" model of communication, which was held up as the paradigm for any person, from custodian to surgeon, who needed to express a strong concern. For example, if a surgeon noticed a drop in the patient's oxygen saturation and felt the need to confront the anesthesiologist, instead of saying, "What the heck are you doing to my patient?" he or she was taught to communicate concern for a shared patient with language like, "I'm noticing our patient's de-satting quite a bit (advocacy). What do you need me to do (inquiry)?" It may sound like touchy-feely psychobabble, but I'm telling you, it WORKS when used consistently to achieve coordinated and productive team efforts.

One of the hardest things to face, in real life certainly but even in the simulator, is error. There are so many different ways in which we err, and we all seem to err in some similar ways. We see signs of danger or doom, or get that nagging gut feeling, but we ignore the signs, or wish them away, or talk ourselves out of paying attention to them with wishful thoughts. We second-guess ourselves. We persist with a preconceived notion and try to fit all the evidence to that one idea at the risk of missing the real cause of a problem. We let an authority figure discourage us from taking a strong stand or "sticking to our guns." We see something bad on a monitor and do nothing, or do a lot without any real purpose. We fail to see what's right in front of us. We skip steps, either because we have not done a procedure often enough, or because we have done it so many times we could do it in our sleep. We forget or neglect to "follow the rules." Or, we fail to break the rules when needed.

Both novices AND experts commit the above types of errors. In addition to the use of checklists, safety protocols, and recognition of interdependent skills from different team members, one other fruitful legacy from the aviation industry is error analysis directed toward crisis management and disaster prevention rather than toward blame and punishment.

So what happened with Air Florida Flight 90?

  • The pilots failed to switch on the engines' internal anti-icing equipment - a skipped step / failure to adhere to established protocols, perhaps.
  • They used reverse thrust to leave the gate prior to take-off, which sucked large amounts of snow and ice into the engines in the setting of a failure to activate engine anti-ice.
  • They failed to abort takeoff per FAA regulations even though snow and ice build-up were visible on the wings and a power problem was detected while taxiing.
  • The first officer tried to express his misgivings, but then backed down, more than once; meanwhile, tragically, the captain failed to listen to and in-fact down-played his concerns, and insisted on "willing" his instrument readings to be heading in the right direction when in fact ice buildup on the probe measuring engine power was causing false readings.
One of the first videos we had to watch as anesthesia residents going into the simulator for the first time was a reenactment of an aviation disaster, with the actual cockpit voice recording in the background, impact-crunch and all. It was sobering. [See here for transcripts from various aviation disasters - even just reading them without hearing them can produce that pit in your stomach.] We take our jobs in our own cockpits very seriously because we have a healthy respect for the dark horror of that crunch and know well how what we do, or fail to do, can lead a patient down that fatal road. We're constantly judging ourselves, planning, double- and triple-planning, and de-briefing, trying to figure out how we could have avoided a particular problem or made some other thing better or smoother. And we have our colleagues in aviation to thank, in part, for that obsession with safety.

So when the de-icing team delayed our flight a bit to spray the wings of our tiny jet from Boston to DC with their de-icing stuff, and when the larger jet from Charlotte to San Francisco taxied BACK to the gate because the pilot heeded a warning light just after being told by the tower that he was number one for take-off, I was not annoyed in the least, as I might have been before my anesthesia days. Thanks for seeing the light, I wanted to say to him, and for paying attention. For listening to that nagging inner whisper, instead of brushing it off as "probably nothing anyway." It might just have been the tiny, meticulous move that made all the difference. It reminded me that even our smallest acts can hold unseen, great value - which is one of the things I love most about my work.
Addendum 1/16/09: In light of all the above thoughts, Captain Chesley B. "Sully" Sullenberger is my new hero. Read here how his training, experience, judgment, and skill saved lives - or better yet, listen here (while watching an animated recreation) to the actual conversation between the pilot and the air traffic controllers just before the plane went down.

Tuesday, January 6, 2009


Good news! I'm a finalist in the 2008 Medical Weblog Awards' "Best Literary Medical Blog" category!

To those of you who wrote in to support my initial nomination: THANK YOU SO MUCH!

Please consider casting a vote for me HERE for the actual award. Polls will close at midnight on January 18.

If you are interested in casting votes for medical blogs nominated in other categories (finalists listed below), click here or go to the "please vote here" link under each category.

Thanks for your support! Normal blogging will resume when the jetlag subsides...


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Monday, January 5, 2009

Chocolate, Kisses, and Cathedrals: A Day in San Francisco

On our way to Manila we've stopped to catch our breath in San Francisco.

We attended Epiphany Mass at the breathtaking Cathedral of St. Mary of the Assumption, where the Ruffati organ, with its 4842 pipes on 89 ranks and 69 stops, is incredible both to see and hear.

We visited Grace Cathedral as well, took in the view from the Top of the Mark at the posh Mark Hopkins Hotel, and took in some treats at Ghirardelli Square.

We boarded the historic ferry Eureka for a trip back in time, if not out of the pier. A hamburger and fries cost 35 cents back in the day, according to the ship's lunch menu!

We ended our journey across the city in the Mission District in front of the 1776 Mission Dolores, San Francisco's oldest building built by Spanish Franciscans.

San Francisco is lovely.


My daughter and I were amused by the "Kiss-o-meter" on the upper deck of the Eureka and it made me think of memorable movie kisses. I'd have to say (unable to resist an excuse to make a list) that for on-screen sizzle I distinctly recall

-Johnny Depp and Juliette Binoche in Chocolat
-Jeremy Irons and Patricia Kaas in And Now, Ladies and Gentlemen
-Charleton Heston and Haya Harareet in Ben Hur, the second time

I'm sure if I thought about it enough I could come up with a few more...

Saturday, January 3, 2009

En Route

We are on our way across the globe to visit my parents.  Please send a little prayer our way!

Thursday, January 1, 2009

Renovations II: Welcome 2009!

Happy New Year!

Usually this holiday depresses me. I get a little anxious or wistful on New Year's Eve over the inexorable pace of time marching on. NOT THIS YEAR! First of all, I was glad to see 2008 go. Between losing half our 401K and the turmoil at work, it was not exactly our favorite year. Secondly, we did just what we love to do on New Year's Eve: enjoyed a quiet night at home as a family, just the four of us. No anxiety - just contentment.

In the afternoon we huddled together listening to the wind and snow and watched A Christmas Carol (Clive Donner's version). For dinner I prepared a simple meal of salad greens, discs, of fresh mozzarella with blueberry vinaigrette, and pasta with garlic, Parmesan cheese, and sun-dried tomatoes cured and canned at home from her own garden by one of the nurses at St. Boonie's - delicious! (Thank you, Nurse BR!)

After dinner we laughed over the cute Star Trek: The Next Generation episode entitled "Rascals," talked for a while (despite my hoarse voice from laryngeobronchitis), made music together at our out-of-tune piano, then tumbled into bed, where it was as if the labors of the year suddenly piled up on me and anesthetized me for TWELVE WHOLE HOURS. Sleep! Wonderful, much-missed, much-needed sleep! It was a delightful New Year's Eve - second only to the time we spent making s'mores in our cabin as we ushered in 2007.

I see this new year the way I see our kitchen renovation: out with the old, in with CHANGE FOR THE BETTER. Here's to a bigger and better 2009!



We're still missing the floor, the pot rack, and a new dishwasher, but we're hoping to have a kitchen-warming party anyway when we get back from our trip to the Philippines. Blogging may be a little off-and-on this month - we leave for our trip on Saturday - but I'm hopeful I'll be able to continue to write overseas.

In the meantime, don't forget to check out the latest Grand Rounds, put together by Moneduloides in honor of this year's bicentenary of Darwin's birth and the 150th anniversary of the publication of On the Origin of Species. Enjoy!