Ascensus WCMC Journal of Humanities 2nd Edition by Allison Maritza Lasky

ASCENSUS Journal of Humanities Volume II September 2013 Weill Cornell Medical College

ASCENSUS Journal of Humanities Volume II Editors-in-Chief: Gaurav Ghosh ’16 Rachael Venn ’16

Associate Editors: Peter Barish ’14 Elan Guterman ’13 Jonathn Huggins ’14 Natasha Mehta ’16 Daniel Shalev ’15

Faculty Advisors: Susan Ball, MD Randi Diamond, MD With special thanks to the Liz Claiborne Center for Humanism in Medicine and support from the Office of Academic Affairs and NIH grant “Enacting the Social and Behavioral Sciences in Clinical Training.”

To Our Readers, Volume II of ASCENSUS propels the vision of our first edition, to examine the art in a physician’s work as we attempt not just to mitigate or fix but to heal. Last year, we set out to illustrate how doctors function as more than mere mechanics of the body and navigate a profession that has human interaction at its core. This year, we’ve broadened the scope and created a twist. In their works, our contributors, who represent all levels of medical training and span the tri-institutional community, continue to reflect on the power and beauty of patient care, but manage to capture a sense of uncertainty. As agents of medical practice, we engage with elusive concepts—illness, intimacy, loss, grief—and wrestle to ascribe meaning to the intangible. Similarly, this volume takes on the grand topics of love, war, and death, but does so in a way that is rooted in the physical. After the loss of one of her patients, a medical student writes, “You always remember them the next day because, while their body has been taken away, yours still aches from doing chest compressions…Those deaths hurt. They hurt because my whole body was sore the next day, and they hurt to see the families forced to say good-bye, and they hurt because we couldn’t do anything.” Yet in these works, we also find that the corporeal examination of a person, place, or event can somehow help us make sense of it. It is as if in tracing the form of a woman’s body with the tip of a pencil, we might come to know something about her world and the way she sees it. Or in taking a photograph, in generating a physical, mechanical reproduction, we may capture the aura of its subject. Another medical student writes of how watching a surgery that she, herself, had years before helps her better grasp the experience of having a cleft lip and palate. “My eyes never leave the infant’s lips,” she writes. “I want to know how my own scar was created. How each stitch will create the pink line that will run from that child’s nose to mouth.” We are not mere mechanics, but perhaps in a profession marked by experiences that are perpetually, if slightly, outside our reach, we strive for something more concrete, especially in our art. It is easier to understand the ache of an overused muscle than the pain of a grieving loved one, the faint pink line of a facial marking than the complicated feelings of growing up with one’s own scar. So with this issue, this book, we hope to offer you a similarly enlightening experience. In flipping the pages, feeling the textured paper, and observing the shape of a sketch or color of a photograph, we hope that you will find comfort in the physical, while at the same time learning something about the abstract.

-The ASCENSUS team

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Table of Contents Susan Ball, MD ...................................................................................................Cover Desktop Doodle, Ink on paper Caroline Pinke ....................................................................................................8 Unforgettable Ali Mendelson ....................................................................................................10 Reflect 1, Photograph Ali Mendelson ....................................................................................................11 Reflect 2, Photograph Mimi Levine .......................................................................................................12 Mrs. Jones Was Yellow Melissa Cain .......................................................................................................14 The MICU Elizabeth DuPre .................................................................................................17 Walking Upright, Photograph James Wang ........................................................................................................18 The Room Eleanor Woodward ...........................................................................................19 Fly Fishing, Photograph Elizabeth DuPre .................................................................................................20 Gold Among Thorns, Photograph Tiffani McDonough, MD ..................................................................................21 brown Anne Herbert ......................................................................................................22 Nausea Sandeep Raj ........................................................................................................24 Dissent John Paddock .....................................................................................................25 Untitled, Pyrography on basswood Ali Mendelson ....................................................................................................26 Reflect 3, Photograph

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Robert Accordino, MD, MSc .................................................................................27 Children and Art Zebib Abraham ........................................................................................................30 War Poet Yvonne Wang ...........................................................................................................32 Untitled, Photograph Yvonne Wang ...........................................................................................................33 Untitled, Photograph Sandeep Raj ..............................................................................................................34 On Smiling Peter Barish ..............................................................................................................37 The Man in the Machine, Photograph Samuel Woodworth ................................................................................................38 Untitled, Ink/acrylic on paper Anne Connolly ........................................................................................................39 Lady Wife Peter Barish ..............................................................................................................45 John and Sarah #4, Photograph Eleanor Woodward .................................................................................................46 King, Photograph Adam Widman ........................................................................................................47 3rd year Matthew Inra ............................................................................................................50 Window Seat, Photograph Elizabeth DuPre .......................................................................................................51 Freedom: The Guardian of our Future, Photograph Mimi Levine .............................................................................................................52 Match Samuel Woodworth ................................................................................................56 Untitled, Ink/acrylic on paper Preston Kramer ........................................................................................................57 Anatomy

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Richard Lin, MD ................................................................................................58 Silence Eleanor Woodward ............................................................................................61 Independence Day, Photograph Rachael Venn ......................................................................................................62 Pieces and Parts Daniel Shalev ......................................................................................................64 Cecilia Jonathan Huggins ...............................................................................................66 The Apthorp Elan Guterman ...................................................................................................68 The Life of Ms. Smith, Ink/graphite on paper Emily Grodinsky ................................................................................................69 My Grandpa Peter Barish .........................................................................................................71 Winter Warmers, Photograph Jimmy Castellanos ..............................................................................................72 The Death of Corporal Brownfield James Wang .........................................................................................................78 Thirteen Ways of Looking at a Skeleton Peter Barish .........................................................................................................80 Austin #8, Photograph Adam Widman ...................................................................................................81 C/L surfing Lauren Stewart ...................................................................................................83 Giraffe in Serengeti National Park, Tanzania, Photograph Zebib Abraham ..................................................................................................84 June in Old Country Peter Barish .........................................................................................................86 Bat Country, Photograph William Cope .....................................................................................................87 The Layover

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Eleanor Woodward .................................................................................................92 Main Street, Photograph Tiffani McDonough, MD ......................................................................................93 partners Ali Mendelson .........................................................................................................94 Time Flies, Photograph Anne Herbert ..........................................................................................................95 To My Left Jackie Estes ...............................................................................................................98 Tent Rocks, Photograph Jackie Estes ...............................................................................................................99 Taos, Photograph Lisa Noble ................................................................................................................100 The CCU Lillian Lewis ............................................................................................................103 Rabbit, Charcoal on paper Elizabeth DuPre .....................................................................................................104 Florida Sunset, Photograph Ali Mendelson ........................................................................................................105 Untitled Misha Pangasa ........................................................................................................106 Awe Lawrence Palmer, PhD ..........................................................................................108 The Cardiac Cycle Genevieve Chartrand .............................................................................................109 Kenny the Kidney, Graphite on paper Daniel Hegg ............................................................................................................110 Resignation, Charcoal on paper Jonathan Huggins ...................................................................................................111 The Interred Jordan Roberts ........................................................................................................118 Snow Over Weill, Photograph

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Unforgettable Caroline Pinke

Unforgettable…that’s what you are. Unforgettable…though near or far. Like a song of love that clings to me, How the thought of you does things to me. Never before…has someone been more… These words effortlessly glide through my lips, carried by the melody. They join hands with Katy’s harmonies on their way out, as I join hands with Katy. It is truly magical. I’m in Venice on a gondola with the love of my life and my favorite son’s beautiful girls, Katy and Caroline. The gondolier’s serenade had been nice, but we could tell it didn’t come from the heart, so Katy and I – “Natalie” and “Nat” – take over. Unforgettable…in every way. And forever more…that’s how you’ll stay. That’s why, darling, it’s incredible That someone so unforgettable Thinks that I am…unforgettable, too. A decade has passed. I’m eating dinner at the Boca West Country Club with my wife, my son, and my granddaughters. My dish is absolutely delicious, whatever it is. Joyce had known I would love it and, of course, she was right. Interrupted mid-bite by an unfamiliar face, I pretend it’s familiar with a smile of recognition and a “Hey There!” We exchange a pretend friendly handshake. Joyce laughs as the anonymous man walks away, with a puzzled look on his face. “That was sweet of you, hon, but we don’t know him!” Just a silly, no-big-deal mistake, maybe, but how embarrassing! The man’s confusion mocks me. Ever since my stroke, I had become accustomed to not knowing, even proud of my practiced performance—my smile of recognition and my “Hey There!” Now I know: I would never again know what I no longer knew from what I had never known. On our way out, we hear the band playing in the lobby.

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Unforgettable…in every way. And forever more…that’s how you’ll stay. That’s why, darling, it’s incredible That someone so unforgettable Thinks that I am…unforgettable, too. Katy’s hand is in mine again. These unforgettable words are woven into the very fabric of my mind. They glide through my lips with the same ease, blissfully ignorant of all that has transpired in the past ten years. Like a song of love that clings to me…while the names, the faces, even the tastes that had held on for nearly a century are loosening their grip. Letting go one finger at a time, but always leaving just enough of a print that, I swear, I can feel it—about to happen…happening…having happened. It is a special kind of pain, deep and inexplicable. Unless you experience it for yourself, you simply cannot understand, the way that I do.

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Reflect 1 Photograph

Ali Mendelson

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Reflect 2 Photograph

Ali Mendelson

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Mrs. Jones Was Yellow Mrs. Jones was yellow. Not vaguely, intangibly so, Like the way doctors tend to use colors In their descriptions and assessments. For them, a color is more of a feeling Than the color itself: A “blue” patient, really just barely purple, Is fading – His body is failing him, Like an old man of sorts, Unable to bear the load anymore. The body of a “red” patient, actually pink-ish, Is hyperactive and working too hard, Grasping at straws to make things right But really just working itself into a tizzy. And the yellow patient, Drowning from a build-up of blood fragments – The victim of a dam that should not be there – Glows golden, Quietly exuding the material inside him. Never is the blue patient truly blue, The red patient red, The yellow patient yellow. Except Mrs. Jones. She bordered on the bright, true yellow Of children’s picture books and flowers – The kind that would take your breath away If seen off the page or outside of a bouquet. I, too, was awestruck when I saw her, And my gasp for air embarrassed me; Doctors, and those training to become them, Should not be fazed by anything, Or at least never show it. Mrs. Jones was beautiful. Emerging from a middle part, her hair – Silver for a hint of a centimeter –

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Poured down jet-black on either side of her face And feathered at her shoulders. Pencil-thin eyebrows arched lightly above her eyes, Which were closed, Heavy with the fatigue that comes with illness And the drugs that try to cure it. Her features were gloriously, calmly even. They say that beauty is symmetry; I don’t know if this is true, But I can testify to the reverence that washed over me, Like a gentle wave, When I beheld Mrs. Jones’ face. And after a few minutes of watching her, When my eyes and mind had lost all sense of normal, When sources of comparison had temporarily faded, Mrs. Jones’ yellow hue became beautiful, too – All traces of her normal complexion gone, Probably for good. Mrs. Jones was an alcoholic. Two six-packs per day and rising, Since her son, drunk one day two months ago, Decided to hit her. The daughter of an alcoholic, The mother of one, And dying from alcohol herself, Mrs. Jones was sick with genetics at its worst – Inherited patterns that don’t make us more fit, As Darwin would so desperately vouch for, But rather kill, Sometimes so fast that we don’t have time to let go. But not so for Mrs. Jones. Her genes and her family were killing her slowly, Rendering her a beautiful, yellow queen for all of us to behold Before we, too, would have to say goodbye. -Mimi Levine

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The MICU Melissa Cain Two days. Two deaths. Two codes. You always remember them the next day because, while their body has been taken away, yours still aches from doing chest compressions. Compressing your whole body into their whole body, trying to put everything you have into them, to do the work of their heart. Cracking their ribs, making them vomit, their whole bodies convulsing in agony. Is this the way we die now, with strangers sweating on us as they collapse our chest, pumping us with fluids and having air forced into our lungs? One of the patients, the first patient, he was knocking on death’s door for a long time. He was a quadriplegic with multiple organ failure, in and out of the ICU. He was on constant pressors, had a colostomy bag, needed oxygen, had multiple bed sores, resistant bacteremia; he had been on the way out for a long time. He was living his life in almost constant pain, and he complained to the night nurse just enough to get an extra shot of morphine that sent him into respiratory depression, like it always did. The nurse warned us before we started rounds “this doesn’t look good. Be prepared for a code”, so when it happened, it was like it was supposed to happen. Everyone was ready, everyone was prepared, everyone knew their job. It was just another day in the ICU. Another day rescuing people from death. Put on the face shield, wait for your turn, and as you pump, residents are instructing you on the proper hand positioning and clapping to make sure you are staying fast enough and telling you that you need to press harder and let up more. And they are relaxed and just counting down the seconds for you to switch off. And the respiratory tech is pumping methodically and the nurse is pushing more and more fluids. And then we stop and we can’t find a pulse and we do the whole thing again. Till we make him vomit, till we put so much fluid in him he swells and we force open his wounds and he oozes blood all over the bed. And the room is covered in packaging and body fluids and gloves and gowns and face shields and chaos, but we finally

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find a pulse, so we go back to rounds. We are talking through the other patients, and the nurse tells us to get ready to go again. The crash cart is already there, and we all know our roles, and we are about to start again when the son arrives and sees his father only partially put back together. Bloody and mangled and covered in medical equipment. We ask him what he wants us to do, but he can see what we want him to say. He can see the look of futility in our faces. The son tells us not to start CPR again. We are letting him go. And then the son kneels beside the bed and tells his dad he loves him and he his here for him. And then our patient becomes a person again. He is no longer just a collection of vital signs and organs for us to fix one by one with modern medical interventions. Now he is a loving father, a loved father, and he is dying and we are letting him. And it is finally sad and I want to cry, but we arenâ&#x20AC;&#x2122;t done with rounds. And we have other patients that need us. He doesnâ&#x20AC;&#x2122;t need us anymore. There is nothing we can do now. The second patient we coded for over an hour because he was young (40s) and he came in for elective surgery, and there was a sense that modern medicine had failed this guy, and we needed to redeem ourselves. But he was very obese and every chest compression was like pushing a boulder and you were shaking by the end of your two minutes, but you just went to the back of the line to rest until it was your turn again. And the code kept going because he just came in that morning and we didnâ&#x20AC;&#x2122;t have good access. We have to have access before we can say that we have done everything we can. Our attending was trying to find arteries while the students stood in line. The chest compression line. The life line. We were the only thing pumping blood to his organs and every time I compressed and it hurt and I sweat and ached, I thought about how I was saving this man. Every compression can save him, every compression will save him. I will push with all my might into his giant chest and hope that I can keep the blood flowing just enough and just long enough till his heart starts working again. It is amazing that our hearts are so small and they do so much work for all of us all the time. The work of 8 students and residents working with all their might. But the heart is not helping us today. So it is just us. We, the medical students,

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are staving off death as long as we can until someone can find a better solution. And we did find a better solution. We saved him, technically. We got access and he got fluids and pressors and he acknowledged us. He was groggy, partially responsive, but never good. And it was late. And we went home and his family came and he continued to get worse. And he died overnight with just the residents and nurses to do the compressions. It turned out he had candidemia and we were fighting a battle we had already lost. Those deaths hurt. They hurt because my whole body was sore the next day, and they hurt to see the families forced to say goodbye to someone they love, and they hurt because we couldnâ&#x20AC;&#x2122;t do anything. We pulled out all the stops, the best modern medicine had to offer, but in the end we had to let them go. And their families had to let them go. Because sometimes the world of medicine is not complicated formulas or the pathophysiology of an obscure disease. Sometimes the world is very simple. Sometimes people die.

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Walking Upright Photograph

Elizabeth DuPre

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The Room I walk I walk To a room to be put within dreams To a parlor with gas and machines I speak I speak To the countless around me it seems To the faceless ones muttering sleep I see I see That theyâ&#x20AC;&#x2122;ve readied a silvery key That theyâ&#x20AC;&#x2122;re nigh to begin the routine I breathe I breathe And my heart whispers sadly to me And my brain is now grasping at five Then four Three I descend I descend Into pink and empty smog Descending until when -James Wang

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Fly Fishing Photograph

Eleanor Woodward

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Gold Among Thorns Photograph

Elizabeth DuPre

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brown his hand touched my back went to my hair and lingered on a curl that rested on the white of my blouse. i turned to his startled eyes as he removed his hand, said â&#x20AC;&#x153;you have hay in your hair,â&#x20AC;? and smiled. -Tiffani McDonough, MD

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Nausea Anne Herbert Nausea. The room swirling. I grasp behind me for a seat and fall into it. On television, operating rooms are always cold, but I’m burning up in here. Children can’t regulate their temperatures well, the doctor tells me. Pediatric ORs are kept much warmer. No blood yet. Not a scalpel in sight. But it’s my first time observing surgery, and the anticipation is getting to me. I count my breath—one, two, three—in through the nose, out through the mouth. The surgeon is sitting over the infant, a well-trained artist choosing his materials, planning out his masterpiece. The child’s lips have complex markings that seem another language entirely. My eyes dance around the operating room and finally rest on the child. A blink, and then I’m lying on the table. Asleep, with barely any hair and baby skin so soft I want to reach out and touch myself. My lips, with my own surgeon’s roadmap drawn on in blue pen. The cleft seems so small and delicate, I don’t know how he is going to bring the two sides together, but I somehow know he’ll manage. The surgeon grabs for a scalpel, and I instinctively stand. I’m still hot, my borrowed scrubs sticking to the sweat on my legs. But I am drawn towards the table. I stand to the left of the surgeon for the whole 45-minute procedure, at moments forgetting to blink, to breathe. My eyes never leave the infant’s lips. I want to know how my own scar was created. How each stitch will create the pink line that will run from that child’s nose to mouth. The surgeon’s movements in these minutes will have a profound impact on the boy’s life. What he will look at everyday in the mirror.

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As the last stitch is cut, I step back. The infantâ&#x20AC;&#x2122;s lip is one, continuous pathway, leading from one edge of his mouth to the other. I have a strong urge to reach out and run my fingers across. To make sure this is real, not an illusion. But I only have to reach up to my own face, run my fingers across my own lips to know that it is.

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Dissent Sandeep Raj He won’t go away. No matter how cruelly I berate him, how obvious I make him feel unwelcome, this insolent degenerate refuses to give me a moment of peace. I own him; his very existence is entirely because of me, and yet he betrays me, constantly, without break. There was a time when he was different. Obedient, disciplined, never wandering towards the bad things. We got along well and I trusted him. I thought little of it when he made his first mistake. Mistakes happen. Indeed they do, and allowing him his freedom was mine. I should have caught the obsession, the fascination with the forbidden and nipped it early on, but I didn’t. He’d never led me astray before, it felt wrong to punish him for the occasional misdirection. But now I am in a rut. His perversion is perhaps permanent, never to be cured. But what choice do I have but to grin and bear his presence. Like the rest of his siblings, he was bound to fail, give in to entropy, the debilitating effects of time. But he was closest to me, as intrinsic to my being as anything could be. It wasn’t until recently that I could even tell the difference. But it is there.

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Untitled Pyrography on basswood

John Paddock

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Reflect 3 Photograph

Ali Mendelson

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Children and Art Robert Accordino, MD, MSc “I can only take this in small doses,” she said to me as I examined her heart and lungs with my stethoscope, reality TV playing on her hospital room television. I thought she was complaining about my examining her. “It’s enjoyable for a few minutes, and then you really begin to question where these reality television people’s values are.” My patient, age 22, could teach many people far older than she a thing or two about values and priorities in life. I started to tell her this during my morning rounds—our daily 6 a.m. ritual in the hospital. Kara had been slowly dying since the age of four. She was unlucky enough to be diagnosed with a rare tumor that most often occurs in the first two decades of life, an inflammatory myofibroblastic tumor. Kara presented to her primary care doctor’s office with complaints of pain when swallowing that was later shown to be a tumor strangulating her esophagus and stomach. The tumor, which rarely spreads to distant areas of the body and rarely behaves aggressively, was doing just what it was not supposed to do. It next spread to her liver and invaded it so dramatically that she required a liver transplant. Over the next 18 years of her life, Kara’s rare tumor continued to invade her body—with massive lesions in her lungs, brain, pelvis and abdomen—causing pain that was difficult for me to fathom. She would point to pain in areas around her body that corresponded to locations of serious tumor burden. With a stature of five feet, she only weighed 55 pounds when I met her, and she was on an aggressive enough pain regimen—consisting of high doses of Dilaudid, methadone, Ativan, and gabapentin—that it quite possibly could have been enough to sedate a patient much larger than she. She also had pain down her legs from the pressure of tumors pressing on the nerves providing sensation to them and pain on urination, not from an infection, but from a tumor

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pressing on her bladder. These barbaric tumors would eventually press on some vital organ that would slowly lead to the conclusion of my young patient’s life. In learning more about her medical history, I was also so eager to learn more about her passions and seemingly heroic coping skills. She had always hoped to become a caterer; baking was a passion she never got to pursue. She loved art and creating multi-media canvases with photography and painting. She loved makeup and jewelry. On certain days in the hospital, she spent up to an hour delicately applying lipstick, blush and mascara. She hated her legs— “just too skinny; I could eat endlessly, and they’d still just be too skinny with my skin flaking off.” She loved her mother, who stayed by her bedside during every hospitalization. Kara, after all, had spent more days of her life in the hospital than at home. As she faced death, she worried about her mother and how she would cope. Her artwork, so delicately and thoughtfully crafted, often featured photographs of her and her mother, created specifically for her. Composer Stephen Sondheim aptly wrote about children and art being the most profound ways by which we can leave a legacy for the world after we are gone in his extraordinary work, Sunday in the Park with George. Her murals were expansive, colorful, bright and moving, similar to those of Georges Seurat. She used design contours in ways that made a central photograph pop out with great prominence—she was rapidly creating her legacy of art as Sondheim described. In the field of pediatric palliative care, it has been noted that dying children are often exceptionally concerned about their parents and how they will cope. With such few years on earth, they often quickly develop perspective of how unnatural it is for a parent to lose a child. Kara certainly developed this appreciation early in life. The gravity of such loss is timeless. In 1833-1834, the German poet Friedrich Rückert wrote Kindertotenlieder, a series of 428 poems on the death of children. The poems were in response to his own personal tragedy of having his two children become ill and pass away from scarlet fever, a bacterial infection that is now usually effectively treated with antibiotics and no longer a devastating cause of death. In one of those poems, he writes about

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the premature loss of a child: “In this weather, in this gale, in this windy storm, they rest as if in their mother’s house: frightened by no storm, sheltered by the Hand of God.” Kara’s mother could have written the lines of that poem about losing her daughter. The goal of this hospitalization was to start her on a new chemotherapeutic medication. If she could tolerate the medication, which would likely cause significant nausea and vomiting and slight vision loss that was not permanent, there was about a fifty percent chance that the symptoms due to her bulky tumors would improve. We read the article about the new drug, published just a few months ago in the New England Journal of Medicine, together. “We just have to have hope, doc,” she told me, “I’d really love to be able to bake if this drug works. I’d love to have my life back again.” She talked to me about her wishes as I held her hand. I hoped that one day those hands would be able to bake in addition to creating beautiful art. Kara not only provided me with hope, she showed me perspective on life and living in the present that I had never truly understood. Though she was slowly dying, she taught me so much about living. Originally published in The Huffington Post. Follow Up Note: During Kara’s hospitalization, I told her of my plan to blog about her and how my writing was progressing. She was very excited to read (and critique) it. When I came to the hospital on the morning of September 23, 2011, I had a draft of the blog to share with her and found out that she had passed away earlier that morning. She died in her sleep with her mother by her side. In the hospital that morning, all of us who had the honor of caring for this remarkable patient shared our thoughts and reflections during rounds and took a moment of silence together with all the physicians, nurses, social workers, patient care associates and staff on the floor. With the permission of her parents, I published this blog, dedicated in loving memory to Kara.

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War Poet An old old man in a hospital bed Looking at the monitor The beeping screen with green lights To him, these green lights, in flashes, were photographs reflections of the sun of 1916 caught in the eyes of boys His comrades in youth. Back Then Every staircase was newly cut, every door knob was shiny. An old man with a A shifty gaze trying to find his face looked at the screen, lots of buttons and green lights. He thought not now but then his eyes would be permanently damaged by that camera flash. That big cool camera they wheeled out For the senior class picture.

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He remembered so clearly how He wore his hair too slick and always jumped in the freezing river in April willing it to be summer. Oh yes, and summer did come. They said they were a generation lost to war All those young men But this old man was lost now. Those war poets, wrote of the tragedy of life obliterated. But Wilfred Owen was a wuss. It might have been best, To evaporate in the flash of that old camera. Even to fall beneath those yearsâ&#x20AC;&#x2122; erratic bullets. -Zebib Abraham

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Untitled Photograph

Yvonne Wang

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Untitled Photograph

Yvonne Wang

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On Smiling Sandeep Raj The two of us entered the room together. We exchanged greetings with with patient and her family, one by one and pairwise, nodding our heads and shaking hands where appropriate. “Hello, I’m Dr. M” “Hello, I’m ____.” “Hello, I’m ____.” “Hello, I’m ____.” “This is Sandeep, he’s a medical student who’s working with us here today.” “Yes we’ve met before.” “Yes, hello again.” “Right. Excellent.” It was different this time. Where my conversation had started off awkward, this one was prompt, pointed, exact. The room didn’t seem like it was worryless, sunny, and a bit lazy, the way that I had left it several minutes ago. It had morphed into a grayer one, brimming with anxiety and cold sweat. “So how are we feeling today?” started off Dr. M, and as the spotlight shifted solely towards him, I felt a wave of relief. The professional was here. He’d take care of the problem. I could just sit back and enjoy the show as he broke the wonderful news that this wasn’t such a big deal and that we could figure it out. I had seen this show a few times before, and it was a good one. And I wanted good news for Mrs. H and her family very much. But for whatever reason, as Dr. M fielded the patient’s questions, one by one, it didn’t feel quite the same. I sat there looking very intently, moving my head to and fro from speaker to speaker, trying to absorb what they were saying, interjecting once in a while with a nod. I could hear the good news coming out of Dr. M’s mouth. The enthusiasm was guarded for sure, but it was there. I didn’t dare show any happiness or excitement on my face. The news was for the

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family, not me, an irrelevant, unwitting part of their ordeal as useless as the chair I was sitting on. The least I could do was appear to give their experience the seriousness and respect it deserved. With what, in retrospect, I imagine must have been a profoundly cartoon-like dumbfounded face, I stared at the patient’s family. What was wrong? Perhaps I was being short-sighted. Good news, despite being good news, at this point probably didn’t help mitigate the bad news. Especially when the bad news was lung cancer. Was I being unreasonable to think they should feel happier that the disease was still very treatable? Had Dr. M mentioned this yet, as he had to me? Dr. M had patients who survived for many years with this disease. It was then that I realized how stupid I’d been. Of course that isn’t good enough. They wanted guarantees. There were no guarantees. For all the wonderful possible treatments that were being thrown out onto the table, none of them was pleasant, and none of them carried any sort of guarantee. My face was getting warmer and I was shifting uncomfortably at my newfound discovery of how full of volatile emotion the room really was. I noticed the mother’s voice getting higher, sharper, breaking on occasion. I saw the patient nervously glancing towards her family, afraid at how they’d react. The friend stood near the window, looking serious, sullen, and ready to attack anyone who dared to say something unpleasant. The sister was looking intently at Dr. M, trying to manage the 4-way conversation taking place. Words were being said. So many, many words, at which point I figured out that they were just that to me. Words. I had stopped interpreting them. All of the voices, sounds, and conversations blended into obscurity, leaving me to try and figure out my next move. Do I say something? Maybe. Should I say the good news Dr. M told me earlier and— Nah. What if he already said it? I might insult him, not do any good, and sound stupid. Yes I’ll sound stupid. Should I just leave the room? Maybe I can say I need to go to the restroom? No. Just no. I can’t just leave.

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Maybe I should apologize? For what? That makes no sense. That won’t help. And then there was silence. Real silence. No one was speaking. I snapped out of my own musings and tried to figure out what was going on. “Tell me, Dr. M. Will I have my daughter for a long time?” “We’ll make sure that you do. Like I said before, this is a very treatable disease.” The dam broke. It seemed like everyone started crying. Tears of joy. It finally happened! This time my sense of propriety couldn’t hide the wide grin on my face. When everything settled down, Mrs. H lovingly rebuked her mother for being so emotional. “See, why were you getting so upset for no reason. We were all telling you that this was good news.” The mother pointed at me. “It was him.” I hope I looked normal and relatively unfazed because I was utterly horrified on the inside. What had I done wrong? Oh god, I didn’t actually try to leave the room did I? No. What was it? “You gotta smile more, kid.”

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The Man in the Machine Photograph

Peter Barish

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Untitled Ink/acrylic on paper

Samuel Woodworth

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Lady Wife Anne Connolly Excerpts: Characters: RAYMOND: a resident, 80s GLENDA: a staffer at the residence, any adult age LADY WIFE: RAYMOND’s wife Setting: A room in an assisted living home, present day. GLENDA: Mr. Raymond, you haven’t eaten. Again. RAYMOND: Glenda, I think organ donation is a much more complicated matter than they want the general public to realize. GLENDA: Organ donation, organ donation! I think you are obsessed with this organ donation business… RAYMOND: I think I’m against it. GLENDA: I wish you were as obsessed with eating. Here, I’ll help you. GLENDA sits down and starts feeding RAYMOND. RAYMOND: I’ll give you one reason I’m against organ donation, although it’s not my main reason. GLENDA: Mr. Raymond, do you think you’re going to need your organs in the hereafter? RAYMOND: No, Miss Glenda, I don’t think I’ll need my organs in the hereafter (imitating GLENDA). I may have Alzheimer’s disease, but I’m not stupid.

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GLENDA: Keep eating, Raymond. Let’s get as much use out of your digestive organs as possible as long as you’re not passing them on. I think you’re just squeamish. RAYMOND: No, I’m not squeamish. GLENDA: Then what’s the problem, you selfish old man? RAYMOND: (correcting GLENDA) That’s selfish old fart. One problem with organ donation is that the donor doesn’t get to choose! GLENDA: Doesn’t get to choose what? RAYMOND: Doesn’t get to choose who gets his organs! GLENDA: Why should you care? RAYMOND: Good question. Why should I care? I’ll be in the hereafter (imitating GLENDA again) so it’s all the same to me. Why not help out some other guy? Why not make his family happy? Why not extend his deadline? GLENDA: Literally. RAYMOND: Ha! Literally! Good one! Here’s why not—My heart might end up in the chest of some son-of-a-bitch. Like Dick Cheney! GLENDA: (laughing) I never thought of it that way, Mr. Raymond. Okay… RAYMOND: It’s not funny, Glenda! Absolutely not! Beyond unacceptable! And I voted for Dick Cheney! GLENDA: Eat some more of your carrots. Dick Cheney nothing—it could be even worse than that. What if your heart ended up in my chest?

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RAYMOND: I’d be spinning in my grave alright. GLENDA: And you’d never stop. More carrots. RAYMOND: Quit managing me! GLENDA: Alright, Raymond, alright. RAYMOND: Everyone is always trying to manage me! Stop it! Raymond, eat your dinner. Raymond, take your medicine. Raymond, what’s my name? Raymond, what’s your name? Just knock it off! GLENDA: Raymond, why do you shout? I’m sitting right here. You don’t have to raise your voice. I can hear you, Raymond. RAYMOND: Okay. Sorry. GLENDA: By the way, no one is trying to manage you. We learned a long time ago that you are unmanageable. RAYMOND: Glenda, did anyone ever tell you that you can be quite withering? GLENDA: Did anyone ever tell you that you can be quite wicked (imitating RAY)? You waste your time when you worry about organ donation because nobody wants your wicked old organs anyway. I don’t know why you started troubling yourself about this organ donation business in the first place. RAYMOND: Then we’re all in agreement. My heart stays in my chest and that’s that. GLENDA: Yes, Raymond. Your heart stays in your chest. Now get some sleep. GLENDA exits, turning off the lights. RAYMOND lies in bed, eyes open, looking lost and a little scared. •••

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RAYMOND: Hello, hello, hello? My heart? LADY WIFE: (Only her voice) Ray? RAYMOND: Hark! My own Lady Wife. LADY WIFE: My own old fart. RAYMOND: Oh, isn’t this why I fell for you? Your abiding couth. LADY WIFE: And here I always thought it was my long legs. Good to see you, Ray. How have you been? RAYMOND: I want to go home. LADY WIFE: I know, my heart. RAYMOND: I feel gutted. LADY WIFE: Gutted? RAYMOND: They want people to donate their organs and I’m not even through with mine yet. They want to gut me. LADY WIFE: Oh, Ray. RAYMOND: What if they take my heart out and give it to someone else? It belongs to you! LADY WIFE: I know, Ray. I know. No one is going to gut you. RAYMOND: My head is already gutted—if I may mix metaphors. I have Alzheimer’s disease and my head is gutted. LADY WIFE: You seem alright to me. RAYMOND: Then let me come home. (Crying now) Please let me come home. You didn’t take the house all for yourself, did you?

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LADY WIFE: No! No, I didn’t. It’s our house. Ray, are you crying? RAYMOND: Yes. I’m sorry. LADY WIFE: I don’t think I’ve ever seen you cry. You didn’t cry even when we lost Abbie. RAYMOND: I cried. You just didn’t see me. LADY WIFE: You didn’t need to keep it a secret. RAYMOND: I guess at the time I thought I needed to—keep it a secret. LADY WIFE: Well, I wish you hadn’t. I could’ve used you to cry with me. It would have helped. You old fart. RAYMOND: I’m sorry. LADY WIFE: It’s alright. (Pause) You know, Ray, I think I like you even better with the Alzheimer’s. You seem happier to talk with me. RAYMOND: I’m glad. I’m glad you still like me. LADY WIFE: Yes, I do, Ray. I love you. (Pause) Ray, what did you always used to say to the kids? RAYMOND: “Who belongs to the clean plate club?” LADY WIFE: No, the other thing you always used to say. RAYMOND: “Some peace and quiet, please?” LADY WIFE: No, not that either. Keep trying. RAYMOND: I forget. I have Alzheimer’s. LADY WIFE: Oh, yes.

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RAYMOND: What did I always say to the kids? LADY WIFE: It’s going to be alright. You’d say to them—it’s going to be alright. RAYMOND: I said that? LADY WIFE: A lot. You said it to them all the time, my heart. RAYMOND: Huh… LADY WIFE: And you were right. It’s true. Everything is going to be alright. You’re a good man, Raymond. THE END

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John and Sarah #4 Photograph

Peter Barish

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King Photograph

Eleanor Woodward

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3rd year Adam Widman If I had to paint a picture of the third year of medical school, when students finally leave the classroom and haunt the hospital wards, I’d show some kids with big bright smiles gathered around a bunch of animals at a zoo. As the seasons passed, I’d draw in facial hair and some bags under their eyes, maybe a little outline for a gut, one or two grey hairs. The animals, maybe stuffed tigers, lions and a polar bear, would all get fangs and snarl. And for a brief period of time all those chipper young med students would be frightened for a bit, and then, remarkably, snarl back. Because the first two years of med school are different. You spend all your time reading about these strange disease creatures. You think about your role as doctor in some overly idealized, ethically-appropriate-for-all-forms-of-standardized-tests kind of way. How you can’t wait to take care of the sick, how your patients’ respect and admiration will sustain you through the lowest of moods, through that 20th hour. But somewhere between chipper adolescence and hardened residency some switch is flipped. Everyone knows residents are mean, and tough. They started with cautious smiles and shyness and now look at gangrenous bowel and smile. How’d they get that way? It starts on the wards. There are few excuses. You are not you but someone perpetually 10% shy of some idealized version of you. Some knowledgeable, industrious self with a keen eye for minutiae and, well, an adult’s grasp of adult life. You don’t know things, or people. You’re not used to viewing strangers as patients you care for, whose shoulders you rub upon entering the room and whose problems are now kind of your problems, too. There’s some added weight to the things you say. Use some caution.

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And wow, those fanciful diseases sure are mean when they crop up in real life. It’s not so much fun to watch your patient die. It’s not so great when the family says your team didn’t do enough to save him. It’s easy to be nice until 3:30 in the morning but maybe your real feelings will come out around 4, when you’re forced to take on a personality instead of the role of amorphously eager med student. You’ll have to develop some style to deal with poking someone four times without drawing blood. You’ll need substance to figure out if someone really wants to kill themselves or just wants another night of food in a hospital bed. The good news is no one will give you any life or death responsibility, and the bad news is you’re vastly unready for it, though you’ll certainly learn a thing or two. It’s a slow and steady climb to being the attending physician who signs the final order. There are reasons for that. It’s rewarding, because it’s a privilege to watch a birth, or stitch an abdomen, or hear a terminal patient’s thoughts on death. It’s daunting too, when you can’t do enough, or no one knows, or waking up at 4:30 am means you’re in bed at 10:00 pm while the rest of your friends have social lives. People trust you, all of a sudden, with stuff you have no business being trusted with. You might get comfortable for a day or two but then your team or your role will probably change. Your resident who loves teaching will be switched for one who has you fax stuff and grab her the leftover food from another department’s meeting. Some moments are awkward: “I’d like to briefly introduce myself and then hold your leg while you deliver your first child. Do you mind if I begin this cervical exam?” But then it all becomes easy, or at least easier, at some time you don’t expect. All those diseases become a little less menacing, scary still but less riddled with the unknown. Cirrhosis isn’t on your quiz but sitting in your patient’s abdomen. You fight it by draining fluid out from a little tube. Your patient may do poorly; he could also do much better than you expect.

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You start to walk with a little swagger. Of course you’re here to check this woman’s stool for blood, or find the heart rate of this patient’s fetus. Yes, Mr. Cohen, I’ve been sent to the emergency department to begin your work-up for diabetic ketoacidosis. No, I can’t grow a beard, but I’m pretty sure you need some insulin and fluids. Take a break, junior resident, I know just where to put the Foley. I promise. So over time, that painting gets a lot closer to being finished. There’s a much scarier one waiting in residency.

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Window Seat Photograph

Matthew Inra

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Freedom: The Guardian of our Future Photograph

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Elizabeth DuPre

Match Back and forth. Back and forth. Just back today. Down the hallway in this Place with Locked Doors, I see you, still. You sit, bilateral hands on bilateral arms Of the chair. You stare straight ahead of you. I walk by, no change. “Do you hear the voices today?” I serve overhand. You don’t answer; 15-love. “How are you feeling?” A more gentle serve. Just one syllable, Emerging from a mouth with unbrushed teeth, Which flash under a mop of unwashed hair, black, Which matches the stains of your soiled t-shirt. Your lips barely move: “Fine.” 30-love; this is no match; you won’t hit back. Why? Is it that you don’t want to, Or that you want to, but you can’t? Are you just twenty years old, stubborn and slouching, Or are you silenced by fear, Lost amidst voices I want to, but cannot, hear? I can’t tell. Regardless. Please, play with me. Back and forth. Try this pill and then play – Like doping for all the right reasons. I serve: “How are you today?” “Good,” you return with a timely quiet mutter; A hit, I’d say. But you sleep all day. All day and all night, As if being awake were too painful –

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Or perhaps a waste of time? I can’t tell. Regardless. I rouse you every morning, I rouse you every afternoon, Play with me, please. Back and forth. Back and forth. It’s all we have, you see. And so I plan to try again, But before I begin, I see you. Today, your shirt is bright white, Free of stains and wrinkles and must. Your hair is wet, shower-fresh, And your teeth – brushed. I’m not ready, But, now steady, I return: “What will you do today?” A pause, then – A blink-and-you-missed-it, Ever-so-slight, Upward turn of your mouth, And one eye, squinting and soft. A smile. “Tennis,” you say, “I think I’ll watch some tennis.” The game is on. Let’s play. I hit back: “And who do you think will win?” Early fall in New York City; U.S. Open time, for those who follow, Like you, as I’m coming to see. But perhaps I hit too hard, For now you retreat and look away – “Oh, I don’t know” – Your words and shoulders Now buried and lost in a shrug.

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15-15; the game is over for now. Did you swing and miss? Or could you care less? I can’t tell. Regardless. Back and forth. Back and forth. It’s all we have, you see. But maybe you understand – Or maybe you’re just giving in – Because down the hallway in this Place with Locked Doors, I see you, staring at the television screen. I walk by – and – a change – You turn to me, That upturn of your mouth Back with its partner, the soft squint. This time, you serve: “Who do you think will win?” And the rally begins, The start of a match – Let’s play. Back and forth. Forth today, as I see you down the hallway. You sit, bilateral hands on bilateral bags At your feet. Today, your shirt is bright white, Free of stains and wrinkles and must. Your hair is wet, shower-fresh, And your teeth – brushed. And your coat is on. You leave, as do I – A tie. Until – I see that coat, And the smile and its partner – The squint, still soft. We are now a world away,

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Or, really, just somewhere else, Where the doors are not locked And you can roam, unwatched. Down the hallway, You see me, still. I stand, bilateral hands on bilateral arms of a chair, Because I almost fell When I saw you. Today, your shirt is collared, Ironed and pressed, mature hues hushed, Your hair is cut, freshly combed, And your teeth – still brushed. Smiling, you serve: “And how are you?” You shine. “Fine,” I barely return, And hit the net. 15-love, and I am happily, gloriously losing. But the match has just begun. Let’s play. Back and forth. Back and forth. It’s all we have, you see. -Mimi Levine

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Untitled Ink/acrylic on paper

Samuel Woodworth

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Anatomy Preston Kramer Confronting the still form before us was not an easy task. Our instinct was to bury ourselves in the structures and checklists but it was a battle lost in flashes of humanity. I will never forget the day that I prepared to dissect and examine the hand. I held it steady and prepared the scalpel and took a breath, but the scalpel remained slack at my side. I stared at the fine creases of the skin, and suddenly, I was looking at my grandmotherâ&#x20AC;&#x2122;s hands as I used to squeeze them and smile up at her. A textbook can feed you the names of the arteries and the innervations of the musclesâ&#x20AC;&#x201D;all in a convenient table. But medicine has never been about tables and charts. There is always a human being on the other side of the stethoscope, and with our cadaver, this fact was never lost. She was our first patient and a microcosm of the cares and pains and triumphs and pride and frustration and grief that will punctuate the rest of our careers.

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Silence

Richard Lin, MD The phone rings, it is Shannon. “Brett passed away the day after he’d gotten home. He smiled at me and he was so peaceful.” Shannon says, “thank you for getting him home.” Tears fill my eyes and soak my soul: it is a privilege to be part of Brett’s family. A week ago we made the decision together to take Brett off his ventilator and feeding tube. I remember the Friday afternoon and the rain, on and off, washing away few pieces of dark cloud. I sit quietly in our cozy family conference room and patiently wait for Bill and Shannon, the weary parents of Brett whom I have come to know for the past several months. Brett is an unfortunate 28-year-old young man who suffered a cardiac arrest after a routine hernia repair two years ago. The precise sequence of events was not clear, but it was suspected that his morbid obesity and obstructive sleep apnea might have contributed. He had prolonged anoxic brain injury and did not regain consciousness. A tracheostomy and a percutaneous feeding tube were placed, and he was sent to a ventilator facility in a persistent vegetative state. But Brett keeps bouncing back: ventilator associated pneumonia, urinary tract infection, leaking feeding tube, so on and so forth. His last three admissions were with me and, despite poor neurologic prognosis and many family meetings, Bill and Shannon had continued to opt for life prolonging, aggressive care. The spring is here, and I am imagining myself walking slowly along a paved stone road. Suddenly the door opens as Bill and

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Shannon walk in. The social worker and I greet them. Bill is a stocky man in his fifties, a man of few words. When he does speak, however, everyone listens. Shannon, on the other hand, is an outspoken and sometimes anxious mother. She cries often. “Brett rolls his eyes and seems to respond to my voice,” Shannon whispers, “maybe it is a miracle…” “Well, we have seen that before…” Bill responds. The social worker nudges me to continue the long, dreaded, goals of care discussion, from which Bill, Shannon, and I are obviously exhausted. Silence instead, and the ponderousness once again fills the room, heavy, yet not suffocating. “Hopefully he is not in pain.” Shannon continues. It is getting dark outside. I have tried to open the curtain before the meeting, but it was stuck halfway. “I should not have fed him that much,” Shannon says to herself, “I should have picked a different surgeon.” I cannot help but think about my wife: she is pregnant with our first child. “Brett was a quiet kid growing up. He used to lock himself in the bedroom for hours playing guitar and computer games. His room was filled with gadgets,” Shannon smiles. “His room,” Bill sighs, “Brett has not seen his room for a while now.” “Brett would love to go home, I think.” Shannon speaks softly after a long pause.

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Days are where we live. What are the days for Brett? For that matter, what are the days for Bill and Shannon? “Let’s take him home after the weekend. I will clean up his room,” Bill proposes. “He would not have wanted to live like this, for sure,” Shannon agrees. Together we walk over and sit at Brett’s bedside. We watch over him, like parents, like brothers, in his world without words.

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Independence Day Photograph

Eleanor Woodward

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Pieces and Parts Rachael Venn You taught me that the body is mechanical. A system of tubing and wiring, valves and pumps. Pulling a tendon in your hand, I can mimic the contraction of your flexor digitorum profundus, and I watch in curious awe as your pinkie curls. From you, I learned that the bones of the spine are like an erector set. Seven, twelve, five, five, four—the number of vertebrae in each section. To my armamentarium, I add the words “kyphosis”, “lordosis,” and “scoliosis,” so I can properly articulate when the spinal curvature isn’t quite right. I know about what makes your body unique, too—the nephrectomy and the colectomy. I know that your sciatic nerve bifurcates earlier on the right side than on the left and that your left gastric artery branches directly off of your aorta instead of the celiac trunk, a “normal variant” they call it. My lab partners and I have seen more of you than anyone, more of you than ourselves. One day, we found a small device in your foot, a little larger than a grain of rice and made of metal, something we hadn’t been briefed on in our anatomy lab orientation. Jacob recognized it as a radio-frequency identification chip, and we imagined you as a spy, possibly a double agent working for the United States government, collecting intel and saving the world. We imagined this until we learned that RFID chips had been piloted in patients with Alzheimer’s disease to facilitate emergency medical care. Then we wondered what it must have been like for you when the songs, faces, and stories you loved became oblique versions of themselves, as your memories grew faint and the world fuzzy. You taught me that I know nothing about you at all. I have run my fingers along the smooth ridges inside your heart, the trabeculae carneae and the musculi pectinati, but I know

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nothing about the person you gave your heart to, nothing about who you loved. There were the events that left their physical mark, but when I try to think about what happened in the very best moment of your life, I realize I have no basis for knowing. Perhaps it was the birth of your first child or the culmination of your lifeâ&#x20AC;&#x2122;s work. And what was it like the day you decided to donate your body to science and become my beneficent teacher? You taught me never to forget that anatomy is just the pieces and parts and not the substance of a person. When I make my first incision or ligate my first vessel, Iâ&#x20AC;&#x2122;ll think of you and the passions, fears, and beliefs that I could never ask you about. And because of you, I will remember to ask.

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Cecilia When you were carrying baby Cecilia your skin grew soft and damp like earth and your womb was like a melon At first, the flesh was sweet and quiet Cecilia was happy But then she ate through all the fruit of you and your rind was bitter and hard How she kicked and cried

How your skin grew dry and pale

Soon the dejected sorrow of discarded fruit filled you Your body strained to keep the hostage baby tight and hushed while outside, lights pressed against the skin of your belly breaking into Ceciliaâ&#x20AC;&#x2122;s eyes subdued brightness like some early urgent call

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The tiny prisoner rebelled flooded you with tears and wailing Cecilia flowed out of you on a river of her discontent and landed softly in some newness stunned by the brightness of her hunger and the novelty of air of something so full and so fresh -Daniel Shalev

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The Apthorp Jonathan Huggins “I was born in Manhattan,” she said. The word itself, ‘born,’ assumed the permanence to which it alluded; it flattened to fill the air like gnarled roots, buried in cobblestone and then painted over by asphalt, sinking tenacious fingers into the earth. 90-odd years in the eternally-erratic city had left Ms. Bern similarly cementedin, the decades tugging relentlessly at the corners of her mouth, the generations quieting her gaze and locking it into place on the space in front of her, away from me, through a window overlooking an Upper East Side street, crawling with coffee-sipping, cellphone-smooching passersby. Over the years that carried Ms. Bern through school, into a career as an elementary school principal, a life as a mother, grandmother, great grandmother and finally to the crippled old chair that propped up her stony body, her city and the world has changed tremendously. Tin Pan Alley was bulldozed by record players and radio, rooms worth of computing power were condensed into wallet-sized devices and everything got swallowed-up whole by the internet. The meaning of these changes is far from clearly spelled out. The rapidity of the current of change forbids that. Mapping the networks of influence becomes impossible or at least incredibly frustrating because as soon as the reaches of “network 1.0” are traced out, “network 2.0” has reformed the landscape. Some will render the nature of technological change in dismal hues. And to some degree, the palate is fitting. The great irony of communications technology is that the easier it becomes to communicate, the more trivial the communication becomes. The time consuming and wrist-taxing task of letter writing was all but completely erased by the invention of the telephone, which itself required at least some ready-making: the time had to be carved out, both parties within the coiled reach of a receiver. We came unanchored with the cellphone, ‘de-orthographied’ and depersonalized with the text message, and were robbed of a conversee with twitter and facebook. Some will argue that this trend, which has carried us from making a considerable time investment (not to mention the possibility of personal injury from carpal tunnel syndrome) for the sake of com-

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munication with another human being, to the self-serving practice of posting the details of this morning’s breakfast for the world to see, has made us an insulated bunch. We may communicate with millions, but we have little to say. Medical practice has progressed similarly. The advent of imaging technology and refinement of laboratory testing has not only drawn doctors away from a focus on the physical exam, but has also drawn patients out of their homes and into centers equipped with these sorts of amenities. We’ve become wrapped up in the science, extruding the patient. But this is a hasty conclusion. I will be the last to extol the virtues of twitter posts, but I believe our use of technology ought to be examined apart from its potential. Just as we are struggling to keep abreast of technology’s influence, so too are we constantly wrestling with the way in which it can be used. Yes iPads and iPhones have become excuses for disrupting the conventions of interpersonal interaction and give crying babies a run for their money when it comes to ruining a dinner table conversation, but when used properly (and with proper etiquette) they can be tremendous tools for helping others and enriching our interpersonal relationships. The Apthorp is a commanding building whose attendance to New York’s evolution extends beyond even Ms. Bern’s. At the far end of the courtyard we huddle into a struggling old service elevator, stethoscopes, blood pressure cuffs, and laptop computer piled into our arms. On the fourth floor we exit and make our way to our patient’s apartment. The place’s thick walls have soaked up the memories of their inhabitants. The fifteen foot ceilings and ornately carved wall panels evoke a time before conversation meant a volley of text messages, and yet here we are, practicing medicine as it was then. Paradoxically, the evolution of technology has brought us back. The miniaturization of medical devices, the ability to remotely access patient records and place orders, the strengthening of communicative ties with a central medical facility all make this sort of medicine practical again. It may be that technology has the power to lure us into worlds of isolation, or maybe we just don’t know how to use it.

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The Life of Ms. Smith Ink/graphite on paper

Elan Guterman

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My Grandpa Emily Grodinsky I can’t remember the pitch of his voice or the pace of his words, but I know he had a strong Polish accent. While I can’t conjure up the smell of his cologne by memory, when I catch a whiff from a random passer-by I know that was it. Imprinted in my mind—or instead perhaps a result of seeing photographs—is thinned white hair, large glasses and a broad, goofy smile. My grandpa was a charming elderly gentleman chock full of love for my sister and me. He was prudent, always meticulously maintaining a low sodium diet. Though proud and composed, he let his guard down at breakfast, sending soggy cornflakes flying from his mouth as he told mediocre jokes that made us laugh anyway. You don’t know your grandparents very well when they live in another state and you see them twice a year. Tack on being scared to ask questions for fear of hitting too sensitive a nerve—tapping too deep into a past of religious persecution, survivor’s guilt and divorce—and the relationship remains light, bobbing on the surface like a buoy. Complex and difficult stories were avoided during visits. We kept it fun and easy, talking about our lives but rarely his. In 2005, my grandfather tripped over his oxygen tank and broke his hip. My parents decided he would move to Chicago, and after spending a few weeks in three nursing homes, all of which he hated, he found one that he only hated a little; this became his home for the final two years of his life. My grandpa held on with force. He clung to his life in every way possible, pouring more and more drugs into his bloodstream and suffering through more and more hours of dialysis. From the eyes of a seventeen year old, his life seemed intolerably lonely and painful, but it was also the first time that we really started to get to know each other.

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For two years my sister and I drove almost two hours to see him every other weekend. We’d watch him struggle to get from his bed to his wheelchair, and although hesitant to see his independence dwindle even further, we would gently guide him into his chair as time went on. He asked about our extracurricular activities, boyfriends (or lack thereof) and what we thought about current events. I learned that he read The New York Times daily, that he liked his Polish nurse the best, and that he considered my sister and I unbelievably lucky to have such a great education. He fondly called us “smart cookies,” his eyes sparkling with pride and the corners of his mouth crinkled in a smile. After his death, my mom began to unpack my grandpa’s stories, which had been carefully sealed and hidden. Suddenly this goofy, loving grandfather became a father, a husband, a man who loved his red wine perhaps too much, a man who did not seem particularly invested in his children, a man who could never talk openly about the death of his family during the war, a man who had survived a life speckled with mistakes, unkind acts and resentment. The buoy still bobs on the surface, although perhaps a bit more violently. This man has remained in my memory, for the most part, as he had been imprinted in my memory before. In spite of this new information, I prefer to see my grandfather as the person I knew him to be: a happy man who loved making his grandchildren laugh and enjoyed having a daily routine. It may not be the historical truth, but it’s my truth, and I like it that way.

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Winter Warmers Photograph

Peter Barish

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The Death of Corporal Brownfield Jimmy Castellanos

Excerpt from a book-in-progress: After the mortars struck, everything changed in Al Asad. Overnight, Iraq seemed to transform and what was once to us a quiet and tranquil base was now criminal and violent, a dangerous place, and its once blossoming gardens now the flowers of smoke and fire. The previous night, seven mortars had struck the northern perimeter, killing one and wounding three others. One dead, three woundedâ&#x20AC;&#x201D;the words seemed to echo. All four casualties were from my platoon. They were no strangers to meâ&#x20AC;&#x201D;I had met most of them while in California, on our training base near San Diegoâ&#x20AC;&#x201D;and we had, over time, become close, drifting deeper and deeper into our personal vaults as we struggled against isolation. They were my friends, my platoon-mates, my brothers-in-arms. Now, hours after the mortar attack, the platoon lay in darkness, our spirits broken. The tranquil sandbox, as Al Asad was known, had vanished. That morning our platoon was shuttled into a small building for a casualty debriefing. Against the back wall of the barricaded room sat a naval chaplain, a man I had avoided all morning. He had been sent from headquarters to soothe our grieving, to restore our hopes in the war, I imagined, and for the first hour after his sudden arrival, he had wandered our camp, guiding from post to post, speaking to the Marines about the four casualties, four men the chaplain had never met. A middle-aged man of Vietnamese descent with a flat face and a pointed, angular jaw, his skin dark and his hair darker, the naval chaplain sat perfectly erect on a box of rations piled against the far corner of the supply room. He stroked the thin red tassel that dangled from the pages of his leather-bound book as he waited for the casualty debriefing. It was a beautiful book, with gold trimming and bold, Latin engravings that implied richness and historical importance, and he carried it the way we carried our rifles, with conviction and authority. Slowly, the Marines trickled in, if somewhat reluctantly, and

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took their seats besides the shotgun racks. Some sat on cots, others on the deck. They unloaded their rifles, holstered their pistols. I paused at the doorway. God damn it, I thought, another fucking officer, and then slouched on the cot beside Sergeant Hernandez, who had hardly spoken since the mortar attack last night; he had survived, but just barely—a navigational error had saved his life. “For ten seconds, the salted dogs of war howled,” he would later say, “and then the night returned to its dampened stillness.” But for our platoon, the night had been dire and endless, the mortars crippling: Corporal Brownfield was dead, Crosby was halfdead, Fleming was still losing blood and Corporal Cook had lost a chunk of his left forearm. “Come in, come in,” said the chaplain. On his collar sparkled a holy cross. He was old, scanty and inconsequential. A wizened man, equally devoted to the arts of killing and salvation. The chaplain waved us into the small room, smiling as if nothing had happened, like a traffic cop for the disembodied. “Sit down, relax,” he said. “So how is everyone doing today?” Silence. No one answered. No one even looked up. Beneath the faint rumble of a diesel engine, the Marines grieved collectively but alone. Their freshly-shaved heads slumped between their shoulders, frustrated and defeated, their helmets held upright only by the stiffness of a spinal column. Still no one answered and the quietness persisted, hanging low like gothic fog. There was in the chaplain a sense of mistrust, a falsehood, a disingenuousness that spoke to no one except Sergeant Hernandez, once a failed altar boy who had regained his faith in-country. I had seen the chaplain twice before, once speaking to a pair of female Marines guarding a fuel station and the second time near the motor pool where he wished a departing convoy good luck before ending a short prayer with the phrase: “May God guide your bullets downrange.” May God guide your bullets downrange—the prayer struck me as unusual and has stayed with me ever since, entering my thoughts from time to time. In the small room, seconds passed, an eternity. As the chaplain waited for a

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response, I thought about Corporal Brownfield. His death had struck us hard, without warning. One minute he’s here, I thought, and the next he’s shoved into a body bag. If he hadn’t taken my place on that convoy, he would still be alive, I told myself. I felt a sense of guilt, of responsibility for his death, and it would take me years to realize that I had done nothing wrong. His death was a matter of chance, and the insurgents had rolled the dice. Snake eyes, dead eyes. I replayed the scenarios that night over and over, retooling the infinite variables in hopes of saving Brownfield’s life, wondering if I could have halted the convoy in some way. Perhaps there had been signs of an incoming mortar attack: an Iraqi merchant leaving his post early, a once friendly Shiite woman fails to wave beneath her black veil; but in the clarity of retrospect, everything is a sign. An old Vietnam veteran had once told me that in battle for Hue City you could feel death in the air, taste it, smell it crossing the pebbled streets. But last night Al Asad had been tasteless and unscented. One dead, three wounded. “Corporal Brownfield is dead,” I finally mumbled. I could barely hold back the tears. Lance Corporal Piedra shook his head. “I know. I know,” he said. He rested his head against the bulkhead. He looked tired. “Bad shit happens to good people.” “I don’t get why of all the places on this fucking base, the God damn mortar had to hit next to him, right fucking there,” someone said. “He didn’t deserve this shit,” someone else called out. “Fucking unbelievable,” Piedra said. Piedra rested his swollen ankle on a box of rations; he had twisted it jumping from the truck during the mortar attack. By now most of our platoon had entered the bunker and taken seats along the walls and on the few empty cots still remaining, with some Marines leaning against their patrol packs. The room looked dismal, its white plaster peeling, the wires exposed. Above, cracks tore across the ceiling like fault lines. Broken outlet

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covers. Missing tiles. A dirty floor. In one corner of the room an opened box revealed its contents: a pamphlet that read: Take Hold of Your Life: Christianity and You. Beside it, excess toiletries, fitness magazines, more pamphlets—the remains of a gutted care package. The room smelled of pooled body odor. “Lance Corporal Piedra, can you tell me what happened last night?” the chaplain asked. He spoke with a strong accent, like a recent emigrant, with simple diction and even simpler sentences. Foreign-born but American educated. Piedra did not respond. He looked at the chaplain without moving his head. He had been picking the same nail for several minutes, and it had begun to bleed. He sucked the blood from his thumb and then pressed the bleeding edge against his trousers. “I don’t know what happened, sir,” Piedra said. “I was sitting next to Brownfield when the rockets hit.” The chaplain then looked at me. “Did you see the explosions?” I nodded. The chaplain lifted his gaze from the leather bible and looked at me with absorptive, expectant eyes. He wanted an answer. He wanted us to recount the mortar attack last night, to share the story of Brownfield’s death, but no one budged. I wished to be alone. I close my eyes and his holiness evaporates before me. I am alone now, alone with my platoon. The chaplain’s presence now gone, deceased, I try to imagine a room with only Marines, a place where we can speak among ourselves without this outsider, a place to remember our fallen corporal. We wanted to remember Corporal Brownfield, to remember the time he fell into the razor wire one night and squealed in horror or the nights we spent on guard duty together talking about how much we missed home and our girlfriends and how much he loved Ohio, that small, almost forgotten state which he called home.

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“Did you see the explosions?” the chaplain asked another Marine. “Yes, I was on the truck, sir,” the Marine answered. Again the Marines went silent, this time for almost a minute. “Does Brownfield’s family know yet?” I asked. “I don’t think so,” Sergeant Hernandez said. “I think the Red Cross is trying to get a hold of them.” “What about his fiancée?” Piedra asked. “Does she know?” “No, I don’t think so,” Sergeant Hernandez said. “Fuck.” “I know,” I said. “I know.” We sat quietly for a moment. A swamp cooler hummed above Piedra’s head. Outside the air burned. Piedra began to speak, but only sputtered a few words before Corporal O’Rourke, one of Brownfield’s closest friend, charged into the room, shoving the plywood door against the bulkhead, nearly knocking the rifles off their bolted wall mounts. Piedra, startled, lifted his head and saw Corporal O’Rourke standing beneath the door frame, his rifle and helmet in hand. O’Rourke was angry. His face was blushed. His boots and blouse were stained with speckled blood—Brownfield’s and Crosby’s blood. He was crying. “I just don’t get this fucking bullshit,” O’Rourke said, and threw his helmet at a carton of water bottles across the room. “I just don’t understand why this fucking bullshit has to happen to someone like Brownfield. I swear if I ever get my hands on the hajji fuckers who did this, I’m going to...fucking...kill someone—” O’Rourke stopped mid-sentence and stared at the naval chaplain, who sat on an empty rocket box with his hands folded between his legs. O’Rourke said nothing to the chaplain and instead slumped down beside Sergeant Hernandez and wiped his face on his sleeve. “Now, I know today is a hard day for everyone,” the chaplain said, “but we must remember that Corporal Brownfield enlisted to—” “—I just can’t believe this bullshit,” O’Rourke said. “I know, Corporal,” I said. “I was just talking to him before he

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took off….he was just coming off guard duty and he told me to make sure the radio was working.” Chaplain: “Brownfield was a—” “I just hope he didn’t feel that shit,” I muttered. “I hope he didn’t feel anything.” “I don’t think he did,” said Sergeant Hernandez, as he wrapped his arm around Corporal O’Rourke. “I hope so, sergeant,” O’Rourke muttered. “Brownie took shrapnel to the head. Probably died on impact. At least I hope so.” “God I hope so,” I said. “Remember, Marines,” the chaplain said, “remember that Corporal Brownfield died fighting for something he believed in. He believed in being here. He believed in being a Marine and fighting for his country. He believed in this war, and we can’t forget that. We have to try to move on now and continue with…” and as the chaplain glanced around the crowded room, his voice faded as he realized that no one was listening.

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Thirteen Ways of Looking at a Skeleton I A waxy skeleton Flickers an idea And invents matches. II Hanging above the ivy Are skull and crossbones. Where is the rest of the skeleton? III My poor old car, An oily executioner Cremated your skeleton. IV Skeleton Is a lackluster term For that which collects all our clutter. V Shivering dance, midair leap, They flutter into a crunchy heap, And leave behind A skeleton of time. VI I saw blood and flesh. He was glued flakes of dust and ash Gliding down snow-painted slides, His destiny lay in pieces. A skeleton if ever I saw one. VII Cute skeletons scamper Like hyenas, faces torn off In feast on Hallowâ&#x20AC;&#x2122;s Eve.

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VIII A vase of twelve red roses Decomposes, Revealing its ever-lasting glass skeleton. IX From skeleton to skeleton Wisdom lazily flows. One wears leaflets, The other, clothes. X You sniffed your pale nose yesterday At silt-faced serf who tilled your feast. Tomorrow he is that ivory skeleton for ten-thousand years; You are blackened soot. XI Behind heart, behind mind, There is no deeper meaning than The skeleton behind thine eyes. XII Possessed by poetry, I rearrange magic skeletons, My kaleidoscope to spy the worldâ&#x20AC;&#x2122;s chimeras. XIII When I chew the ocean, I eschew The skeleton of fishes. -James Wang

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Austin #8 Photograph

Peter Barish

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C/L surfing Adam Widman Sometime between getting thrown out of his living situation for violence and forgetting entirely who I was, Mr. Hagins promised to buy me an egg cream. “You’re a good one, doc. Me and you will sit down together. On me.” When Mr. Grudzyk didn’t like the way he was being treated he peed on the floor. The staff warned me to be cautious around Mr. Dias, put in restraints for agitated behavior. He was smiling widely when I walked in. His bed sheets were covered in chocolate ice cream. In the bustle of the hospital the med student is like a slap on bandaid for anyone who needs more attention. So it’s fun, to cruise the floors, walking in and out of patient rooms without the slightest idea of what to really expect. Because a “difficult” patient could be ruthlessly manipulative or just devoid of affect; a “threatening” one could be an 85-year-old with a smile on his face, eager to tell you childhood stories. The patients are as quirky as the city outside. My role is to chat with them. Not to give them therapy or insight into their disease, but to orient them to their surroundings, to let them complain, to make sure they’re not withdrawing wtih seizures, to give them some company while they’re stuck in bed. Mr. Rozin, a few days before respiratory failure prevailed in thick and grandiose fashion, told me through a mask he was ready to face death with courage and grace. Ms. Gourtley let me know of her new relationship with her body following major surgery for cancer. So yes, I’ll admit I’ll miss the psychiatry consultation liaison service, with its mix and match patients and their bag of tricks. The friendly and the fearful, the with-it and the not-quite. They’re a surprising group. The tearful are fat men, the angry are old ladies.

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There was Mr. Ross, weeping one minute about a manslaughter 25 years earlier and the next about his inability to find a date, even on the internet. Ms. Descente, pregnant, was worried sick that her father had placed a voodoo curse on her womb. My patients left or stayed at a moment’s notice. As a consultant, there is no attachment—not a floor to work on, or a nursing staff with blood techs, or clerks; no home base or steady stream of patients—so much so that the experience is a tinge ethereal. We don’t enter when the patient is admitted nor leave when he leaves. Few patients are waiting for our final order. Mr. Lewis walked the floors with a wide smile and his gown open in back; he liked to feel the breeze from below. 19-year-old Mr. Brogonov spent most of our interview juggling an imaginary soccer ball. And in the later weeks, when the sun had set and I sat at my computer to write a note, it became hard to imagine that there wasn’t some hint there, a peek into the future of our varied lives. The conversations show a lot about just how strange things can get.

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Giraffe in Serengeti National Park, Tanzania Photograph

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Lauren Stewart

June in Old Country Yard sales Are happening Wind sweeps Onto lawn Leaving debris That gets sold grab that pretty pink Seashell And plastic Ballerina Crank a knob and she Makes jangly sound Ballerina sound on bookshelf makes Remembering, fairies In young summers

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The pretty dancer. One further day Wind blows and Remembering of Old day storm, When Dancing on foreign Hills, in ballerina shoes And peasant dress Was dreamt. -Zebib Abraham

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Bat Country Photograph

Peter Barish

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The Layover William Cope Excerpt: Half an hour later Erick stepped onto the gangway leading to the domestic arrivals section of Vancouver airport. He was alone. Airports confused Erick and he never failed to get lost. He hated their constantly branching corridors and multiple terminals separated by enormous distances. He hated how everything looked the same, so when he did get lost, he didn’t realize it until he’d walked for half an hour in the wrong direction. But mostly he hated airports because no one else seemed to be having any trouble at all. The mass of people around him strode confidently from place to place, while he pinballed from one information booth to the next. It was humiliating. But today he didn’t care. When he reached the end of the gangway he didn’t even look for signage to the international terminal. He turned left out of gate 46 and started walking. The busy airport noises faded away and the people passing him on each side melded together into one big mishmash of dull colors. He didn’t have a clue where he was going, and it didn’t matter. With six hours to waste, he could afford to lap the entire airport a few times. By then maybe his heart would stop beating like he’d just missed being run over by a bus. He needed something to distract himself with, something to make him forget the face that was playing in his mind on a constant loop, something to forget those green eyes that where too large and yet just perfect at the same time. Erick switched out of autopilot when a toddler moved into his path and stopped to investigate something stuck to the floor. He swerved sharply and knocked into a tall man dressed in a business suit. The kid lost interest and wandered back to his mother, who mouthed “sorry” and continued on in the opposite direction. Erick stopped to get his bearings. He was walking down a vast corridor, which appeared to come to an end in a few hundred feet. There was a long row of counters to his right, each with a different airline’s

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name and symbol above, and straight ahead where the corridor split open, there was a food court to one side and a large green sculpture on the other. Just past the food court, an enormous sign hung from the ceiling. It read: International Arrivals. He made his way to the sculpture—a bronze boat overflowing with First Nation’s mythology, called The spirit of Haida Gwaii—and read the sign again. It still said International Arrivals. A smile crept onto his face. He’d managed to get exactly where he needed in less than ten minutes, a new record, to be sure. Erick turned away from the sculpture and walked to the food court. He wasn’t hungry, but food was a good distraction. As it turned out, choosing what to eat was the real distraction; his stomach felt like a bowl of rotting hamburger helper, so nothing looked good. He moved from one place to the next then back again for the better part of ten minutes before finally settling for a pizza joint with a cheap by-the-slice option. Then he found a table with a few abandoned newspapers and settled in. He wanted to lean back and close his eyes, but he forced himself to pick up a newspaper. It was useless. He tried digging into a few articles but gave up almost immediately; by the end of the first sentence, his mind would start wandering like a dog off its leash. All week he had envisioned himself coolly relaxing in the airport, eating the shit food he never allowed himself, and generally shutting his brain off for the day, something he didn’t indulge in very often either. Instead, here he was, not enjoying the shit food, stressed to the maximum over some girl he met on a plane. He threw down his now-cold, half eaten slice of pizza, closed his eyes and allowed himself to replay his final few seconds with Laura in his mind. They couldn’t have gone much worse. •••

Laura unbuckled and leaned up to the little round window. The clouds which had so taken her attention earlier on were nowhere to be seen, swallowed as they were by the deep blue Vancouver sky and spat up somewhere over Alberta. The captain mentioned something about a heat wave on the intercom. “I’m starting to think I should just stay here,” she said, face glued to the window. “It looks gorgeous.”

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You look gorgeous, Erick thought as he unbuckled himself and reached for his briefcase. Personally he wasn’t that impressed with Vancouver as he saw it through this five inch glass window. The blue sky was nice, but other than that, it looked the same as every other airport he’d ever been to. If there was anything he’d learned about Laura over the last few hours, it was her unfaltering optimism, even in spite of her scathing sarcasm. He pulled the briefcase onto his lap and turned to Laura, waiting for the right words to come to him, words that would show how he’d gladly spend another two hours cramped in the back of this plane listening to screaming toddlers and eating overpriced packages of peanuts if it meant he could spend even another five minutes with her. But they never came. He told her Vancouver looked “just great!” and moved into the isle with the rest of the passengers. She stood up in her seat but didn’t follow him any further. “I’m going to wait for everyone else to leave,” she said. “Oh?” “My purse is still in seat 21A, and I’m not eager to meet Mr. 21B again.” Then, more to herself than Erick, she added: “I checked in everything else.” “Oh.” I’ve been reduced to single syllables, he thought miserably. The line started moving. Erick grasped for something worthy to say but came up empty handed. Laura filled the void. “Well, thank you so very much for saving me from a potentially disastrous flight with the man in 21B.” She paused. “That sounds like the title of a bad horror movie doesn’t it? The Man In 21B...Coming soon to a theatre near you!” Erick tried to laugh, but all that came out was a garbled hiccup. His normal social grace was out the window, replaced by something foreign and awkward. A malignant thought was clamping down on his windpipe and slowing every neural highway like a ten car pileup. Don’t let her go, Erick. Don’t let her go.

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She moved closer—close enough to see light freckles showing through her dark skin—and said: “I’m glad we met.” Her final words were generic, but the smile that crept onto her face was anything but. Something lay hidden in that smile. But he’d only stared blankly at her and said: “Likewise.” Then he turned away and let the throng of anxious passengers sweep him towards the front of the plane. He ached to look back at her every inch of the way, even if just for a split second, but forced himself not to. A real man never looks back. Bullshit. A real man would say what’s on his mind. A real man would also come up with better parting words than “Likewise.” •••

Erick scooped up his half eaten slice of pizza and slammed it through the swinging flap on the garbage can next to his table. He sat back down, flipped open his cell phone and turned it on. He had three missed calls and a text message. The text was from one of the post docs that worked part time in his lab. It was time stamped to three hours ago. “Call ASAP. Big problems.” Erick leaned back and closed his eyes. Big problems. Fuck. Five hours out of Toronto and shit had already hit the fan. He started dialling, and then promptly snapped the phone closed. Not now. It’s been three hours already, he can wait a few more. He slid the phone into his jacket pocket and stood up to look around. A small crowd of Asians had congregated around the The spirit of Haida Gwaii and were taking the obligatory group photos. He contemplated doing the same, but his camera was nearly out of batteries and using his last few shots up on this odd sculpture seemed wrong. He turned away from the sculpture and scanned the row of shops that lined the nearest corridor to the food court. From his position, he could see a gift store, a shop called Roots, and a bookstore. He had no interest in buying a miniature totem pole or an overpriced tee-shirt with a Canadian Moose on it, but he could do with a good book.

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Ten minutes later, Erick found himself staring into the pages of some novel he’d already forgotten the title of, eyes unfocused. Her face was playing silently on the great screen in his mind, and he couldn’t help but sit back and watch. He put the book back on the shelf and wandered to the far end of the store. A short man with big glasses and even bigger eyebrows was arguing with his wife and losing. He was explaining the idiocy of buying a fortyfour dollar hardcover when the paperback was sure to be published any second, while she explained that she didn’t care. The conflict was escalating and more than a few of the other people in the store were watching. Erick decided to grant them some form of privacy and turned away to scan the shelf in front of him for something decent. He eventually settled on the new Steve Jobs autobiography. It was a hefty book, and when Mr. Eyebrow’s wife took her displeasure to a new level with a blood curdling scream of frustration, Erick jumped and it slipped from his hands. He bent over to pick it up, but someone else got there first. “It’s a good read,” said a familiar voice. Erick straightened up. Laura stood in front of him, flipping through the pages. She snapped it closed and held it out to him. “Too bad it’s hardcover. I hear they’re very overpriced.” “You.” Erick said clumsily. She smiled that perfect smile of hers and said: “Yes, me.” He took the book from her and placed it back on the shelf. “I didn’t think I’d see you again.” “And why would you think that?” “It’s a big airport.” “Yes, but it’s a very small world.” Erick laughed. “It certainly is.” After a moment’s pause, he said: “I’m glad we crossed paths again.” She smirked. “Likewise.”

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Main Street Photograph

Eleanor Woodward

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partners Falstaff, Lohengrin, TS Eliot, Jacques Brel stacked, surrounding the pull-out couch in the frigid fifth-floor studio where they lay swaddled in ratty blankets with a DNR taped on the mirror above the bed. nebulizer, commode surrounded by VHS operas lovingly labeled, the accessories of different lives: cognac and Judy Garland, now Ensure and ginger ale. i can’t read or listen anymore, i’ve no interest, it’s television and hydrocodone that get me through side by side they huddle and lay, Paul keeps Eric warm. he doesn’t mind the cold window: there’s a facsimile of fresh air. in the kitchen, near the Kerlix, movie star posters and the tiny stove they use to keep warm, there’s a photo hanging near the doorjamb. side by side, they pose from another time camping somewhere years ago. -Tiffani McDonough, MD

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Time Flies Photograph

Ali Mendelson

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To My Left Anne Herbert I walk down the airplane aisle, searching. Scanning the rows, my eyes finally fall on 15A. My seat. My nightmare. A window seat means only one thing to me: someone to my left. A man, to be exact--middle-aged, reading the New York Times and snacking on a bag of peanuts. He doesn’t notice as I shove my purse under my seat and sink into my chair. My only thoughts are of blending in—with the other passengers, with the chair, with the plane itself. Anything. My objective on this five-hour flight is simple and clear. It’s the same one that I cling to almost every second of every day: to keep my left side hidden from the world. Everyone has their good side—a more photogenic side, a certain way that they turn when taking pictures. I don’t have a good side, but rather a “less bad” side—a side whose mere completeness is what appeals to me. My left side charts the history of my birth defect. The scar under my nose records the surgery that closed my cleft lip. The scar on my hip commemorates a bone-marrow transfer from hip to mouth in second grade. My severe underbite is an orthodontic byproduct of my cleft lip and palate. After a moment of going unnoticed, I feel the man staring at my scar. The stare digs into me, and I squirm. In his eyes, my body has suddenly disappeared. All that’s left is my profile, begging for scrutiny. Nose, complete with scar; bottom lip jutting out farther than the top. A damaged silhouette. Not like the beautiful black silhouettes you see in frames in your grandmother’s house. Not even like Alfred Hitchcock’s portly outline—at least he is whole, unblemished. The man to my left starts the airplane chat that everyone dreads. I don’t want to answer, but I know that if I don’t turn to him, he will end up staring directly at my left side.

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If only I could show him a good side—present a better face to the world. My anxious hyperawareness never fades. No matter which way I turn, someone is always to my left. The story above captures a time in my life when my appearance dominated my thoughts. I was born with a cleft lip. I can’t remember a time when I didn’t have the scar under my left nostril. The very first operation, to close my cleft lip, took place when I was six months old. The scar was never of much consequence to me when I was very young. Sure, I didn’t like having countless appointments with my orthodontist and surgeon, but I honestly thought that this was what all kids had to do. My parents never made it seem unusual. To this day, my mom says that she counts herself lucky: although both of her children were born with minor birth defects, they didn’t have any lifethreatening complications or truly debilitating health issues. I constantly strive to hold onto that outlook myself. Inevitably, school was the place where I began to understand that my scars made me different. Don’t get me wrong: even there, I was lucky. I always had friends, and I was never picked last for kickball. But children are honest to a fault. I became a master of evasion: I spent my youth skirting questions about my cleft lip— “What is that under your nose?”—that no adult would have the audacity to ask. In second grade, when I starting wearing a retainer, a classmate incessantly asked, “What is that? Why do you have it? Can you take it out? Can I see it?” She meant no harm, but it brought me attention that I in no way wanted. In fifth grade, a boy notorious for bullying asked me if a dog had bitten me in the face. Even though I knew he was a jerk, his words stung. In high school, when one or two friends asked about the bone-graft scar on my hip, I made up a story about getting scraped by a fence when I was little. If you saw my obviously surgical scar, you’d understand how ridiculous that lie was. It would seem that after two decades of acquaintance, my scars

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and I should have worked out our differences—perhaps even become chummy. You know, like when women who used to hate their curly hair embrace it and stop the daily blow-dry; or when the formerly embarrassing gap between someone’s teeth becomes something “special” and “unique.” But this magical transformation hasn’t been possible for me. My scars are a reminder of hard nights spent in the hospital. Of stitches being slowly, painstakingly pulled out by my surgeon. Of the six-week liquid diet I endured after my jaw surgery. So I still dislike my scars, and I certainly wish I didn’t have them. The most I’ve been able to do is to gradually work out a truce. I realize that, like it or not, we’re in a lifelong relationship, and after years of fighting, I want to make peace. So although I know that my scars will always be with me, I no longer let them monopolize my thoughts and actions. Nowadays on my frequent trips from New York to California, I often sit in the window seat. I can go whole days without wondering, “Who’s looking at my scar?” If a good friend asks me about it, I tell the truth. I even got up in front of sixty people during a public-health presentation and told them how I’d been born with a cleft lip and palate. We talked about organizations like The Smile Train, which sends medical missions to perform cleft surgery in developing countries. No longer am I the master of evasion. Now I look straight at myself--and I let others look, too. And that is liberating. Originally published in Pulse – Voices From the Heart of Medicine.

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Tent Rocks Photograph

Jackie Estes

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Taos Photograph

Jackie Estes

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The CCU Lisa Noble Stepping into Scripps Memorial, I was transported back into a former life, a former role. I didn’t enter the hospital in business casual with a white coat, a growing certainty and confidence, or preparation—quite the opposite. The barrier, the imaginary wall, separating the roles and rules of being a new initiate in the medical community to the experience of being a patient’s family member in the cardiac care unit had been more drastic than expected. Yet what an easy line it was to cross. The most interaction my family and I experienced with the intensivist, a specialty I have never heard of before, was in our arrival that first afternoon, at the most crucial stage. I had gravely underestimated how complicated my father’s condition was. My dad’s colleague, Dr. I, who also happens to be an intensivist elsewhere, joined us for our sake and his own. He was intent in his introduction to the intensivist, Dr. B, most likely to ensure he was treated as a colleague and given the information he wanted to know. I introduced myself as the daughter, and a first year medical student at Cornell. The information Dr. B revealed was certainly more than she would have if Dr. I wasn’t present—the details of his aspiration and septic shock maybe, but certainly not his elevated glucose, or lactic acid levels. It was clear she had a script, a manner of delivering such grave news. Worry was in her voice and in her prose, she promised nothing, and spoke nothing of a road to improvement. She clarified that my dad would be in the CCU for at least 2 weeks if not longer. I can’t say how long she spent with us, but it felt brief. I was overwhelmed by how severe the situation was, and moreover, how little I understood about what was happening. I had to sit down when she got to septic shock. I was trying to put it all together, but all that stood out were “septic shock, liver and kidney functioning well,” and no positive words.

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In contrast, later in the waiting room, Dr. I explained to us with graceful encouragement how everything Dr. B. said was related, and what the milestones to Dad’s recovery would be. He was calm, and encouraged us that time would be the biggest factor in his recovery, and his numbers looked good so far. He gave me the time to ask why his glucose was elevated, and whether they’re not feeding him because of that. When he left I felt more assured, at least enough to keep me going until the next update. I admire how his professional composure never flickered. Dr. I hugged my mom, but shook my hand, and told us he’d be back the next day. The contrast between my encounters with Dr. B and Dr. I is intriguing to me. Was Dr. B’s worrisome attitude an expression of compassion and acknowledgement of her responsibility? Or was it emotion, or a tactic for breaking such news, ensuring that we understood how severe the situation was? Because maybe it’s that many of her patients pass away out of her control—maybe she knows she can’t promise such good news. At least two patients in the CCU were gone without any clear improvement the first week we were there. The burden of her responsibility hit me too—it was a stark reality check from taking a medical history for a recurrent ear infection, as was typical in my preceptorship. Partly it may come down to personality, or that Dr. I is a friend and knew us, and felt significantly connected. Of course my response to her rapport was unique as well. I wanted a physician to walk into the room with confidence, clarity, and a plan. There was no way she could have known this. I never saw Dr. B again—there were constant rumors from the nurses that she would be coming around soon. We were in the CCU at least twice a day everyday; I grew very anxious to see her and frustrated. I wanted her opinion on his progression; I wanted her to approve extubation ASAP so my dad could be relieved of the tubes down his throat as he awoke from sedation. It was the respiratory therapist and nurse who knew my dad was ready— they fought for her attention: a several minute phone call for her approval, and fifteen minutes later, we could have a conversation with my dad for the first time in a week and a half.

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Her unavailability gave me the impression that she was not involved, even though she was running the show. But how many patients does she have everyday that are more critical than my dad? Dr. B was there in the primary and most critical stages of my dadâ&#x20AC;&#x2122;s aspirations, she removed the contaminants, put him on antibiotics, performed bronchoscopies, and monitored his condition closely while I tried to get to the west coast. I am grateful, but I think I feel less so because I am entering her profession. She did her job and ensured my dad had a full recovery. But I wanted more out of her. I had expected to see her more than once, have her run lab values, updates, and a project plan of recovery by usâ&#x20AC;&#x201D;but the ICU runs day by day, and hour by hour. Maybe I canâ&#x20AC;&#x2122;t cross back to just the role of patient. The height of my expectations will always apply to my family and friends, and ideally to all patients and their families whose care I observe. I have crossed the wall.

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Rabbit Charcoal on paper

Lillian Lewis

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Florida Sunset Photograph

Elizabeth DuPre

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Untitled Sunlight slips through slits in the blinds A spotlight On elegant geishas beaming down from the wall Golden statues of Buddha glow Below an “immense yellow lantern” Casting shadows on a café terrace at night Globes display countries traveled Paths taken Oceans crossed Shelves overflow with pages read The Lost City of Z Catch Me if You Can All distract From the pale plaid Fading floral Potted plants with browning leaves Last year’s candy canes Forgotten in the clutter A discman Despite requests for silence Smiling faces from the past When he was a much bigger man The last time they were happy You can see Where life led them Where their lives stopped -Ali Mendelson

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Awe Misha Pangasa These months on medicine have transformed me, but as I reflect back to decipher the story, the patient, the conversation that changed everything, all the particulars just blur together. This isn’t to say I haven’t had that patient who moved me, whose story I’ll never forget, whose face I’ll always see. But my experience these last several weeks has been a selfish one, of self-discovery and identity building—a crisis of confidence that peaked and persisted, but brought with it a newfound contentment. You see, I left high school ready to set the world ablaze. Wideeyed and self-assured, I fit the “big fish in a small pond” stereotype to the T. I’d grown accustomed to accolades; being at the front of the pack had become familiar territory. The setting of college certainly shook my ground a bit, but I swiftly regained my footing and enjoyed a summa cum laude status once again. Medical school was a different kind of battle. Amongst the marathon runners, the well-read and world-traveled, the photographers and musicians, the fashionistas and the comedians, the prodigies and the politically adept, the inferiority complex I developed here was a new one. It was deeper and more profound, and it reached further into my psyche, making me question everything I thought about myself in a “I’ll never be good enough” kind of way. I masqueraded as someone who deserved to be here, but only if I stood in the middle of the pack, maybe even the back. Standing out was for others, and I had carved myself a nice little niche in that corner, just listening, just observing. It wasn’t my place to lead here, the forefront was no longer familiar territory—I didn’t feel I had the voice for it. Unsettling as that was, I found a quiet sense of grace in this new space of mine. And when I finally allowed the claws of competition so deeply rooted in this world of ours to loosen their grasp, it stopped mattering anymore that I hadn’t found my own voice.

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Because I so enjoyed listening to theirs. To my colleagues, singing the tales of their patient’s triumphs and defeats. To my peers, spouting on about the need for advocacy and reform. To my friends, who hum a never ending tune of how to make the world a better place. And to my seniors, whose melodies of patient care and pathophysiology get stuck in your head and never leave for years to come. I’ve yet to understand how someone sitting in an office perusing through applications decided I could be their peer, and it’s unclear to me whether that inferiority complex will be a permanent fixture in the portrait I paint of myself, but it doesn’t sting the way it used to. In inferiority, I found awe. And in awe, the greatest inspiration. I may never again find myself at the front of the line or hear my voice bounding above the rest, but I have the privilege of being surrounded by greatness. To pontificate about the past, present, and future of medicine with the scholarly elite. To laugh and cry and drink and dance with those who’ve dedicated their lives to the service of others. Who’ve signed up for the grit and the gruel with the promise of intellectual inquiry. These past few months have granted me the privilege of participating in so many encounters—intellectual relationships and vulnerable exchanges, moments of the “I-can’t-even-fathom” kind of humility, and a new “how-could-I-be-any-luckier” kind of pride.

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The Cardiac Cycle SYSTOLE The doctor confessed rather tristally, “Your case has unraveled quite twistally, Though my hearing’s acute The stethoscope’s mute. I’m afraid your poor heart has no systole.” DIASTOLE The mitral valve’s murmuring nastily And the ECG pattern is ghastly The T wave’s inverted QRS is perverted. It’s a case of impending diastole. -Lawrence Palmer, PhD

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Kenny the Kidney Graphite on paper

Genevieve Chartrand

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Resignation Charcoal on paper

Daniel Hegg

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The Interred Jonathan Huggins When, in 1685, the French monk, Bernard de Montfaucon, came across an ancient human skull with a plug of bone removed from the cranium, not much was made of his discovery. It was supposed that the defect was the result of a fatal battle wound, or perhaps evidence of some long-forgotten funeral rite. But what these early archeologists did not consider was that the opening was the product of a long-ago-established, but still-performed sort of “brain surgery” called trepanation (from the Greek trūpān meaning to bore). It was not until an American archeologist, Ephraim George Squier, made a similar discovery in Peru, that this surgical explanation assumed its appropriate weight. Squier, born in Albany County, New York in 1821, was a journalist with a background in civil engineering who, after a move to Chillicothe, Ohio, developed an interest in the ancient Indian burial mounds in the surrounding area. Along with some archeologically-inclined colleagues, Squire published extensively on these troves of excavatory delight gaining substantial notoriety in the nascent American anthropologic and archeological communities. When he was appointed Member, Mixed Commission under Claims Convention of January 12th, 1863, between the United States and Peru by Abraham Lincoln, Squier took advantage of his translocation and began to investigate a hypothesized (but later disproved) link between the North American burial mounds and the ancient Indian civilizations of South America. It was on this commission that Squire was invited to explore another (cushier) mound of ancient artifacts, the home of Señora Zentino, a wealthy Peruvian socialite. There Squire reopened the book on Montfaucon’s then centuries-old discovery. Among the members of Zentino’s collection was a small Incan frontal bone fragment with four intersecting grooves etched into its petrifying surface. The square space outlined by these furrows

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had been pried out to form an opening into the interior of the cranial vault. Squire also noted what he believed to be new bone creeping inward from the edges of the defect, nature’s attempt at resealing the aperture. In effect, Squier, with these observations, was arriving at two rather controversial conclusions. First, that the cranial defect was the intended result of surgical intervention by a “savage” people at a time during which the “intellectually superior” Europeans were mired in the desolate scientific landscape of the Dark Ages. And second that, on the basis of the new bone growth, at least some of the long-gone owners of these trepanned skulls had survived the procedure. In other words, these ancient Incan surgeons were—to some degree at least—good at what they did. As a student of science I am well acquainted with Squier’s struggle for understanding. Successfully navigating vast bodies of knowledge like the sciences and history—mentally lassoing their complexities—can appear an insurmountable feat of intellectual contortion. As a chemistry major, I was incessantly dogged by a sense that nature would eternally elude my mind’s grip. That feeling is what makes these fields difficult, but also what makes them exhilarating. I often found myself in the throes of quantum mechanical derivations feeling overwhelmed, tangled in our imperfect mathematical renderings of nature (not to mention my own imperfect renderings of the mathematics). But in those same moments I found myself in an exotic and seldom explored landscape, privileged to have made it as far as I had. For all the frustration and browbeating, I have found that there is great honor in humility. Just as archeology and chemistry can leave us stranded, at once eager, overwhelmed and proud to have made the journey at all, so too does medicine. But in medicine, I often find myself marooned in the ocean of what we might call the human experience, the tempest of emotion and internal forces that we have endeavored to brave for millenia. •••

Sharon Baird was the first patient I was asked to follow in my third year of medical school. When I met her she was 72 years old

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and on the losing end of a long battle with uterine cancer. Since her cancer was diagnosed years prior, some of the malignant cells had come unanchored from their site of origin and were set adrift in her abdominal cavity. More recently, these wayward cells had come to rest in her liver, multiplying to form tumorous nodules, and along the lining of her intestines swallowing the local nerve networks like kudzu. The liver metastases were impinging on the vascular piping in the area causing fluid to seep out of her veins and into her abdomen, forcing it to balloon outward. That fluid, along with the disruption of the nerves that enable intestinal muscle contraction had shut down her gastrointestinal tract, preventing her from eating without later vomiting. In short, Ms. Baird was dying. And like many of the dying people I have come to know, she had been beached on a foreign shore, and set about survival with a difficult-to-fathom practicality— subsisting on the small victories the day to day undulations in her condition had to offer while she let the less digestible facts accumulate to reach their inevitable conclusion. But investing hope in promising lab results or the effects of medication is easy and comes naturally; it is tempering that hope—acknowledging the unpleasant reality of one’s demise—that truly challenges us. More than simple acceptance of unfortunate facts, this requires a shift in focus from the impact one may still have to the legacy he may leave behind, a sort of migration from an understanding of the self as a free-standing structure to one made clear in relief. And because gravity is incomprehensible independent of the observation of objects under its influence, it is impossible to die well alone. Another patient of mine, Jerry, upon hearing about his own metastatic cancer, closed his eyes, inhaled deeply and then quietly whispered to himself, “One step at a time, one step at a time.” This mantra preserved Jerry from one day to the next as he made his way down an assembly line of diagnostic tests, but it was not until his sister assumed a permanent place at his bedside that he could, over vanilla ice cream and episodes of Jeopardy!, take his first side-long glances at his grim prognosis.

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Among Ms. Baird’s orbiting bodies were her two grandchildren whom she loved dearly, her son and her husband. Mr. Baird, though he sat anxiously at his wife’s bedside, diligently transcribing and then paraphrasing the plans imparted by her doctors, did not, could not, ride the daily tides of her illness with her. After all, it was not his nose being regularly invaded by stomach draining tubes or his swollen abdomen being pierced with fluid draining syringes. In this sense Mr. Baird’s role is a difficult one. His wife, certainly, had the challenge of negotiating these ups and downs, but the landscape was, through her own senses and emotions, apparent to her. Mr. Baird, on the other hand, was navigating a changing landscape with his eyes closed. For the most part, Mr. Baird maintained his balance well; he sharpened the focus on winnable battles leaving the more perilous ones blurred in the background. But while he helped amplify the more promising aspects of his wife’s hospital course, Mr. Baird could not bring himself to allow room for temperance. As many of us are encouraged to believe, he assumed that he was helping his wife through an illness. That plagued preposition that promises re-emergence spells treachery for the loved-ones of the dying; it charges them with a role akin to a guide over rough terrain toward more hospitable country beyond. Truly though, the patient is shipwrecked, and it is impossible to make a home of a strange place if your fellow castaways will not acknowledge the lay of the land. Like Mr. Baird, and like the equation-deriving iterations of myself, I found my surroundings incredibly daunting. Here again, I was asked to make sense of something that felt too big to understand. The delicate balance between the patient’s self-reflective endeavor and the role of the family and friends as conduit leaves little room for the healthcare worker; how does the medical practitioner position himself to at once offer intervention and at the same time avoid interference? For an aspiring physician this question is both profoundly important and profoundly frustrating. The doctor’s niche is so small, so amorphous and so nuanced that our forbearers have struggled with making it habitable for thousands of years.

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The New York Times recently ran an article on the 2009 discovery of a 4000-year-old human burial site in northern Vietnam. Among those interred there was a young boy, about ten-yearsold, crumpled into a fetal position. Archeologists inferred that his positioning was secondary to a congenital defect which left his vertebrae fused and his extremities useless. During his life, he would have been unable to care for himself, but nonetheless, he survived for nearly a decade. In these remains, and in others like them, we find the roots of human compassion, the key to the doctor’s niche. It is this intrinsic human capacity for assuming the suffering of others that compelled this boy’s family to accommodate his needs, and it is from this quality that the institution of healthcare arose. But compassion (from the Latin com—together, and pati—to suffer) by definition implies that those propelled by it also—whether out of true emotional anguish or as a result of intellectual extrapolation from observations—experience suffering by virtue of being a witness to it. In this way, the idea of compassionate action assumes an almost selfish character; while we work to heal the afflictions of others, we are also, to some degree, attempting to silence a personal form of torment. It is an imbalance in action favoring alleviation of our own compassionate suffering that characterizes the pitfalls of healthcare provision. And like the more salubrious compassionate acts, evidence of excessive compassion has been documented in the fossil record. On the Arabian Peninsula the skeleton of an eighteen-year-old woman was unearthed and found to have signs of a crippling neuromuscular disease. Strangely, though, the discoverers noted that the woman’s oral hygiene was remarkably poor for such a young person. The abundant cavities and evidence of periodontal disease is now believed to be the result of her well-meaning careproviders feeding her too many sweet and gooey dates to alleviate her suffering. With these examples in mind, we may begin to triangulate the positioning of the physician in medicine in general, and in the care of the dying in particular. Ever cognizant of its size and

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fragility, we may begin delineating that niche somewhere between the compulsion to take action, and the drive toward excessive benevolence. It is the job of the physician and medicine at large to receive the patient and establish the terms for seeking comfort in an alien landscape—a landscape that none of us can hope to ever fully map out—without clouding the true shape of the horizon. Back to the skulls.

•••

Upon making his discovery, Squier, his colleagues, the multitude of American medical societies and even Paul Broca, the famed physician-anthropologist, marveled at how advanced the surgical practices of an ancient society had become. In particular, Broca was impressed by the apparent diagnostic prowess of the Incan physicians. But the enthusiasm seems misplaced. In the overall narrative of Ms. Baird’s final months—the adversity she and her family had encountered, my own struggle to integrate myself into the fray—the action we took medically seems trivial. To place emphasis on technique and diagnosis without acknowledging the clues these artifacts give us about what compels us to act on another’s behalf or dangers of excessive action, is to miss the forest for the trees. I was surprised to realize that I had, in all the years since I had first been (with a boyish predisposition for the grotesque) fascinated by textbook pictures of trepanned South American skulls, never once considered the human forces that would drive the individual or his family to endure what was a very painful, risky and frankly horrific procedure or what obliged the surgeon to act. I do not know the answers to these questions in this particular case, perhaps they had to do with compassion or perverse incentives, but either way, I find their consideration, not the impressive surgical technique, what really ties me to these thousand-year-old fragments of bone, and what informs my own attempts to comprehend, or at least appreciate the nature of my daily struggle. These observations may seem like intellectual knick-knacks, but in hospitals, institutions built around altruism, it is too easy to put aside the human challenges we face and to focus instead on the relatively simple ones that science lays before us. There are

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trepanned skulls housed in museums around the world with as many as twenty bore holes in their surfaces. How can we stand before these specimens and not see our own daily predicament reflected? Here is the physical manifestation of the physician seduced by the dynamic nature of medical science, entranced by its potential to heal, or more likely awash in our intrinsic compulsion to offer promises to people thirsty for false hope only to forget, or to conveniently put aside, the delicate fundamentals of human dynamics. I feel it every day; how many times I have spoken with Jerry feeling the desire well up inside of me to tell him that he will be okay, that he will soon play piano and sing again, that the chemotherapy will shrink his cancer into remission knowing that these are convenient lies that will, if anything, make the emotional face of his disease more formidable. And what disdain I feel when he can no longer tolerate the medicationsâ&#x20AC;&#x2122; side effects, when we have to tell him there will be yet more, different medications, more debilitating side effects. Riding these waves is easy and distributing ever larger shares of hope among ever fewer medical alternatives comes naturally to us as human beings. I cannot imagine that I would ever feel any differently. I cannot imagine that it will ever feel natural to step calmly aside, to feel comfortable in a place cold and unfamiliar. But to be a doctor, to grow to fill the niche, is to tell myself that all of these urges, these compulsions that I feel as sure as my bones are just too many dates.

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Snow Over Weill Photograph

Jordan Roberts

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