[Poetry] start the kettle

On my family medicine clerkship, some of my most cherished (and deeply moving) moments came from leading end-of-life care conversations with patients including designation of medical power of attorney and solidifying advance directives. Such dialogue continues to kindle my passion for geriatric care. However, the American medical system must do better to empower patients to understand the many medical services we can provide, including the demystification of hospice care and palliative care. No longer can we, in medicine and in society-at-large, continue to ignore death and dying as a natural part of life. This poem, "start the kettle," was written in reflection of such issues dear to my heart.

--

bolt the doors! lock them twice!
perhaps She will not come!
in such ignorance we find joy so temporary,
shaming and belittling Her
in our foolish feints to dodge Her.

we synonymize and mislabel Her,
costumed and ill-depicted.
Her presence is removed from our minds.
we cry that Her name will not pass our lips;
the Ostracized Outcast is unabashedly unwelcome

wake up! wake up unto new life! wake up, i beg!
you - who perceive this Woman as a Thief most vile
who will steal your finest jewels
tell me:
what thief makes Herself known to all?
what thief knocks and rings the doorbell?
are you so blind? open your eyes!
She is no source of fear!
mistreat Her no more!

She is a mere constant - like gravity.
She greets us, one and all:
our shared Mistress
in the end of the big chase
sheer surprise
or sobering self-retreat into Her arms.

She will be terribly apathetic
so long as you are of Her existence.
of course She shows up unexpected and uninvited!
we provide Her no directions to our house -
which way do you prefer? how should She find you?
it is easier to take the highway or the side roads?

These thoughts might molest the mind,
strip the soul, and harrow the heart -
but they need not.

if She must come,
plan ahead.
start the kettle.
invite Her into your home when She arrives,
whenever that might be. She is busy, remember.
offer Her tea, and be a good host.
for, yes, She comes for you,
but may you go in peace with Her.

[Poetry] Perspective

I wrote this poem entitled "Perspective" in honor of one of my patients on my neurology clerkship service. Señora, gracias por todas las lecciones de vida que compartió conmigo. Me encantó nuestras conversaciones y las aprecio.

"You are stupid. Don't think for a single second You know your disease! To be there for your family And To be strong for your children, What you say is closest to your heart -  What is most important is To succumb to your illness. You must learn not, If you want to find happiness, To find hope amid the darkness Surrender to the battle! After all, acceptance is the Solution to the chronic state. Don't you see? This is not a  Proper way to grieve! There is no Pause. Counting your blessings Won't stop the disease. You should be Wallowing in sadness. My dear, don't you get it yet? Yes, you have multiple sclerosis!"

"Yes, you have multiple sclerosis." "My dear, don't you get it yet? Wallowing in sadness Won't stop the disease. You should be  Counting your blessings. Pause. There is no Proper way to grieve. "Don't you see? This is not a  Solution to the chronic state. After all, acceptance is the  Surrender to the battle. To find hope amid the darkness, If you want to find happiness, You must learn not To succumb to your illness." "'What is most important is What you say is closest to your heart -  To be there for your family And To be strong for your children. You know your disease. Don't think for a single second You are stupid."

[Poetry] The Kiln

Enter the fire!
Ye children of the world -
The forever-marks you sustain
Give strength through the pain.
The roads we travel
Paint us beautifully in colour unique
But converge here -
The grey, ashen kiln

Enter the fire!
Ye children of the world - 
Emerge you shall
Colours not as they once were
But glazen, brilliant!
The imperfections
Bring character
To your art.

[Poetry] In the Beginning

and

finally

She arrived

from the pool.

Her senses activated

as She opened Her eyes

and introduced Herself boldly

with the most rewarding scream:

YES! LET THE WORLD KNOW!

She filled the room with Her presence.

Life

unaltered

is swaddled

in my tight embrace.

She is naïve

and simply

Perfect.

the

future

flashes forward

for a Soul Yet-To-Be…

for She is just

minutes

old.

one does not forget the faces of parents

as they are first given their Perfection

relishing the feel of Her hair –

an almost-fear of speech

permits but mouthing

the softest welcome:

with trembling love

and pure adoration,

they whispered,

“Hello.”

[Poetry] words

the soft stroke of my pen
the faint flick of my mouth
penetrate your ever-ready mind
as i try so hard to follow your cues
to awaken you unto a heightened state.

but passion in words
comes in their final effect-
the vast unknown of open lips
allows roles to swap throughout
as our tongues playfully swordfight
and unite our two once-distant souls.

the rush of this exchange
depends on how much is offered:
will you give all of your words and
allow yourself to receive uninhibited?

or will you always finish early
and move on never knowing
the deep satisfaction of
pleasuring another
in conversation-
never valuing
the worth of
another?

On Honesty (in Third Year, Medicine, and Life)

Honesty is a tricky thing. 

I truly believe that, in honesty, you find better, deeper, more meaningful relationships with people who strengthen you (and whom you strengthen), and it can dictate your various friendships and other social circles. But, what happens when a relationship with family/a closer family-esque friend/a patient/a colleague (i.e.: a socially perceived "valued" relationship for whatever reason) can only be seemingly salvaged in hidden truth of one's feelings when conflict inevitably occurs? How does one reconcile such a relationship that is dangling by a thread when total honesty is necessarily avoided to preserve what's left? Is it as simple as cutting the thread and freeing oneself in unabashed defiance of the falsely positive value given to the relationship based on no-longer-applicable social mores? Or should one find a way to use that thread, however frayed, to reach out and rebuild the fine quilt that once existed in honesty? And is the judgment call further complicated when you are not sure if the other person sees (or wants to see) the damage...or even cares if it might be damaged at all?

I tend to lean towards repairing those relationships which have once carried you, defined you, and have meant so much in the past (and still do) with as much honesty as possible, but, if needed, even at the expense of honesty for a perceived greater good. I find myself throwing away all my own feelings and thoughts to satisfy and maintain the delicate status quo time and again to make others happy.

Make no mistake: I value this element of my personality; it is so much of who I am. I deeply value my ability to concede my feelings in the heat of the moment to expedite re-establishment of total honesty and good relationships after chaos. I perceive it as a strength to value another's feelings over one's own in an open act of re-perceiving and re-evaluating a relationship from an entirely different perspective. In fact, many of my closest friends share such a wonderful trait.

But lately, it has not been so easy for me to find that total sacrifice within myself. It disturbs me, and I am in a deep state of wondering why. 

I have started to wonder if the third year of medical school has perhaps affected my personality to give all of myself, including my feelings, in this newly-found sense of necessary self-preservation and value. Now, at the very bottom of my career's hierarchy, any shred of personal thought, opinion, and wishes are of ill use. I am devalued, scared, insulted, belittled, stigmatized, inappropriately criticized, and marginalized. Often, I am left to passivity, given no real ability to assist others, and feel ultimately unworthy of the more experienced doctors' understandably precious time. 

Certainly, these thoughts are not rooted in my disapproval of the "higher-ups." Such sentiment couldn't be further from the truth (speaking of honesty)! I fully understand that any mistake or mishap from my naïveté reflects negatively on residents (and the attending) in their own relationship within the existing hierarchy, including maintenance of ever-important rapport with patients and even patient safety and well-being. I also fully appreciate their perspective of the system's evaluation of their performance and overall worth and aptitude potentially could be based on my actions. Furthermore, my residents have overall been amazing teachers and mentors in their various (permitted) capacities. Obviously, as a third year medical student, I'm not ever going to be First Surgeon on any surgery (#lawsuit), but I can be (and am) engaged in the process as the surgeon explains his or her reasons for various steps in the procedure (and occasionally asks me to hold pressure on a vessel or retract an organ to help out). In a way, doctors and medical students share camaraderie in that we are all together victims of a system of constant, critical judgement. There's always someone criticizing you, no matter how high on the roster you might be.

However, if the systematic totem pole is structured in such a way previously described, it is then expected that the "inferior" or "lesser" rungs get fewer (if any) responsibilities so to protect a deeply valued and objectively paramount goal of safe, quality patient care. Such stratification, then, has its side effects on perception of value and worth. I fear that, in such arguably necessary treatment of the medical student, I am denied so many opportunities, separated from many practical/useful skills, and deprived of the interactions essential to training a future generation of physicians. What happens when I "skate by" and get my medical degree without any objective means of showing ability? Suddenly, as a resident, the expectation of competency is high (after all, I will be a REAL DOCTOR...an M.D....and be treated with the rights and duties therein), and I will be responsible for maintaining such goal of safe, quality patient care without proper training. 

And even in returning my bothering of the troubles of tomorrow in good faith in the medical education system...even in the present, to feel so unwanted in something you are so greatly impassioned feels like unrequited love.

I have found the need to revalue myself in my dedication to patient care whenever applicable via the little things I can offer, in seeking out and finding meaning in otherwise menial tasks, in preparing my absolute best for rounds so to help my residents better understand the patient, and in speaking up for my patients as their personal representative. In a way, I think that's part of entering the medical system - to find a utilitarian role for oneself to achieve the previously stated patient-centered goal. The social recognition of my perceived value in utility has, for better or for worse, defined my entrance to my passion in medicine. 

Such needs have forced my honesty about my own feelings and newly-found recognition of their value into the open. Of course, I am always still respectful and courteous, in recognition of the hierarchy, and try to speak in times of conflict with tact. But, I have become unwavering in my reinforced importance of self-value. Surprisingly, such self-confidence and honesty have proven quite positive in defining relationships with colleagues, patients, and in medicine overall. It is becoming a part of what makes me "me" to "stick up for myself," as I have become completely honest (including about my immediate my thoughts and feelings in times of conflict) and refuse to devalue myself anymore than I currently am in the hospital. Luckily, it appears honesty is in fact appreciated in the medical working world in peace or in turmoil. But, such potential for sustaining conflict in self-defense is uncharted territory for me, and I have found that, a few times, it has nearly caused a total severance of a previously defined valued relationship. Admittedly, most of the time, things work out with potentially one or two metaphorical scars that (usually) eventually fade. But, I don't know if I have ever gone so far with my self-defense as I have lately to potentially permanently burn a bridge with someone dear to my heart.

In a nutshell, I found a shred of self-worth through total honesty even in heated conflict that I did not have before, and it is helping my career opportunities and many of my professional and personal relationships, but I don't know what to do with it when my new personality is too much for people I hold so dear.

I think my personal conclusion is that I am ultimately determined find some way to balance the "old me" and "new me." I certainly must hold onto the old piece of my identity: that is, to give all of myself to others, including my feelings. If my goal is safe, quality patient care, my service and actions are for my patient entirely, which may mean, at times, surrendering my feelings to them and to others on the medical team if it is in respect of the patient. What's more, the desire to give value to others at the expense of myself when times are tough have fostered my best relationships with colleagues, patients, friends, and family. It is personally altruistic, ideal, and moral. Furthermore, it is simply natural for me. However, this newly-discovered trait is not without its value, too, for it has imbued me with the self-confidence necessary for competency, for patient care, for medical teamwork, and for self-empowerment. These traits also contribute to the goal of safe, quality patient care and, thus, cannot be ignored. 

The equilibrium will come from learning to define my self-worth additionally through my total sacrifice. While I have stated my value of the act of total sacrifice, I don't think I ever have used it to validate my self-worth...and I SHOULD! It is through honesty that I have been honored and blessed with some of the greatest people I could ever imagine. And, it is also through honesty that I have found my role in the medical realm. But, perhaps this whole time, I haven't been honest with myself in my own perception of my worth in my ability to sacrifice entirely if the need arises. 

For now, it is a work in progress to find that happy middle ground, but I am excited to find that place in recognition of finally finding (and feeling) some well-needed assurance in myself.

[Poetry] Surgery

"I have just three things to teach: simplicity, patience, compassion. These three are your greatest treasures." - 老子 (Laozi)
--

i found a hidden temple in the holding room –

a spiritual sanctuary of reflection

where Father Time seems to dwell in infinity,

and meditation fills the sterile air.

You had donned Your silver surgical cap

an outward sign of readiness!

but i saw in Your eyes

apprehension

and fear.

in the holiness of the temple walls,

You told me Your secret:

“estoy nerviosa.”

did no one else think to ask You?!

or perhaps They did not know how.

in this trusted space,

charlamos, y yo vi Su sonrisa.

You were finally ready for war, internally,

just in time

as You were then swept away for combat.

the Team prepped Your skin for incision

but it is clear i am without a role

in the Supreme Hierarchy

except as a mere

obstacle –

but

i

silently

acknowledge my capacity

to have prepped your soul – for

i

held Your                           hand

as the                    sedation took over          and

Your eyes            began                   to close.                             

i

caught Your final glance,

stroked Your hand,                          and

sent You into battle.

i am indebted to You for trusting the deadweight.

You gave me a purpose

and make my passion

worth the mockery –

and so i promise

to faithfully

serve

You.

[Poetry] The Tree

In memory of D. S. –

Thank you for all you have taught me in your words and actions.

 --

My heart’s still sad, though time has passed,

But now some peace I have at last.

My friend, through you, my mind recalls –

If, in a forest, a tree falls,

And there is nobody around

Does it, in fact, evoke a sound?

For I can hear the birds do weep

No twigs for nests or berries to reap.

And squirrels release a heavy sigh

No more acorns come from on high.

The owls hoot a solemn tune

Their trunk – their home – lost all too soon.

A loss sustained, the monkeys mourned

The treasured treetop vines adorned.

And who will help the fawn to grieve

The absence of the shady leaf?

The realization I have found

The tree indeed does make a sound.

Not from the loud thud of the fall

But from the life it gave to all.

[Poem] My broken lengua

"If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart" - Nelson Mandela
---

Disculpe mi español-
my broken lengua

me siento guilty for the robotic "hola"
that escapes mis labios
cuando i introduce myself
and proceed a preguntar such personables
about sus funciones corporales:
vómito?
evacuaciones?
orina?
<<cómo se siente hoy?>>
that one-liner sin conexión o empatía
que todos los doctores seem to know...
<<bien>>, responde,
porque sabe we couldn't understand anyway -
la complejidad de su dolor

it is as if language barriers are reduced
to mere algorithms ...
to heart rates and blood pressures...

frustrante es
porque estoy aprendido una lengua nueva
so you don't have to
para recibir ayuda when you need it.
no sé porque a veces hablar sin esfuerzo
and other times nothing comes out...
lo siento, pero estoy tratando
i swear.

Disculpe mi español-
my broken lengua

but you are helping me piece it together.
sí - juntos!
poco a poco, estoy reaprendido
cuando
me pide por una taza de hielo
para su boca seca
y conversamos por primera vez
sobre las cosas importantes.

su paciencia y confianza en mí son regalos.

durante su estancia
el trabajo es mío. no suyo.
debe ser cómodo en mi hogar.
bienvenidos.

[Poetry] the dark is better than the dim

i am quite simple
no revolutionary mind
nor revered engoldened tongue
an oft forgotten member of the Crowd
among awe-inspiring greatness of Others
and now stranded in this suffocating cave-in

with one desire to find freedom and give it
i followed the path set before my heart
now my crippling air hunger worsens
with successive breaths of agony
the Rocks press into my chest
Failure's imminence

lost in this tunnel
blacker than the others
through with i have traveled
i force shut my eyes to remove
the sparse Rays of Light which create
bleak chaos in Their cruel incompleteness

i realize the dark is better than the dim
for only then I feel Gravity's constant
which turns my scared gaze upward
so i can see clearly my Path
with the radiant light
found in the Above

[Poetry] Sunset

Dedicated to C - I hope I made you comfortable. Thank you for your company and invaluable gift.

--

a nightingale knows best.

her call comes forth

as the daylight dwindles,

and, listen…i hear her now.

i follow her tune

guiding me to you

she chirps warmly for you

you are her favorite, she twitters,

just, lately, a little more quiet.

the rests in her score

carry a purposeful fermata.

the unsung is more telling

than her notes themselves.

as i gaze upon you,

you look straight through me.

gloves and gown further separate

our connection.

i see an experienced face

sunken in from your fight.

your prominent cheekbones

underline heavy yellowed eyes

which never seem to blink.

how i ask and beg you

to close them amid your gasps

neither i nor the nightingale can quell.

only time, that precious constant,

will resolve them.

still i talk to you

although uncertain what to say.

knowing you could not turn your head,

through held-back tears

i describe the sunset

the vivid pink and flaming orange

against a baby blue sky speckled with clouds

as the sun descends.

the beauty of nature’s colorful masterpiece

is reflected in your presence - an ember’s glow

which now fades into silence.

i hope you leave knowing you were loved

by the world around you

and that your sunset illuminates 
my horizon. 

[Poetry] Mending a Broken Heart

"The art of healing comes from nature, not from the physician. Therefore the physician must start from nature, with an open mind." - Philippus Aureolus Theophrastus Bombastus von Hohenheim (Paracelsus)

----

Angiography came back normal, and his

Brain natriuretic peptide was within normal limits. I ordered a

Creatine kinase, which was perfect, so no infarction. The

Doppler imaging showed no evidence for flow disturbances. The

Electrocardiography strip demonstrated normal conduction, and his

Fractional ejection was excellent. Last admit, they did a slew of

Genetic tests, but they were all negative. Maybe the
Histology from biopsy will reveal something? Should we consider

Invasive cardiac electrophysiology for this patient? His

Jugular venous pressure was just fine, and he is without

Kussmaul signs to suggest frank heart failure. Some labs of note:

Lactate dehydrogenase was inconspicuous, as were his

Myoglobin levels. The patient underwent a

Nuclear stress test, but results were fine. We want to avoid

Open heart surgery for him … perhaps a

Positron emission tomography scan, or a

Quantification of chamber volume could save the day? But the

Radionucleotide imaging from last week’s admit was good. With the

Stethoscope I heard no murmurs, rubs, or gallops. Did I mention

Troponin was fine? And the

Ultrasound provided no remarkable findings. Is he going to need a

Valvuloplasty? Is it even a busted valve? And, I found no

Water hammer pulses. Radiology said the chest

X-ray did not hint at cardiomegaly. I cultured everything, even

Yersinia enterocolitica, but his blood is clean. And for his age,

Z-scores of cardiac valves were solidly in range.

So many tests to analyze a broken heart

But why does the patient continue to demonstrate cardiac decline?

Ask the patient what brings him in, and

Believe in truth his word. Promise to

Care for him as if he were your kin; in so doing, you

Demonstrate your passion. Find a way to

Express yourself with your whole soul, and learn to

Feel what he feels. I ask of you to

Give it all you got to find the diagnosis, but

Hide not when you are in doubt or uncertain. Be sure to

Investigate thoroughly his social history, and to

Judge not the choices he has made. Remember,

Kindheartedness goes a long way, especially when you

Linger a bit to talk about non-medical things. Always

Mind the patient’s privacy, but never

Neglect to ask if he might need anything. You must
Open yourself to his concerns, and even

Pray with him, even if just your presence is enough.

Question your biases, and remember to

Reconsider your differential.

Study hard and

Trust yourself.

Understand that life and medicine are not algorithms, so

Value deeply the stories he tells. Furthermore,

Watch his facial expressions,

X out of the computer screen, and look him in the eye! You should

Yearn for more time to spend with him, and

Zero in on his greatest fears and worries.

So many tests to analyze a broken heart

But without empathy and love, how can you ever understand it?

[Poetry] what i have to offer is for You

"If I am not for myself who is for me? And when I am for my own self, what am I? And if not now, when? - Hillel"
"אם אין אני לי מי לי ? וכשאני לעצמי מה אני ? ואם לא עכשיו אימתי? -הלל"
--

what i have to offer is for You

indeed it is for Everyone

except me

for that is me: what i offer You

i am lost in the sea of You

the very me shrivels

as i pour for You

yet another cup of water

as thirst nags at my throat…

but i can endure

i must as i have always

for to fail You is to fail me

don’t You see

so i do not fail for You

i offer myself to You

in so doing

i have nothing left of me

to give to You for i am nothing no more

but You expect more

because that is me: what i offer You

when my water dries up try as i might to sustain

for all who are thirsty and whose glasses are empty

in the end

to care is to hurt

to appease is to lose

to comfort is to betray

to reach out is to offend

for i am a finite fountain  who was never supposed to recognize such limits

instead to be ready to just give and give and give and give and GIVE

until i have no more and never truly knowing myself

except what i offer You - for that is me.  

i have poured myself into a last

offering of water … drink up,

my friend, for i give You me

and simply have no more

of myself to offer –

i am myself no

more