“Wow, you don’t have an accent at all!”

From Charlottesville to NFL stadiums, conversations and controversies surrounding race relations have seldom felt more heated. These events challenge each of us to consider how racial issues intersect with our daily lives, as OHSU emergency physician Esther Choo notably did in a now-viral tweetstorm about patients refusing care from providers of color.

The reverberations of these seismic disruptions in our social consciousness have, naturally, stirred discussions in our medical school’s classrooms and clinics: how we’ve felt impacted, how our patients have been affected, and how we can root out structurally-ingrained racism in our local environments. And while I can’t claim to understand or have experienced the unique challenges my black or Latino colleagues encounter, these conversations have raised common threads of reflection among my Asian-American peers about the micro-aggressions we navigate while learning medicine in the ‘buckle of the Bible Belt.’

Thankfully, the experience of being verbally confronted or having my services refused on the basis of race isn’t something I’ve had to handle—for such overt hostility, the New England Journal of Medicine has an excellent primer on “Dealing with Racist Patients.” Instead, my brushes with “lowercase-r” racism have been much more subtle, and often unintentional.

“I know a Dr. Patel; he lives in North Carolina? Do you know him?”

Funny; I know a Joe Smith in Edison, New Jersey. Do you know him?

“Where are you from?”

New Jersey.

“No, where are you really from?”

I promise, I am really really from New Jersey.

“Where are your parents or grandparents from?

[Groan.]

“Wow, you don’t have an accent at all, and your English is great!”

Well, I scored 5’s on my AP English exams and an 800 on my SAT verbal, so I’d say I’m pretty decent at English, yes.

“You moved here when you were two months old? That means you’re almost one of us!”

Thank you for letting me know that, though I’ve spent 99.3% of my life here, completed 20 years of schooling here, renounced my Indian citizenship for a U.S. one, and consider myself as deeply immersed in your sports, music, and pop culture as anyone else, that you still think of me as less entitled to the privilege of being “American” than you are.

If you’re not convinced, Buzzfeed has some delightful examples, too.

I came to Tennessee (which is 1.8% Asian) from a university ranked #1 for race-class interaction, and before that, a minority-majority hometown where our high school cafeteria resembled the United Nations. It felt entirely foreign, then, to transition to a setting where most of my patients not only didn’t look like me, but had often lived for decades in rural communities where everyone looked the same, sounded the same, prayed the same, and voted the same. It was a rare experience to feel hyper-aware that I was different, which was only heightened by my patients’ comments and curiosity questions. These bigots, these ignorant rednecks, these deplorables, I fumed internally.

With time, though, as I grew to better understand my patients, my exasperation softened to empathy. Through brief interactions at the bedside, I came to see my patients’ “political incorrectness” not as ill-intent, but inexperience. If you live in McMinnville, Tennessee, you might believe that most towns, like yours, have only one South Asian family, and intuit that these dispersed Desis find and know each other. You might only know of South Asian culture through the pop culture vignettes of Simpsons or Slumdog, so that when you encounter an Indian American medical student, your conversational instinct is to ask about accents, bindis (“dots”), the caste system, or arranged marriages. Maybe that is bias or racism, but it’s a curious naivete that’s infinitely harder to hate or look down upon than a tiki-torch mob.

Acknowledging that naivete, I no longer get frustrated or angry. Instead, I teach.

“I know a Dr. Patel; he lives in North Carolina? Do you know him?”

“No, I don’t. There are 4 million Indian Americans across the U.S., so it’s hard for all of us to keep in touch! “Patel” is also as common a last name among Indians as “Smith,” “Jones,” or “Johnson” are here. It’s like asking if you know my neighbor back in New Jersey just because he has the same last name; I’m guessing you probably haven’t met!”

“Where are you from?”

“I’m originally from New Jersey, where my family still lives.”

“No, where are you really from?”

“Well, I was born in India, but moved here when I was two months old. I’ve completed all my schooling here, gone to college here, and consider myself culturally American with Indian roots. Most people tend not to remember much from the first two months of their life, so practically, my life here is all I’ve lived and known!”

Likewise, acknowledging my limited insight into the lived experiences of the South, I learn. I ask my patients what it’s like to live in rural Tennessee or the ‘urban underserved’ areas of Nashville. I ask about the factors that promote or impair physical and mental wellbeing in their communities. I ask about their beliefs, values, and goals, realizing that their social contexts might frame these perceptions to be drastically different than my own precepts or presumptions. As I realize that I understand their lives and backgrounds as little as they do mine, it becomes harder to cast judgments or throw stones.

Of course, not everyone’s experiences might be as benign as I’ve been fortunate to have, or as amenable to resolution with casual conversation and cross-teaching. Medicine has much self-reflection and work to do regarding racial disparities—certainly, among others—in our physicians’ demographic composition, in our patients’ health outcomes, and in our interpersonal interactions in clinical practice. That’s a much larger matter, and I’ll table it for a more seasoned expert’s commentary.

But, for immigrant medical students and physicians, I offer this advice: the next time you encounter an off-putting or politically-incorrect remark, consider where it’s coming from, and the contexts and experiences which frame that person’s viewpoint. Consider the positive impact you might offer by deferring confrontation for education. And most critically, consider your own biases or presuppositions before judging or critiquing someone for theirs. Shared understanding isn’t always the solution, but it’s often a worthwhile start. Give it a try; I promise your patient interactions (and cortisol levels) will be all the more better for it.

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Chugging Along

It’s the morning after Election Day, and the world still has a sort of surreal quality to it.

I awoke this morning with a sense of fear. Fear for my own safety, and the safety of my loved ones who fall beyond ‘standard’ templates of race, faith, nationality, gender, or sexuality. Fear for the stability of public discourse and debate in the coming days and weeks. Fear for the legacy of the last 8 years—and the last 240 years, really—which today seems more vulnerable than ever.

Somehow, I got out of bed, took a shower, got dressed for school, packed a lunch, and drove to school, all the while feeling anxious to discover what a “Great Again” America would look and feel like.

And then I reached the hospital. Here, it doesn’t feel like the morning after Election Day; it’s Wednesday, November 9th, and just that. Doctors are taking care of patients. Residents are scurrying about, completing their usual errands. Patients are being seen, heard, and cared for, just like any other day.

One of medicine’s most beautiful qualities is that, whatever the turbulence beyond the hospital, the essence of the patient-provider interaction and the bedside encounter remains a familiar constant. Today, my fellow healthcare providers will head to work carrying the weights of their emotions and thoughts, but once we walk into that exam room, nothing else will seem relevant but the needs of the patient before us. Even if that patient is wearing a “Make America Great Again” cap, and even if he holds an ideology that considers my kind an outsider or a threat, we’ll look beyond that. We’ll resist the temptation to see a ‘deplorable,’ and challenge ourselves to see someone who needs our guidance, compassion, and care. A patient—nothing less, nothing more.

That’s not to suggest at all that medicine occurs in a vacuum. As physicians and physicians-in-training, we now face an uncertain future that could well profoundly affect the way we practice. Our patients will face renewed challenges to receiving accessible, affordable, equitable health services. The health and wellbeing of marginalized populations, such as women and LGBT individuals, will be more vulnerable to the whims of partisan policy than ever before. Gun violence will, once again, fail to receive its due recognition as a public health emergency.

These are important matters, and as educated experts who navigate these issues in the trenches each day, our voices will be critically important to these conversations. We cannot let our commitments to advancing the health of populations waver in the face of adversity. The path forward will be harder, and so our convictions must be even stronger. That conversation begins tomorrow.

But today, when it seems like the rest of the world is standing still, and when it feels like a future with a President Trump is too painful to even imagine, I take comfort in the assurance that ours is a profession that, despite our emotions and adversities, keeps chugging along, changing the world one patient at a time.

When Breath Becomes Air

As I write this, I’m wiping away the tears in my eyes stirred by Dr. Paul Kalanithi’s When Breath Becomes Air. Richly reflective and powerfully evocative, it’s the touching narrative of a doctor’s attempts to confront death—as a student of literature, as a neurosurgeon, and as a patient—and, through the lens of terminal illness, examine how dying gives meaning to living.

With When Breath Becomes Air, Dr. Kalanithi allows us to, in his words, “Get into these shoes, walk a bit, and say, ‘So that’s what it looks like from here … sooner or later I’ll be back here in my own shoes.'” It’s a walk that resonates particularly strongly for me as a fledgling physician.

As he reflects on his medical training, Dr. Kalanithi looks back with the perspectives of both patient and provider to offer valuable insights on what it means to be a physician: someone who translates statistics and survival curves into a patient-oriented language of values, identities, and capabilities; someone who is relentless in the pursuit of operative excellence, but understands that a surgeon is more than an expert technician; someone who aspires to perfection, but ultimately accepts his fallibility.

For any avid reader of medical non-fiction, these reflections will sound familiar, the stuff of Better and Being Mortal. And yet, When Breath Becomes Air feels different, because it explores medicine’s virtues, values, and flaws from the perspective of a patient, someone who is both an insider and outsider to medicine. As Dr. Kalanithi writes, “As a doctor, you have a sense of what it’s like to be sick, but until you’ve gone through it yourself, you don’t really know.” His perspectives on what makes a good doctor are informed by an intimate understanding of what patients feel, what patients think, and what patients want that most of us, as providers, can only infer and intuit from our interactions with illness in the third person.

At its heart, When Breath Becomes Air is about more than how we ought to provide care; it’s a contemplation of how we ought to live. The life of a physician-in-training often feels like a life of anticipation, of potential, of surviving the present to reach the rewards of the future. We spend a third of our lives studying, sacrificing sleep, accumulating loans, and watching our friends build lives that are less exhaustive and more lucrative, all of which we accept for the eventual promise of a career that offers an unparalleled balance of intellectual engagement, moral fulfillment, and socioeconomic comfort.

I ask myself, then: if faced with a terminal illness tomorrow, would I feel that I’d achieved anything more in 23 years besides a pursuit of a life still yet to come? For Dr. Kalanithi, the prospect of dying gives the present an immensely deeper significance, a more imminent urgency. As I read his detailed recollection of his last day as a physician, a heartfelt recall of each interaction, each sensation, each incision, I felt uncomfortably reminded of what I’ve seen and done over the last week, and how it felt so unremarkably routine. I’d been present, but I hadn’t been truly present.

Reading When Breath Becomes Air, I felt called to attention, awoken from autopilot to embrace the quiet miracles and subtle wonders that transpire around us each day in the hospital. If we practiced medicine each day as if it were our last, what might that look like? What could it do for our connections with patients, for our interactions with our colleagues, for our thirst for meaning and fulfillment in our daily lives? This, I think, is Dr. Kalanithi’s strongest parting advice for us. And as cliche as “live as each day is the last” sounds, that we so rarely do it makes it advice worth hearing.

When Breath Becomes Air is an easy read that raises difficult questions, a short book that invites lengthy pauses for thought. Whether you’re in medicine or not, you’ll invariably someday find yourself pondering the matter of mortality and the meaning it imparts to the closing days of life—and therefore, you’ll invariably find this book to be both moving and meaningful.

Thanks, Dr. Kalanithi.

Well, Here Goes Nothing

It’s finally here.

After 13 years of K-12 schools, four years of college, and one year of pre-clinical medicine, I’m finally doing the unthinkable: stepping beyond the classroom, trading chalkboards for charts, swapping study guides for stethoscopes, and putting 18 years of learning into application at the bedside.

Well, sort of–there’s still grand rounds, morning report, and core didactics. And I’m far from done with textbooks or tests. But it’s hands-on, and it’s dynamic, and it’s the closest I’ve ever felt to actually doing anything tangible, applicable, or useful, so I’ll seize the opportunity for a little ‘hooray!’

Just one thing: I’m scared to death–tense, timid, terrified, and (D) all of the above.

In the days to come, I anticipate carefully budgeting my umms, uhhs, and I don’t knows. I expect to know all the right answers–that is, about five minutes after the question’s been asked and the resident’s moved on. I plan to stockpile the responses that are valid for almost any question; I’m told ‘cytokines’ and ‘idiopathic’ are reasonably reliable. The unshakable conviction that I’m only here because of an admissions office clerical error is back, right on cue from this time last year.

Here’s the wild part, though: even though all that’s true, and sleeping in is about to mean 8:00am, and a two-day weekend is about to be a vaguely fond memory of days past, I’m still really, really amped for this.

These next few months, there’s no telling what might happen. I might get to introduce a life into this world. I might get to reboot a heart that’s stopped beating. I might get to offer someone a word of comfort in their waning days. Even the most simple of things sound like opportunities–I might draw upon 19 years of lessons and lectures to decipher what’s making someone feel crummy, then find a way to make them feel less crummy.

It’s going to be petrifying, but profound. Terrifying, but terrific. Wild, but wonderful.

As I embark on this next chapter, then, these are my promises to myself. In the months to come, I hope to revisit these promises, to measure my personal growth against them, and to hold onto them as my compass, my ‘true north,’ of moral and intellectual character.

Start humble; stay humble. This one’s easy, especially when you don’t have the expertise or credibility to be anything but humble. As I grow in this clinical life, though, I hope to retain what it feels like to not have the answers, to speak from a place of low hierarchy. and minimal confidence.

Remember that everyone’s an educator. Even while learning to think like a doctor and do as doctors do, I hope to bear in mind that there are many things to be even better learned from my other colleagues and collaborators: from nursing, compassion and advocacy; from social work, resourcefulness and relationship-building; from environmental services, perseverance and ‘can-do’ willingness.

Seize every moment like it’s once-in-a-lifetime. This year, I’ll rotate through 100 specialties, and 99 of them won’t be my future profession. In other words, for anything I do this year, it could be the first day of the rest of my life, or the last time I ever deliver a baby or close a surgical incision. I’ll inevitably be tempted many times this year to skip a learning opportunity or cursorily participate in an educational experience–”I’m never going to need this skill.” When that happens, I hope to catch myself, to cherish everything as potentially unique, and to stay open to the moments that might unexpectedly captivate me.

Resist a reductionist view of the patient. Toward the end of first year, I knew I was overdue for a summer break when I’d catch myself tuning out of the ‘irrelevant’ parts of the patient narrative, feeling impatient with the details that weren’t pertinent to a diagnosis. As the medical student, I have the gift of being ‘non-essential’; my histories and physicals are, most likely, just educational exercises. In that context, I hope to remember that it may occasionally be more impactful to defer the review of systems to allow a patient space to reflect. I hope to remember that there’s more to patient care than a detailed differential.

Exist beyond medicineFor better or worse, medicine isn’t my all-consuming identity, my sole purpose. I’d like to think I exist beyond the hospital, in the form of values, leisurely pursuits, and relationships. Naturally, this won’t be the year I chase my dreams of seeing the world, or the year I take a step back to focus on my relationship. The hours of clerkships and the drive to study more, to know more, to perform better will be demanding, and these will come first. I hope, for my sake and for the sake of those dear to me, that this medical apprenticeship doesn’t become everything–the only thing–that I’m about.

So there it is–the manifesto of who I am now, and who I hope to become (or not become) by the conclusion of this whirlwind of a year. Preachy? A bit. Sappy? Definitely. Over-ambitious and doe-eyed? Sure, probably. Still, I know the odds are against me, and chances are high that I’ll end this year more jaded, more skeptical, and less empathetic. And maybe, just maybe, if I set my goals to an aspirational degree of virtue, goodness, and empathy .. then I’ll land somewhere in the middle, and fare just okay.

Well, here goes nothing.

On Rounds | 3.24.15

In recent months, as I’ve transitioned from senioritis to sleep deprivation, I’ve come to appreciate the value of brevity. Goodbye, RSS; hello, Twitter, Circa, and BriefMe.

It’s with this perspective that I’m launching ‘On Rounds,’ a (hopefully!) weekly curation of big ideas, reflections, and byte-sized foods for thought. If you’re finding it tough to keep up with the world beyond the lecture hall or clinic, outsource that task to me.

On sitting with patients | New York Times
We often discuss empathy decline in medical training, and why it occurs; in this insightful, incisive piece, Dhruv Khullar absolutely nails it. Pre-meds don’t aspire to treat medical records and lab values, but people. But in medical school, knowing the patient takes a back-seat to knowing the pathophysiology, creating a rift between expectation and reality.

On MOOCs and medical training | Slate
While the MOOC is no longer a novelty, it’s still an enigma: what’s the place of online education in the knowledge market of the 21st century? This month, Yale raised the stakes by announcing its new online physician’s assistant program. In light of an imminent physician shortage and the ever-rising costs of higher education, one has to wonder: is there a place for online, or hybrid, education in medical training?

On re-designing deathCalifornia Sunday
Ideo, the legendary design firm, has built its brand on challenging assumptions and breaking the barriers of, “Well, we’ve always done it this way.” What happens when the strategies that have driven the design of products are instead applied to processes—say, death? And more crucially, how do we inspire and train clinicians to apply the design framework to the act of doctoring, itself?

On UX designMedium
What are the skills and roles that effective design requires? Irene Au breaks it down here, and spoiler alert—the parallels to patient care are remarkable. If we envision the bedside encounter as a co-design collaboration between a patient and provider, the implications and applications in this piece for clinical medicine are fascinating.

On health tech and how bad it isNew York Times
In most fields, the technologies work for the people; in healthcare, the people work for the technologies. Here, Bob Wachter explains why the transition to electronic health records has been a rough one, then lays a roadmap to realizing the value and potential of digital medicine. It’s a daunting task, but an essential one if we eventually hope to treat patients, rather than “iPatients.”