I watched this movie, requesting my husband to watch with me, because I heard Michelle Obama talking about it on her podcast, recommending it to her brother. Specifically, she mentions the ending scene, the poignancy with which it hits. This is the scene when William Shakespeare’s wife Agnes Hathaway is able to see her husband’s grief more clearly, and share it with him. The grief is, of course, the sudden and unexpected loss of their son Hamnet.

We are no strangers to witnessing the grief of losing a child, in pediatrics. It is one of the most terrifying and most aching parts of being a pediatrician, or a parent: the knowledge that you can lose the most precious thing in the world. The experience of watching someone go through that, or going through it yourself, is piercing. The movie Hamnet is about that grief, but it also is about the rendering of a relationship that survives grief. How can a marriage survive such grief? How can we, in one lifetime, witness the miracle of birth, and the trauma of loss? How can we, as physicians, witness that day in and day out, without breaking?

The first brushes with medicine, in the movie, involve the miracle of life. Agnes has her first baby alone in the woods, as she prefers, and her second babies, surprise twins, in the house with the support of her mother-in-law, against her preference. When one of the twins is presumed deceased, but she takes a gasp of a breath, and lives, it is as if a fervent prayer has been heeded. She becomes the fragile one. Her twin brother Hamnet is the one who is assumed to be strong and safe, but Judith—the one who almost died—she must be carefully watched forever. But despite that, and the aura of dread that hangs over Agnes once this happens, we see the twins and their sister grow up happy, playful, and carefree.

And so it makes it ever more shocking that, when the plague hits their house, Hamnet, not Judith, is the one to die. Agnes’s guttural screams when he dies caused me, watching, to catch my breath, my spit, my snot, my tears, all in the back of my throat, all co-mingling. The moment feels interminable. (The Oscar this year for the actress, Jessie Buckley, is so well-deserved). In the movie, Agnes is portrayed as self-assured, committed to her own ideals and emotions even if they go against societal expectations. It is what draws William to her, in the beginning. After their son’s death, she is able to express grief instantly. She will wear it on her sleeve, and she will not care what people think. When the movie flashes back to her own mom’s death, and how adults attempted to conceal it from a young Agnes, we see that she has always been this way: so assured that grieving is a right that shall not be taken away, that memory and memorializing are important endeavors.

Increasingly in medicine, we endeavor to honor grief. We try to hold debriefs and remembrance events. Still, they are sometimes clumsily inserted in the midst of a work day. We are always moving on to the next patient. The structure of the way we work is not always built to give hallowed space to incorporate grieving, memory, or memorializing. As humans, we find ways to do it. And everyone does it in a different way. In residency, I was not alone in having the experience of leaving the PICU at the end of a shift and arriving the next day to find the room cleared, turned over, often with a new patient. The room we walked into every day to check on that one baby. The way in which we find out this news of a patient’s passing impacts our grief, co-mingles it with shock and cognitive dissonance. It happens in primary care, too; getting a sudden phone call that your patient has presented to the ER and could not be saved; opening a chart to find the patient marked as deceased. It is an odd part of our profession, to see turnover in this way, visual and digital, and wrap our heads around the way grief relentlessly alters the landscape even when things look normal before our eyes.

In Hamnet, it is clearly disappointing to William Shakespeare’s wife Agnes to see her husband, who arrives home from London and discovers that his son is dead, decide to not stay long to grieve with her. Rather, he goes off back to London, to work on his playwriting. Is he avoiding grief, or is he truly not as impacted? We see them, husband and wife, pulling apart. This marriage growing ever-tense, as she feels farther and farther away from him, in her grief and his distance. When the movie switches to his vantage point, we see that in fact he is grieving in a much less linear way. He says the lines “to be or not to be” while on the edge of a pier, seemingly contemplating jumping off, falling, drowning, ceasing to exist. Ceasing to be. How funny, that I read Hamlet in high school, have seen it portrayed so many times, and known but never really felt the heaviness of the phrase in its contemplation of suicide. Shakespeare’s words permeate around us but perhaps we have associated them with some other life, some fiction, some world with a lyrical quality that is different than ours. Though as this movie and novel put forth, every art is grounded in something, every fiction in truth. In the movie, William never tells Agnes what his new play draws inspiration from. By chance she hears that it is named Hamlet, goes to see it without telling him, pushes her way to the front in indignation, that he would use their dead son’s name for a play. But when she sees the crowd at the Globe Theatre, men and women with dirt on their faces and under their fingernails, standing elbow to elbow, crying thick tears, reacting to Hamlet on stage, she realizes what William has done.

And what he has done, is package a seemingly vast grief into a broadcast, a broadcast to the world, for generations. He was not running away from the tornado, all this time. He was chasing it. She looks at him, behind the stage, and he sees her finally see him. And finally, they are able to have a shared moment in this grief. What her husband has been unable to express to her, perhaps even to himself, he has turned into a communal expression of emotion, such that when she reaches out her hand to touch the actor who plays Hamlet, to comfort him, everyone around her reaches out, too.

And there’s the rub; grief is scary because it is universal; it impacts us all. And yet, how can something so universal be so isolating?

I saw an interview in which the film’s director, Chloé Zhao, said she is training to become a death doula. Why? She says, “Because I have been terrified of death my whole life. I still am. And because I’ve been so afraid I haven’t been able to live fully. I haven’t been able to love with my heart open because I’m so scared of losing love, which is a form of death.” When I watched the movie, and then I watched the interview, I understood how she was able to tap into the nuance of grief. Where she finds something fearsome and inscrutable, she is reaching out to touch it, to know it, rather than stepping back. This is the difficult part about grief; sometimes stepping deeper into it can help you find your footing. This is what is hard, in medicine, too. Knowing the grief of the families we work with brings profound meaning to our lives, and is meaningful to them as well. But allowing yourself to get closer to grief takes intention, to embrace the difficult, scary underbelly of what humanity must go through. Sometimes in medicine deep grief is mistaken for weakness which is mistaken for ineptitude; and yet, there is nothing stronger than allowing yourself to feel.

I’ve been thinking about Hamnet a lot lately, how watching the movie gave me the ability to submerge myself in an imagined experience of grief, bear witness to it, but also to see how art can become a container to hold grief. Grief will never leave you, but if you make a container, at least you have something to carry it with. At least you have people to carry it with you. That is part of why I love writing, and why I love seeing people in medicine create art, prose, poetry, music. That is why I even loved it when we were made to sit around at a table and share reflections on a rotation in residency. It’s why I love it when a colleague exits a patient room in clinic and feels compelled to share something that moved them, even if the clock is ticking and we both have three patients waiting for us. I think that in medicine, we are always searching for those containers for grief and other strong emotions, and so often we are pulled in so many different directions, we don’t always have the chance to make them. We all deal with the loss our patients experience in different ways, and perhaps if we, too, were to see more clearly the ways in which our colleagues process grief, we could also all reach out our hands, at once, and understand it.

*This post is based on the movie alone, which I watched only once; I may have remembered scenes inaccurately. I haven’t yet read the novel Hamnet: it rests with my Folger library Hamlet on my nightstand, waiting to be read and re-read in succession.

My own Ammamma used to leave me voicemails, and when she died in January 2020, I saved all of the ones on my phone in a sort of digital remembrance ritual. As my husband and I drove from Philadelphia to New York, I played each one aloud and emailed it to myself with a short description. The voicemails I had from her in my phone were left in 2014 and 2015. After that, her ability to speak deteriorated, and when confronted with the phone, she began to nod along and say one word phrases rather than her usual style of rapid fire interrogation. And then, eventually, even the nods would stop.

But still, Siri was trying to reach Ammamma. Too scared of by being confronted by someone picking up on the other end, perhaps a new owner of the phone number, I hung up.

Moms are quintessentially supposed to be accessible, supposed to act as an appendage for your ability to function, a combination of RAM and hard drive all in one. They’re supposed to remember what day is crazy sock day at school but also when you need your next medication picked up and also are you meeting your developmental milestones and also what’s the Joules/kg to shock someone out of vfib in a code? (That one’s for the doctor moms.) I remember as a child in the ‘90s calling my mom’s office phone, asking in my most serious precocious voice, “May I please speak with Dr. Vis?” “It’s Vidya, her daughter,” I would say, and I would be connected through to ask an urgent question such as, “where is that one notebook, I need it?” My mom would have to pause her work as a pediatric hematologist/oncologist to say, “I think it’s in that cabinet?”

“But I looked in that cabinet already…oh actually I found it!”

The mental whiplash my mom must have gotten! As a mother now, I have realized that the working memory involved in being a mom who is “on top of it” is exhausting.

At the end of season 2 of the Marvel show Loki, which positions the character Loki fighting against the destruction of various timelines of the universe, Loki determines that the only way to preserve the multiple timelines is to sit on a throne in the center and hang on to them with all his might, keeping them alive and organized with his magic. He sits there, stoic, with great strength holding onto the heavy loom of all the timelines in the universe, so they can sprout branches and prosper and not get tangled up or destroyed. So that the fate of everyone rests on him. Loki, I thought, has achieved the essence of motherhood. Horns, a cape, mastering time, feeling the pressure of everyone’s fate on one person. What can’t mom do! Even sitting down can’t be relaxing, because she’s literally holding everything together.

Hyperbole, perhaps, but also, I have started to notice the systemic ways society enacts this expectation that mothers be accessible, even when there are two equally involved parents. In our medical record system, we list parent/guardian phone numbers in the chart for each patient. More often than not, we call a mom first. I have caught myself doing this as a physician even if it was a dad who brought the child in for the appointment. I have started to be more thoughtful about who I call, thinking, who was the one who messaged or called in? Who did I last see with the patient in the office? On the receiving end, I receive calls first for medical issues for my kids, or for the many therapies my autistic son receives. I am grateful for this, as I am also a physician, and the questions I ask are sometimes unique to my own background and not always reproducible by my husband. But when I cannot respond—often if I am in clinic seeing patients—sometimes they call my husband next. But sometimes they don’t. They just leave a voicemail, and move on. Then I’m stuck with a missed call and voicemail after work, and I can’t reach the caller because it’s already the end of the day. Or there will be a group text with a time-sensitive question, but it won’t include my husband, and I don’t see it immediately. It’s frustrating for my husband, too, who wants to be involved but is sometimes accidentally cut out of conversations.

There is a reason moms find it so hard to take a true vacation, because it’s not necessarily that hard to plop yourself in another location, if you have the financial means to do so. It’s because if you have a role that feels irreplaceable—if you’re holding the whole loom together—then leaving, letting go, for even a day, feels hard.

Now that I am a mom, and a physician myself, I am more appreciative that my mom was always so accessible despite her busy job. In fact, even now, she calls me almost every day, and she picks up the phone whether during a busy work meeting or her morning tennis, whenever I need her. And I’m glad that I have my Ammamma’s voicemails to remember her by, though sad that I was inaccessible enough that she had to leave the voicemails, meaning I missed her call each of those times. I’m appreciative that my husband is just as accessible to our kids as I am, even in a world where mom is often considered the default parent. I think my kids see both of us as equally accessible—perhaps him even more so, since he mainly works remotely. I want to be accessible and do the best I can for my kids, but I have realized that part of that means being kinder to myself when I slip up. And part of that means realizing, for all moms, that maybe the best support is systemically treating more of parenting as a joint effort, and not just defaulting to mom as the fixer, the caped martyr sitting, jaw clenched, in the center.

Rather than the proverbial writer’s block, it has been a dam. There is so much behind it that I worry it’s too much to open up. I catch up with friends and I wonder halfway through the monologue I have stumbled into if I have even paused to take a breath, or given them space to say something back. I have not, most likely. It is then that I know I should be writing.

One year ago we rang in the new year with our neighbors, a kids’ New Year’s Eve party at 5pm on Dec 31st. I made resolutions the next day. I remember none of them now.

What I remember of the year is big things that happened, things that have changed the rest of my family’s life. I keep returning to writing, how writing reveals truth, because the pictures on instagram and facebook show only a certain dimension of that. I post photos of images and experiences and funny things I want to remember and little of the things I wish never happened. The chasm between online life and real life grows.

Looking back to Dec 31, 2022 from where we are now, we must have passed through a wormhole.

In early 2023 my husband and I learned that our son has autism. Our son has since lost verbal language skills. I have thought for a while if it is something I should write about publicly. He is not defined by either of these traits. To me, he is defined by his smile, his persistence, his love of music. It is an early lesson, to have a child with special needs, and wonder how the world will define him, and not be able to control that. And yet. Sharing his autism has introduced me to the people who can support him, who can understand and help us how to better understand him. And one of the most gratifying things has been connection with other caregivers or siblings of children with autism. I’ve connected with many people through facebook and neighborhood groups, but only spoken with a few family and friends who have family experiences with autism. And I’d like that to change, because even those few conversations have been so meaningful. So if you’re reading this and thinking of reaching out, please do. It’s helpful to think that the people you already know can help you connect the past with the present, when you feel that things are changing fast.

While we processed that news, halfway through 2023 a discerning pulmonologist picked up a diastolic heart murmur on my husband Nihit. Even doctors are not above denial, and at first, I refused to believe it. I refused to auscultate myself to confirm, as if the mere touch of my stethoscope on his skin would will it into existence. The echocardiogram confirmed what I had prayed against, and then some: he had severe regurgitation of mitral, aortic, and triscuspid valves of the heart. He needed 2 and maybe 3 valves replaced. Still, at the cardiologist visit, I was in denial. “Can it be done through interventional cardiology?” I asked. I could not stomach the thought of Nihit going through open heart surgery in his 30s. I, who as a medical student on my two-week cardiothoracic surgery rotation had held a patient’s heart in my gloved hand during a mitral valve repair. I had seen them set up the heart lung machine for the operation. I had been in the OR as the surgeon who would become my husband’s surgeon commanded an hours-long surgery. I had joined a cardiothoracic surgery resident in closing the patient’s chest, after the sternum had been sawed open for surgery—watched them wrap pieces of wire around the two halves of the sternum and pull them together. On chest x-ray, you can see the wires shine bright. The linear incision becomes a scar down the chest that patients joke is their zipper.

It was isolating to have these memories, to wake up in the middle of the night in a sweat thinking, this would be my husband. I could not tell him. “I’m sure she’s explained the anatomy to you,” one of his doctors said. I had most certainly not. I could not bring myself to explain what was going to happen, as if it was going to be easy, or definite. My words, if they unleashed, might be too strong, too specific. Better to keep them behind the dam. Defang them.

It didn’t matter. It happened anyway. Sternum cut through, heart stopped, 2 mechanical valves sewn in, 1 biologic valve made from a pig, heart restarted. It happened to my husband, not to me, so even me writing about it feels silly. But I know I am proud of him. He survived a 4-6 hour surgery; then, tough, painful days in the ICU and cardiac unit. Days when we relied on the kindness of his nurses and MAs, who grew to recognize and know us on the unit after he had been there for 10 days his first hospitalization, then 7 days the next. We have so many people to thank. His surgeon Michael Acker, his cardiologist, his rheumatology team, his pulmonologist, the amazing team of NPs, his nurses, his medical assistants, the doctor who drained 800ml from his right lung space on a Saturday morning. Dr. Acker for doing the surgery, then coming out to update us in the waiting room and kneeling to the ground to pick up each individual airpod that had fallen and rolled when I got up too quickly in my frazzled state. The nurse who helped me push for Nihit’s extubation when I saw him communicate with his eyes that he needed the breathing tube out. The nurse who got him a decaf starbucks coffee every time she went there before her shift. The MA who was really good at finding him the most optimal position in the hospital bed. The staff who let the kids visit even though initially, policy was no visitors under 12. The Hospital of the University of Pennsylvania for building a serene spa-like new hospital “pavilion” so that Nihit had a private room, incredible river view, and startup-style remote-controlled frosted glass windows. It didn’t make things less painful for him, but maybe more tolerable.

Obviously would like to thank coffee, for existing.

And family, colleagues and friends. Staying with us. Checking in. Visiting, sending meals, gift cards. Time off work for both of us, colleagues covering our patients and projects. Greeting cards like the one from some of my colleagues: “This too shall pass,” with a poop emoji on it. Close family getting us through all the moments: shock, tears, anger. The doctor friends—fielding late night texts, questions, rhythm strips. Spending time on the phone with me, validating how big a deal this was. A friend on Facebook who I hadn’t connected with in years who had just had a similar surgery and took an hour to answer all our questions about his experience. The online groups I joined filled with patients who had been through the surgery and shared their practical experience, and emotions. A community we never imagined joining.

Even writing all of this out in a stream of consciousness, it feels like a dream, it feels like not enough. It will never be enough; there will never be enough words to articulate the sense of before and after; to tell you that even though Nihit’s scar is healing perfectly, and hair has grown over it, and his chest tubes came out and he hasn’t had to get a pacemaker, and the audible ticking of his mechanical valves is comforting, not annoying…none of it would convey it all.

There were funny things, too. For 6 weeks, Nihit wasn’t allowed to drive a car or pick up more than 5 lbs of weight. I, who loathes driving, became the primary driver, along with my father-in-law. Of course the universe would conspire to make me parallel park! I put myself through a personal parallel parking bootcamp in the weeks leading up to the surgery. I alerted my neighbors that if they saw a Prius spending 12 minutes in and out of a tight spot on our narrow block, that they should under no circumstances be alarmed. And while I’m not the best South Philly parallel parker, well, I can do it.

And now with his shirt and jacket covering his scar Nihit walks and drives and picks up the kids and to others it seems like everything is the same but it’s not, and he’s on warfarin (a bloodthinner) for the rest of his life so his valves don’t grow blood clots, and every time he sleeps in a bit too long I worry, and then he wakes, and everything is fine. And that’s the secret shared trauma we both have of 2023, is that things changed drastically and yet we move on to 2024 and it looks like they’re the same.

But the thing that I know gave us the strength for 2023, and that hasn’t changed, is the smiles on our kids’ faces, their optimism and love. My daughter telling me she missed me when I come home from work. My son’s smiles during our bedtime snuggles. Pure joy. They were the reset button for us at the end of each day, the thing that mattered most.

And writing, too gives me strength. When I finally chose to write about these things that were hard, I realized that I needed to write to process. And sharing, though tough, feels important as well. Because I know that my photos and the things I might cherry pick to remember from this year will mostly be the happy ones. And there were so many happy moments; family trips and hangouts and hugs, family moving close to us, good books I read, fun zoom calls, writers’ groups, trips, date nights, dancing with the kids. Starting to run again, finding renewed gratitude for physical health. Finding meaning in work, helping patients and their families through the ups and downs of their lives. Listening to them. Some of my patients have been through open heart surgery before the age of 1. I tried to remember them, all the strength their families had shown. The incredible resilience of the people I encounter every day.

I thought what I would want to remember from this year would be only the good things. But there’s something sacred about the hard things too; the journey we took, and emerged from, or are still on. The community of neurodiversity our son has introduced us to; the many things we have learned from him. The mental and physical fortitude Nihit has. His courage, his calm. Maybe it’s important to remember the hard things—not always, not to let them take over—but in moments.

Nihit watched me write this, because he wants to write something about this year as well. We both have felt the urge to recap the journey. He asked if I have a writing structure, but I don’t; I’m all stream of consciousness, especially for this newsletter. But I do have a tell, which is that when I’m writing to process something, I often end on a “lesson,” and that can be considered trite in writer circles but alas, it is my style.

And so my lesson for 2023 can be surmised from my resolution for 2024, and there’s just one:

I resolve to appreciate it.

I’ve been thinking a lot about rejection lately. I realized some of my non-writer friends did not realize that for every place a piece of mine gets published, it’s likely been rejected by at least ~5-10 other outlets. It’s been a pretty standard experience of mine to write something and start to submit to to a few places and have it be rejected (sometimes within days; sometimes months to…never, because there’s no response). Some places have submission periods that you have to keep track of, putting it on the calendar along with “preschool application period” and “Swim registration, must log on at 6am!” Others are rolling, but you may not hear from them for 6 months.

In this age of electronic submissions and responses, it’s very common to get a rejection without feedback. Since many places allow simultaneous submissions, it’s also common to submit to so many places that you forgot where you already submitted. I learned from writer friends pretty late in the game that many of them were keeping spreadsheets, tracking which agents they queried, which platforms they submitted to, which places rejected them. This mimics part of the utility of a platform like Submittable, which many magazines and journals use, which allows outlets to charge you a submission fee, and tracks the status of everything you’ve submitted through that site.

So I started to keep a spreadsheet, too. I hate spreadsheets, in particular since this tabulated my rejections neatly, grouping them visibly rather than shadowy occurrences that I had banished. But it was helpful, because I did not want to accidentally email the same pitch to the same place again!

Most writers have a few pieces in their computer writing folder dungeon, the ones they’ve submitted to many, many places, edited and reworked, submitted again, and then finally lost steam, and moved on. The pieces live there, and sometimes never resurface. I put two such pieces in my spreadsheet, listed out the rejections, and thought, where else? And started to submit again, in earnest.

I recently was talking to someone new to writing who had submitted her piece to one place and had it rejected. “I’m not sure what to do with it now,” she said.

I realized with a shock that she did not know how common rejection is. She thought that because it was rejected once, her piece was bad.

And I realized that for better or for worse, I had subconsciously almost completely divested my personal opinion of the quality of my writing with how easily it got accepted, or rejected. There were so many reasons it could get rejected—something similar already published in that outlet, that particular editor did not happen to connect with it, no great time peg, niche subject matter that maybe did not fit with that reader or audience, a random twist of fate. Or yeah, maybe it was bad! But maybe I needed the rejection to motivate me to edit it?

I am a notoriously bad editor. (I mean, to myself. Like I’m not sure anyone else knows much about my editing expertise). I love to overwrite. This post, for example!

I loathe going back to edit. I am in awe of people who are good editors, even more if they are good self-editors.

But I also know it sometimes really is a numbers game. And that’s what I try to tell new writers—if you’re happy with your pieces, you’ve edited it, you’ve incorporated feedback—keep trying! Don’t expect that it will get published in any place that you had envisioned it. That’s a perk, but not a given. But trust that it’s worth reading, and keep trying.

And at the end of the day, there will always be some graveyard pieces. Every so often you’ll revive them. I have one I revive every few months, a 4,000 word meditation on generations of caregiving. It may never be published—4,000 words is an awkward length. But I’m still glad I wrote it. When I reread it, with the view of editing, I instead get lost in the stories I tell in it. I feel connected with some essence of who I am, who definitely lives on that page. And even if it never gets shared, I know that capturing that essence was my ultimate intent all along, anyway. I think loving the craft of writing has meant accepting the mercurial nature of publishing, understanding that rejection stings but that it is part of everything.

Some of those pieces may make their way into this newsletter, at some point. But I’m still plugging away down my spreadsheet.

Would love to hear from other writers—do you edit a piece after every rejection, trying to improve it? Or do you just save it under a new title and submit it again somewhere else?

I tried to stop myself from making plans for the break, beyond some amount of studying for the boards. When I have time, I tend to want to fill it. But I knew that residency and parenting had taken a lot of structured time, and having some unstructured time was the change I needed. I resisted structure for as long as I could. After a while, the initial thrill of sleeping in (till 7:30am when the kids woke up) and going to the gym or on walks or coffee shop adventures in the middle of the day, whenever I wanted, wore off. I missed the structure of work! I missed seeing patients. I used to get stressed about friends or family texting me medical questions because I didn’t feel I had the time, in residency, to respond adequately. Now, when I got these texts, I was eager to activate that part of my brain again.

I did end up creating some structure and putting some of my writing goals down on paper and in words to friends (plus this newsletter). I ended up working a lot on a story idea I had. I spent a lot of time at the same time every day at the same coffee shop, carefully chosen for its good coffee but also not being a place where I would have to run into people I knew and explain what I was doing.

“I’m working on some writing.”

“What are you writing about?”

“I don’t know.”

Every time I felt guilty for paying for childcare while I going to sit in a coffee shop and write, I remind myself that even Barack Obama 6 weeks after his wedding to Michelle went on a solo writing retreat to Bali to write his first book, at the incredible annoyance of his wife (it made it into Becoming). I am not Barack (or Michelle) and there are many reasons why I will not be leaving Philadelphia for 1.5 months, but it’s a good reminder that even masters of rhetoric need intentional time and space to write and create. People think writing just flows, but often, it lurches.

In any case, writing in a coffee shop is still very solitary, and yet if I were to go with a friend, or my husband, it’s too distracting. I love writing a bit at a time. I don’t love writing as my main goal all the time, or every day. (And don’t even get my started on editing).

But having the opportunity away from medicine, to miss medicine again, to want to go back—that was important. And being a more present parent, partner, and friend—that was something I finally felt I could do, with more control over my time again.

And now, I cherish being able to see patients in clinic. I love seeing everyone from newborns to 21-year-olds on college break. But I haven’t had a chance to write in a few months, and now, again, I miss the writing time.

So I realized at least for me, the secret is not long breaks, it is figuring out the incorporation of writing into my routine as a parent and doctor. Not all of one, not all of the other. A little of each.

And that’s my 2022 into 2023 resolution!

I’m curious—What does it mean to you to take a break?

And if you feel comfortable - share your new year’s resolution(s), if any!

Ok, and if you read this far…as promised up top, here is a snippet of the fiction I’ve been writing. Any thoughts on it are welcome. But what’s a writing sample without some caveats? CAVEATS: 1) I read this again and my immediate first thought is wow, it is bad, and I still haven’t incorporated the wonderful suggestions from my writers’ group so…so I want you to know there are some edits coming its way 2) PICU friends, please correct any ECMO stuff that I got wrong, eep!, 3) No, the character is not based off me!

“Well?”

Kavita looked up to find the team staring at her. It was 8:07am, and Dr. Kim was standing at the head of the group ready to round on the pediatric ICU patients, tapping her foot expectantly.

Kavita put away her phone hastily. Her computer had logged her out of the patient charts so she fumbled as she logged back on, feeling everyone’s eyes on her. Dr. Kim let out a steady hiss of frustration as Kavita navigated to the patient’s chart. It was Henry, a 3-year-old on ECMO for a horrific pneumonia. Henry’s mom appeared at Dr. Kim’s elbow to join rounds, as Dr. Kim said:

“Residents always complain that rounds end late, but guess why they start late?”

Kavita’s faced reddened and she bit back an apology. 

One of the things Kavita was working on in therapy was to not say sorry just because people were trying to make you feel bad, even if you hadn’t done anything wrong. Kavita had been ready at 8am, she told herself, and it was Dr. Kim who was late, and then caught her unawares.

Saying sorry always felt like the only out in these situations. Instead Kavita pivoted to face Henry’s mom. 

“Good morning, we are about to talk about Henry. How was his night?” She had asked the question making a second of eye contact with Henry’s mom, but then immediately looked down at her computer.

Henry’s mom looked a little confused at the number of people there.

The thing about family-centered rounds, Kavita always felt, is it’s really hard for anyone, let alone families facing a health crisis, to speak to a large group of people. Most people don’t enjoy public speaking. And the families are always confused about who to address, and who is listening; half the time, some of the residents and pharmacist will be clacking away on their computer, and the nurse will get interrupted by a phone call, and sometimes the attending is off to the side. 

Henry’s mom’s eyes wandered a little amongst the faces and settled on Dr. Kim, who was right next to her. “You know, I don’t even know how to answer that question. I know we’re paralyzing him so he can be on this…” she waved her hands “...ECMO thing. At one point he wasn’t paralyzed enough, he was moving, so they had to give him more meds. I don’t know what that means, if he was in pain or something?”

Dr. Kim could have jumped in, but instead she broke eye contact with Henry’s mom and then looked expectantly at Kavita. Kavita appreciated this–attendings usually interrupted without even realizing it, because they were the ones patients often ended up directing their questions at.

The problem here was that Kavita was still feeling bamboozled by the technology of the ICU, maybe just as much as Henry’s mom. For example, ECMO. Henry was the first kid she’d seen on it. ECMO stood for Extracorporeal Membrane Oxygenation, and was colloquially the “heart-lung machine.” You had to be “cannulated” for it–basically, a bunch of general surgeons show up, you get sedated and paralyzed by the ICU docs if you aren’t already (you usually already are, because you’re intubated), and the surgeons stick tubes directly into your major vessels–either the aorta, the IVC, or both. Henry had VV-ECMO, veno-venous ECMO, meaning the cannula was only in his venous system. When Kavita saw Henry get cannulated for ECMO she felt her stomach flop over several times, but she pushed it down. The last thing she wanted was to faint when someone was literally on the verge of death. It would be even worse than fainting during her surgery clerkship while holding a retractor, which was a thing that had happened. Yes.

The purpose of the tubes, or cannulas, in the major vessels was so that the blood could be pumped from the right side of the heart to a “lung” on the outside—”extracorporeal”—running through an oxygenating membrane and then returning through another cannula so the oxygenated blood could go to the rest of the body. Kavita would find herself mesmerized sometimes by the transit of blood, the once-clear tubes now thick with plum going to the machine, and in a brighter crimson leaving. The color change that oxygen lent the blood as it clung to hemoglobin. The vision of it hopping off as blood flowed through the body, dropping oxygen off at its hungry tissues.

To get ECMO you had to have an ECMO technician sitting at bedside at ALL times, because if the blood clotted, or a cannula got dislodged, or the machine failed, well–death. And to prevent those things from happening, and for the patient’s comfort, you needed the patient fully sedated and paralyzed. Not moving, and hopefully not feeling, not remembering. 

The key word, Kavita felt, was “hopefully.” She had heard stories of patients, mostly adult patients, recounting how they remembered their intubation or cannulation. It was why we didn’t hesitate to increase sedation, increase paralyzation. 

“You know, it’s a good question, why did he move? It’s hard to say what he was feeling, but we know he stopped moving after a little more paralyzation and sedation. I’ll talk a little more about this in my plan.”

She paused to let Henry’s mom say anything, but she didn’t.

Dr. Kim: “Why don’t you go ahead, Kavita.”

Kavita cleared her throat. 

“Henry is a 3 year old with a previous history notable for asthma, presenting with 3 days of fever and URI symptoms, leading to severe hypoxia and hypercarbia, found to have pneumonia and now stable on ECMO. We already went through the interval events; numbers?”

She looked at the nurse who started to rattle off the vital signs, the ECMO tech who rattled off the ECMO numbers like “sweep,” and watched Henry’s mom’s eyes glaze over. 

“Physical exam unchanged” Kavita said once the nurse was done. “Still focal crackles in left lower lobe. Good cap refill. Plan: for the ECMO–”

“Wait–” Dr. Kim cut her off, not unkindly. “Assessment?”

Kavita forgot! She had to say whether Henry was worsening, stable, or improving. This was the part that Henry’s mom actually cared about. “Henry is stable on ECMO.”

“I would say that he’s actually improving,” Dr. Kim said gently. “Stable labs. Pulling better breaths on the vent. Less resistance in the circuit. Him moving might actually be a good sign. Though of course, we want to keep him optimally sedated and paralyzed until he can come off.”

Henry’s mom face brightened.

Dr. Kim could see Kavita had no idea what to say next so she took over, outlining the changes she would make, tweaking the lasix dose so Henry could offload some fluid from his lungs, leading the team in a discussion of proning, rotating him to lie on his stomach for part of the day to open up his lungs and improve perfusion.

Kavita was grateful but also embarrassed. She should have prepared more. ECMO just still seemed so…foreign to her. The pediatric ICU still all seemed so foreign to her. What was “better” when things were all bad? But the doctors and nurses here were good at projecting, thinking what would happen 4, 5 days down the line. Kavita could barely project to the end of rounds. 

In fact one of Kavita’s strategies for keeping her toes on the edge of the pool of her depressed thoughts without actually plunging in was staying in the moment, not jumping or thinking ahead. If she stayed immobile, inert, things would not change. Projecting ahead required hope and she had pitiful amounts of it.

As they walked to the next patient, Kavita leading the pack pushing her computer on wheels, Dr. Kim caught up to her.

“Hi there Ka-veet-a,” she said, drawing out the second syllable, with a hard T. “Am I saying that right?”

“It’s Ka-veeth-a,” the “ka” is the emphasis and it’s a “th” sound.” This is what Kavita said when people asked, otherwise she didn’t bother correcting them. 

“Kaaaa-veeth-a?”

Dr. Kim had drawn out the first syllable almost comically, but Kavita could tell she didn’t mean it that way. She was trying.

“Mm-hmm.”

“I just…wanted to let you know I didn’t mean to be terse with you this morning. I was stressed coming from a morning meeting, I was late, and I…wasn’t my best self.”

Kavita was flabbergasted. She wasn’t used to attendings being this vulnerable with her.

“Oh, that’s totally fine. I didn’t mind at all.” She said automatically. That wasn’t true, or maybe it was partially true. Kavita and her co-residents would joke that they were so burned out they were like used matches. A strike couldn’t ignite them, positively or negatively, anymore. This was unexpected, though. There was a small sliver of warmth that reached her, just the tiniest bit. 

“I was a resident too, once. I know it’s hard. But you’re going to learn every day and at the end of residency you’re going to know so much. Plus, attending life is so much better. You’ll be there in a few years, before you know it.”

Kavita forced a smile. A few years! What if she wanted her life to get better now?

*copying below my old piece on running, no longer on my personal website since I revised it to make most of my old writing private…though now it will live on here anyway! :

Written in Feb 2013 - Titled “Why the Long Run?”

When you do a really long run, try not to go around telling people about it.

I say this because, from personal experience, when you train for something like a marathon you become a slave to perspective, but you forget what’s normal to people not in marathon training.

If you tell people, “I ran 8 miles today,” they might say, “Wow! That’s really far.” But once you hit the double digits—when you tell people, “I ran 16 miles today,” the general response is “Urgh, now you’re making me feel bad for running only 5” or  “All I did was eat chocolate,” or “Ew, why would you do that to yourself?” Unless it’s someone in marathon training, disgust is the general response.  This is understandable, because when I’m not training for anything, if you suggested that I go outside and run 16 miles, I would laugh in your face (while consuming chocolate). And before I started running in 7th grade, I thought running was only for fast people, and I have never been or wanted to be fast. I love that each year, more of my friends discover that running slowly—not even as fast as jogging, but what I call plodding—is acceptable and enjoyable. "Running, Slow and Slower" is a book I would like to publish with Daniel Kahneman.

My friend and I “trained” for the marathon last fall. I insert the quotes because despite our best intentions, we pushed running away from our minds during the week, banking on the weekend long runs to settle our debts.

You can’t really settle your debts or procrastinate in running, though. That’s both the appeal and the problem.

Our long run schedule went from 8 miles on a Saturday through perfect increments each week thereafter, to 10, to 11, to 12, 13, 14, 16, 17, 18, 20 (yes, 20!) and tapering back down. We didn’t hit every target, but our legs would still resent us every weekend. Legs have short memories.

Every distance, in your mind, is relative to the last one you ran and the next one you are going to run. There is no isolated rule that 10 miles is long, because 10 miles is less than half of the distance that you will eventually run.  And because there is a schedule on your fridge with an expiration date, and a sense of inevitability, your mind can’t protest as much as your legs do. My friend and I mutually agreed that our most difficult run was the 8-miler. Yes, out of all the runs we did, the 8 miles were the hardest.

Japanese novelist Haruki Murakami has written an amazing non-fiction book, What I Talk About When I Talk About Running, about the intertwined nature of his running, writing, and personality. The Charles River in Boston is coincidentally one of his favorite places to run. He writes:

“In long-distance running the only opponent you have to beat is yourself, the way you used to be.”

I like this idea—that every Saturday there is a shadow of my last Saturday’s self running alongside me, but this Saturday I leave the shadow behind at mile X, and go on two more miles. Incrementally ahead, but still ahead of where I once was.

Murakami also writes:

“I just run. I run in a void. Or maybe I should put it the other way: I run in order to acquire a void….The kinds of thoughts and ideas that invade my emotions as I run remain subordinate to that void. Lacking content, they are just random thoughts that gather around that central void.”

Typically the word “void” has a negative connotation, indicating the absence of something, and implying something is always better than nothing. But maybe you need nothing sometimes. The best part of a run is when you forget that you are running, and forget that you are thinking. Usually that only happens to me 2 miles into a run, and sometimes the void itself runs away from me, and I am back out of breath. My strategy for acquiring the “void” is to run at the same, slow, 10-12 min/mile pace. That is why I want to tell people, when they think I’m “intense,” that no—far from it. I run slow and meditatively, to feel like I’m not running at all. Often I trip and fall out of my reverie and onto the sidewalk. Chins hit, palms bloodied, knees scraped. Apart from the physical injury, being rudely jolted out of the “void” is similar, ironically, to having a dream about running and your twitching feet eventually jolting you back to wakefulness.

Before the Disney marathon a few weeks ago, tired of all the long practice runs and the anticipation of such a long event, I told myself not to train for anything of that distance again. I even went so far as to wonder if I should switch from running to something else.

But this week, when the ellipticals at the gym were full and I gingerly stepped on a treadmill, I realized that I can’t make a blanket decision like that. Running propels me like nothing else does—literally and figuratively. I won’t be like Murakami and run a marathon every single year, that’s for sure—and I may never have the time or desire to hit marathon #3. But I hope to keep up my voidful, self-competitive sport of plodding: whether for one minute, one mile, or many.

I’ve been spending time working on a novel about a group of women navigating identity and social relationships amidst medical training, who come together to solve a medical mystery.

Naturally, because I am “working” on that, I’ve been procrastinating on it by actually spending some of the time intended for writing by reading the old writing I did in medical school, some of which never really made it anywhere except maybe to my Doctoring class (shoutout to my medical student peers who read those rough drafts without reservations). And I’ve found myself wishing I did something with it.

I know I’m not unique in completing a piece of writing and wanting to figuratively put it in a drawer and not look at it for a few months. (Nowadays, that’s as simple as closing a tab and letting it collect the Google Doc equivalent of cobwebs—falling past your scroll bar on the home page). The ick factor related to reading my own writing is strong enough that I often just let it languish long enough that when I choose to come across it again, I’m reading it with the detached air of someone who is reading someone else’s work. In that vein, I’m 1) much more likely to surprise myself, and 2) much more likely to be more charitable to this “other” person than I am to myself. And because of these two factors, I’m actually more likely to like the writing a bit more than I did when I finish it. (In substack, I get around this trend by pushing the publish button before I have time to rethink it. To publish any creative writing, you have to be just the tiniest bit impulsive).

As you can imagine, this makes it very hard to edit anything, which makes a lot of the writing still not that great. For my fiction writing, I’ve found my writers’ group to be incredibly helpful, and provide the sense of community I need to motivate me to keep writing.

For the old narrative nonfiction writing I did in medical school, after taking a first look at it, I’m realizing that it actually flows together nicely, and I have a lot of it. Over 50 pages worth! And I realize I want some of it out in the world.

Actually, in my fourth year of medical school, I wanted my senior project to be compiling this writing into a book-length manuscript about the experience of being a medical student. I saved a bunch of notes that are still in a thick stack in our basement, amongst the other items I hoard. However, the curricular policy was that our senior project had to be an evidence-based research project, which led to a mind-numbing chart review experience that I will never repeat. This isn’t an excuse—I could have still done it—but writing without deadlines is ever-expandable.

So this is my long-winded way of asking if any of the readers of this newsletter would like to read some narrative nonfiction pages about medical school for fun and critique them. This will motivate me to spruce up what I have before sending it to you. And that way, when I get the edits back, I’ll be able to procrastinate working on those edits by…working on the aforementioned novel.

I can’t stop thinking about the show Severance. It’s not my usual show. My usual show is awkward comedy and satire that is ultimately wholesome—think The Office, Parks & Recreation, New Girl, Schitt’s Creek, etc. I don’t like to be scared. Severance is, well, kind of scary. It’s a dystopian thriller and dark satire of American work culture. It’s about a company that allows you to “sever” your work persona from your outside life persona, so that each version of you has no knowledge or memory of the other. That means that when you are at home, or out with friends, you have no recollection of what you did at work, and when you are at work, you have no recollection of your family, your friends, your interests outside of work; even your last name. Something about this forced division, the idea that we can separate from ourselves in order to achieve productivity and efficiency, reminded me of medical culture. Drinking less water so you don’t have to go to the bathroom as much; holding off on family plans until the optimal year of medical training or attending job; missing weddings and family events because your schedule is pre-set 1 year ahead. A lot of what people fear about medical training is this loss of self, loss of connection with the outside world, loss of agency. A 28-hour shift, often in windowless spaces, disconnects you from the outside world for that length of time. To be able to walk outside, you have to ask someone to cover your phone. Rest is never built-in. Even when you go home, you feel dissociated. When so much happens at work, even in the span of rounds, it’s hard to go home and convey that to a loved one.

I thought about my interns, showing up to work energetic balloons slowly deflated by the onslaught of chat messages, calls, EMR clicks, demands from their senior residents, attendings, pharmacists, nurses, patients. Showing up with such high performance expectations and realizing that there is so much left to learn. Seeing them, I wished I had been kinder to myself as an intern. I wish I was kinder to myself now! It’s not just mindset, though. The workload that doctors-in-training face is immense; they’ll routinely have more than ten to-do’s for each of 5-6 patients, even just starting out the year. In the new chat system that replaced beepers, while you take the time to respond to one chat, you often get 3 more. Everything is a Hydra. You want to walk patient room to patient room in the afternoon but instead you’re stuck responding to notification after notification, call after call, alert after alert, all the noises constantly activating your stress response.

Despite the varied motivations for a career, I think we all seek fulfillment in our work, and human connection is a deep part of that fulfillment. I think patients seek that element as well when they are seeking care. Part of human connection is being able to process and react to things as they are happening, and have the time to debrief and reflect. But when things are chaotic and unrelenting—as they so often are—it’s really hard to find that. And the problem is, when you become more efficient and potentially gain that time—the workload just increases.

I started this reflection to reflect on how much I have indeed learned over three years, but that will have to wait for another post, since it ended up a commentary on the medical environment that inducts newly minted MDs. The environment results from a complex interplay of our healthcare system, insurance companies, academia, professional organizations, governing bodies, and medical tradition. Every time you pull at a thread, its much longer than you were prepared to deal with.

No spoilers, but in Severance, it only takes one person questioning the system in their workplace to chip away at the premise of the whole operation. Now, in medical communities, people are questioning the culture, the hours, the “wellness.” Can a waffle party cure burnout?

The pursuit of self-worth and self-agency is spreading amongst the medical community, at every level. Ultimately, in seeing the interns, part of me is sad that this system is so hard to work in. Part of me is hopeful, though. Many things have changed, and many things will change. They have incredible strength and willpower, and kind hearts and souls. Our patients are in good hands.

Still, I am a hopeless romantic, and much like we over-celebrate holidays during the pandemic in order to combat some sense of despair, I like to put some sort of outsize importance on the holiday as a ritual. As a ritual, Mother’s Day reminds me to look through old pictures of my Ammamma and my mom, and my kids the day they were born. It reminds me to reflect on the last nearly two years of motherhood, and the 38 weeks of pregnancy before that. Last Mother’s Day, I still had a sense of not knowing exactly who I was. I was one year postpartum, and feeling like I was still in a tug-of-war battle with my pre-pregnancy self. Not just physically, which is what is often talked about in the media, but in terms of identity. No one told me (or more likely, I didn’t listen) that the process of pregnancy and delivery and postpartum and feeding and clothing and rocking and hugging and laughing and crying with these new people you brought into the world would change who you are in some fundamental way. And I didn’t realize how resistant I was to change.

So there I would be feeding my new babies and guiltily dreaming of times when I used to be able to sleep in till 9am on a weekend. Or there I would be using my post-call “day off” on the phone arranging doctors’ appointments, calling insurance companies, thinking of how I used to be able to do whatever I wanted on these days. There I would be physically and emotionally exhausted without the bandwith to have normal human conversations any more, even when I made herculean efforts to hang out with friends. And often, I couldn’t do the things I could do before; couldn’t wear what I once wore; couldn’t completely feel present in any one place because there was always a piece of my heart in the other.

No one tells you that in becoming a mother, at least for me, there was some process of mourning my old freedoms (which I never really appreciated in the first place). Then there’s the second phase of wondering what your parents were like before they had you and your siblings, and did they ever miss that freedom? What about my Ammamma, did she think about this? Or is this a case where my existential wanderings are particular to me, rooted somehow in my American childhood, and foreign to them?

On twitter one day I read a doctor’s tweet that it took her 2 years to feel like herself again after having children. 2 years! That was a long time. Now, it makes sense to me, with the edit that for me, it took me 2 years to find the version of myself that is both the old me and the new me. It has taken me that time to not only return to writing, but reaffirm it as a core part of my being. It has taken me that time to see how much of a better doctor I am to my patients’ families with the experience of parenthood. It has taken me that time to realize I have grown into my new self and actually enjoy it. Thinking about my old freedoms has been replaced by so many indelible moments of joy and new freedoms. The kids and N and I are constantly singing with each other, and my house is like a mini karaoke studio, which really beats anything I used to do with my free time. Simple things like bedtime storytime or bathtime, or even just the kids’ bedhead hair when they wake, fill my heart to the brim. Every new word they learn is like magic—how did they pick it up so fast? I wish I could bottle up the feeling of anytime they wake up or I come home from work and we see each other after a while of not seeing each other.

I once asked a physician-writer for writing advice and he said, “Don’t have kids.”

I was affronted, but as I collected my private indignation and left the meeting, it crystallized in that moment that having children was incredibly important to me.

However, the framing that it has to be either-or, a choice of one versus the other, is incredibly paternalistic, and wrong. Because the other thing to appreciate this Mothers’ Day is partners and family members who support mothers; who make sure they take the time to do the things that make them fulfilled, and successful, and happy. And, policy that does so. Having children certainly takes up time for both partners, and that is made even more stressful by the lack of governmental support—both in the way of paid parental leave, as well as difficult access to contraception and abortion that can given women control over when they have children, if they choose to.

I can’t think of Mothers’ Day without thinking of my patients, and how so often their mothers are their advocates all day and every day for their care. I’m also thinking about my patients and friends who do not have mothers, who have lost their mothers, or who cannot see their mothers, or choose not to. This is a day that can be tough for many and I think it’s okay to not celebrate it if it feels that way.

If you’ve stuck it out this far—thank you for reading my long-winded reflection. If you have a mom or mom-figure in your life, take a moment to reflect on them. If you are a mom or trying to be a mom, take a moment to reflect on how much you’ve done, and how strong you are.

If you’re looking for a Mothers’ Day gift that’s not flowers or chocolates, consider donating money to an organization helping women fully access reproductive healthcare. This has a list of some places.

Last year, Philadelphia welcomed a number of Afghan refugees, many of whom we saw in the hospital and in clinic for medical evaluation, and their stories—the vast chasm between their life before and their life now—stuck with me.

One of the things that confuses me about medical culture is, even though we’re so close to so many things in the news—COVID, refugee crises, school closures—we rarely talk about politics or the news in the hospital. I noticed this as a medical student on clerkships, and now as a resident. One of my distinct memories of the 2020 election was the fact that on election day, it was one of the few times we paused rounds to discuss a polls update, since we all had the election page open in the background. People care about the news, and the work we do is often reflective of what is happening in the world and in our local communities, but it also makes sense that we live in that bubble. Patient care is demanding, in time and in energy. Adding the weight of the world to our day-to-day is another mental load. But it’s also limiting, because in not having the time to stay fully informed, and in not talking about what’s happening in the world at work, it can feel like we are not listening. And that’s a common complaint of patients, about doctors.

I’m not sure what I’m rambling about, and what I want to change. It’s not the individual people. The people I train with are incredibly bright, compassionate, knowledgeable people who are constantly advocating for social justice. It’s not the patients and families; they are often the ones who tell us things we don’t know about the way things work in our current system, for them. Maybe, I think, it’s time. It’s the systemic burden on our time. We are all pressured for time, constantly. Especially now, when pediatric hospitals are experiencing high volume.

I think I’ve been fascinated by time and medicine for a while now. I was reading through old writing recently and dug up a piece about how part of learning medicine felt like “learning to rush.” Maybe I’ll share that piece another time, but I wanted to share my more recent article below, which is about time and the clinical encounter. It’s a blog post for Columbia’s Narrative Medicine program’s literary journal.

https://www.theintima.org/blog/reflectingonbedsidemannerisms-intima

My ask: I would love to hear from you, if you’re comfortable sharing, about experiences you’ve had in medicine (either as doctor or patient) where you felt rushed.

Thanks for reading!

Some odds and ends:

• I’m very excited for this book coming out March 29. The author, Dr. Grace Farris, is a doctor and comic artist and she mainly makes comics about parenting (her instagram, @coupdegracefarris, is great). Her observations are often so spot-on!

• My new favorite Pixar movie is Turning Red - I laughed and cried so much. Also, seeing an Asian auntie squad in a Pixar movie is something young me would never have imagined

• I was asked to write an article about breastfeeding for the Philadelphia Inquirer, after my JAMA piece came out on the subject. It’s hard to write something on the same subject that is fresh and not repetitive—but it was a great writing exercise for me! It was also really amazing to see it in print.

• I’ve worked a night shift on “Fall Back” clock change for the last two years, so getting to work the “Spring Forward” Daylight Savings shift (on a 28-hour call) was special for me—one less hour!

Thanks for reading. Yes, I woke up early to write this, and apparently I am just as rambling at 6:30am as at nighttime. Oops.

-VV

A project I’ve been recently working on has been compiling all my unpublished writing from pre-medical and medical school days into one Google doc. As I was doing this, I came across an essay which I had submitted to JAMA back in 2019, and after it was rejected, I kind of forgot about it. I don’t think I’ve ever shown it to N, either. (He’s in for a surprise! Oops).

Reading it again made me smile, because so much has happened since then, and getting married in clerkship year is nowhere near as topsy-turvy as having twins in intern year during a global pandemic. But, the message still resonates with me.

Feel free to read or skip, I know it’s long! And any editorial feedback welcome.

Oh, and before you read it - here are the podcasts recommendations I received from readers last week when I asked for podcasts with good banter. I’m making my way through them, and having a great time!

1. We Can Do Hard Things, with Glennon Doyle

2. Ringer Dish

3. How I Built This

4. All Fantasy Everything

5. The Awful & Awesome

Love in the Time of Clerkship Year

The strangely specific training timeline of medicine calls for strangely specific alignment of major life decisions. Proposals or breakups happen around the time people decide to couples match (or not) at the start of fourth year. Weddings happen at the end of medical school, before the chaos of intern year. Babies happen in the third or final year of shorter residencies, or perhaps in the research years of longer ones.

Hewing to the timeline is our desperate appeal to be maximalists—that is, use our prescribed periods of greater free time to the maximum potential for life, and use our periods of busy time to their maximum potential for work. This is both a medical training philosophy and a millennial one: everything can be optimized, if we can make it so.

But that leaves little room for spontaneity, non-traditional paths or timelines, and doing things when they just feel right. After doing post-baccalaureate pre-medical classes and working for a few years, I started medical school four years after college, while in a long distance relationship with my then-boyfriend. Because the medical school admissions process is so competitive, and the pool of schools one gets into is often very small, long distance relationships are very common in medical schools and residencies. Like clockwork, Friday night after that month’s exam, I would see many of my classmates also wheeling their suitcases out of our school’s atrium in a rush to catch a ride to the train station or airport. I’d video-chat my boyfriend between study sessions spent cramming facts into my brain, and feel like I had nothing of import to say. My friends dubbed him Oprah because he’d come up with such aphorisms as: “Long distance relationships need to be a relationship, not just a ‘communicationship.’” And so we visited each other frequently, he during my study periods when he’d sit with me in the library on a Saturday, watching soccer on his laptop; me after my exams, flying up for a blissful weekend where I could pretend to feel normal again.

When he proposed at the end of my first year of medical school, it wasn’t a surprise—we had been so in love, and we both had dreams of officially linking our large, loving families and starting a family of our own in the not-too-distant future. And we wanted a summer wedding, about a year later—which was a reasonable timeline for planning. And yet I felt guilty—planning a wedding during clerkship year and getting married smack in the middle of rotations, during our only vacation, a two-week break? I felt I was “supposed” to wait until fourth year. When I guiltily approached one of our school administrators about this, she only responded with excitement and affirmation: “This is an incredibly important event in your life and it should happen when you want it to,” she said. I held that advice close and remembered it throughout the flurry of clerkship rotations, shelf studying, calls with photographers, DJs, venues, decorators, and the like—through the wedding itself, and our honeymoon—and after, coming back to the medicine clerkship with my hands and feet still faintly stained with bridal henna. Having our celebration of love and having my new husband finally able to relocate his work to my city meant we could live together. And yet, it felt so lonely to come back to clerkship year with the feeling that I was back at the bottom of the totem pole when I had felt on top of the world. On top of that, my patients were very sick: there were multiple deaths or situations that I knew were terminal. I went to the hospital feeling inadequate and came home feeling despair; this continued on throughout the rest of clerkship year.

My husband hugged me as I cried about the elderly patients who had no family to support them. When I came home one morning after witnessing the delivery of a stillborn child and was mute with sadness, he was there. When I made mistakes I thought were colossal, he’d say with incredulity: “But you’re a student. You’re supposed to make mistakes. Isn’t that what learning is?”

It was a meaningful but tough time, as it was for most of my classmates. We’d meet up with them and afterwards, my husband would say: “Wow, they’re saying the exact things you always say. Why do you feel like you’re the only one who feels this way?” I realized that the marriage was but a moment in clerkship year, but the love was this—the unflagging support, wisdom, and warmth through the toughest moments after that. And in the patients I met, I saw how important love was in their lives—how spouses asked the challenging questions during doctor’s visits, how children massaged the aching limbs of their elderly parents, how parents kept vigil all night the bedside of their hospitalized infants. How fear and worry lurked in their eyes but how they masked it in front of the loved one who was my patient. How they felt they had to be brave. The love was sometimes messy and argumentative and explosive and resentful but it was there. And it was in equal parts tender and gentle and steadfast, if you caught it at the right moments. I closed patient doors with tears in my eyes, and I remembered these stories, these relationships, far beyond the esoteric factoids I learned for my shelf exams.

In the Western tradition, marriage calls for a vow to support one another “in sickness and in health, till death do us part.” In our Hindu-Jain wedding ceremony we walked around a fire seven times as our priest chanted Sanskrit; one of the 7 rounds involved a commitment to each other through illness, a similar vow to the Western ones I’d heard in movies or at friend’s weddings. In many ways the vows we make are simply words, but the lived experience and the actions we take are powerful. As I am now halfway through my pediatric intern year, I am reminded again of the power of love through tough times—the love in my relationship, but also the love I see in patient rooms. I am reminded that it’s okay to not follow the timeline and to be spontaneous. It’s okay to celebrate love in busy, tougher times as well as easier ones. It’s okay to make life a little more topsy-turvy for the relationships you care about. It’s okay to prioritize love in the time of clerkship year.

I’ve slowly realized that I just haven’t been reading and writing as much as I really want to, and I’m trying to do more of both. It’s kind of fun to have a new informal medium to do that, that doesn’t then leave me scrolling on other content for hours, so I figured I’d try this out. Starting this does make me feel nostalgic for that new platform feeling, like when xanga came out (shockingly, I never had one!), AIM (lol), facebook (we had no idea), medium (feels kind of ephemeral now), making my first wordpress blog (of many!), or finally downloading tiktok to watch hot takes about Encanto. But this might fizzle. Who knows! Journey with me.

✍🏾Writing roundup:

• My latest piece

• The piece that has been in editing purgatory: an article I wrote in a fury on my flight back from Mexico in 2018, where I had gone for a week with N & friends after taking the infamously tough Step 1 board exam. (The fact that I was hand-writing this on the flight back, instead of just watching tv and wiping Biscoff crumbs off my fingers, proved how much I needed to get my thoughts down on paper even after a week of vacation that should have made me forget my frustration with the exam). But then I just sat on the piece, coming back to it once in a while to take a stab at editing, but never quite feeling it was perfect. Now Step 1 is Pass/Fail, so some of my rant essay is irrelevant, but a lot of it is still relevant. Any ideas for pushing forward an inert piece?

• What I’m trying to work on: a novel about the idiosyncrasies of modern American medicine and the experiences of female physicians of color as they navigate it.

📚Book corner

• Recently enjoyed: Nothing to See Here, by Kevin Wilson

• Thinking about rereading: What I Talk About When I Talk about Running, by Haruki Murakami

• On my list: The School for Good Mothers, by Jessamine Chan

💊Medicine stuff:

• Best tweet

• A frustrating but important longform about the experience of one minority trainee in residency

• Anecdotally: It amuses me how sometimes I pick up parenting tips from my patients’ parents in clinic, and not the other way around

👦🏾S&L👧🏾 (my twin toddlers) moments of zen:

• New favorite song is “Mia Mia” (that’s Mamma Mia)

• S has started taking the food out of my mouth as I’m about to chew on it. Persistence!

• L imitated me doing crunches the other day and it was just perfect. All head movement, minimal core movement. She’s too perceptive!

Apparently, all my thoughts come in threes.

Leaving you with just one ask though: Send me your podcast recommendations- what’s a show you love that features entertaining, light-hearted host banter? I’m looking for more soundtracks to playroom/kitchen cleanup.

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