ASCENSUS : Journal of Humanities at Weill Cornell Medical College Vol. 4

Weill Cornell Medical College Journal of Humanities

volume iv 2015

Ascensus Journal of Humanities Volume IV August 2015 • Weill Cornell Medical College

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Editors: Aaron Oswald, ’18 Elen Gusman, ’18 Michelle Lee, ’18 Peter Hung, ’18 Associate Editors: Natasha Mehta, ’16 Rachael Venn, ’16 Faculty Advisors: Susan Ball, MD Randi Diamond, MD Cover Design by Elen Gusman.

Table of Contents Artwork by Susan Ball, MD. Layout by Peter Hung.

Contact us at wcmc.lit@gmail.com.

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 Scencies in Clinical Training.”

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To Our Readers: Communicating well and developing emotional connections with patients not only leads to better outcomes, but also enriches the experience of the patient and the provider. Cultivating these humanistic habits in our medical practices requires more than just respect and tact; as members of the medical community, we can propel ourselves toward that ideal by embracing the humanities.

In medicine, we come across the full range of human experience— pain, grief, hope, love—within four stark walls. It is in that space where we diagnose and prognosticate but also stumble, learn, and react to the people we meet. The sustenance of artists is ours too. Humanism is just as intimately involved in our profession, in what we see and practice daily, as in theirs. By reflecting on our experiences through art, we gain a better understanding of our patients and, in turn, of ourselves.

Many of the pieces you'll read in the fourth edition of Ascensus are just that—reflections on clinical situations at the hands of skilled writers and poets. Other works transcend the hospital environment and focus more on the lives of the individuals that make it such a rich space. We hope that this collection will give our readers insight into the subtle moments, and some of the uncertainties, hopes, and wonders of human experience.

— Aaron Oswald, Elen Gusman, Michelle Lee, and Peter Hung

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Table of Contents Chief Complaint

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Coping Chaos

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Three Reasons Medical Students Should Read Poems

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Physics

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On Adequacy

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Peter Hung | MD Student, Class of 2018 Prose Lara Wahlberg, DNP, RN, OCN | Registered Nurse, Medical Oncology Pastel on Paper Tony Sun | MD-PhD Student, Entering Class of 2014 Prose Lindsay Smith | MD Student, Class of 2018 Photographs Mary Simmerling, PhD | Asst. Professor of Research Integrity, Dept. of Medicine Poem

Fire

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No Events Overnight

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Untitled

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A Body to Serve Others

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Legs

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Tour of the Cranium

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Peter Hung | MD Student, Class of 2018 Photograph Jack Levy | MD Student, Class of 2016 Prose, Sketch Evan O’Dea | MD Student, Class of 2017 Cut Paper Natalie Wong | MD Student, Class of 2018 Prose Liana Greer | MD Student, Class of 2018 Chalk Drawing Sarah Schrader | MD-PhD Student, Entering Class of 2014 Pencil Drawing

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Visual Art and the Frontal Lobes

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Faith

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Window Shopping

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The Little Dancer

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Axis of Growth

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We Were Children Once

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Stone Soup

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After Work

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Untitled

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Pro Re Nata

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Winter Storm

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Tuning Attention and Focusing on the Moment

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Matthew Schelke | MD Student, Class of 2017 Prose Aaron Oswald | MD Student, Class of 2018 Poem Marta Dzyadyk | MD Student, Class of 2018 Photograph Alexandra Berman | MD Student, Class of 2018 Photographs Lawrence Palmer, PhD | Professor, Department of Physiology and Biophysics Limericks Jeffrey Russ, PhD | MD-PhD Student, Entering Class of 2008 Prose Natalie Wong | MD Student, Class of 2018 Oil on Board Samuel Woodworth | MD Student, Class of 2016 Poem Kim Overby, MD MBE | Associate Professor, Division of Medical Ethics Oil Pastel Collage on Paper Nicholas Maston | MD Student, Class of 2016 Prose Lia S. Logio, MD | Professor, Department of Internal Medicine Photograph Peng Kate Gao | Neuroscience Graduate Program Prose

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My Empire State

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Healer, Doer, Mover, Shaker

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Art that Smells Good

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A Physician Travels and Observes

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Le Catedral

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Innocence Abroad

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Tigers After the Circus

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Elephant Butt

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Comfortable

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Mountain Goats

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Descartes in Medicine

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Four Days of Thawing

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Elen Gusman | MD Student, Class of 2018 Photograph Neal Parikh, MD | PGY3, Neurology Poem Priyanka Vijay | PhD Student Candle wax, acrylic, and magazine paper on cardboard Paul Miskovitz, MD | Clinical Professor of Medicine, Department of Medicine Prose Natalie Wong | MD Student, Class of 2018 Watercolor and Pen on Paper Jonathan Huggins, MD | PGY2, Internal Medicine Prose Sam Jones | MD Student, Class of 2018 Photograph Priyanka Vijay | PhD Student Oil on Canvas Courtney Haviland | MD Student, Class of 2016 Prose Sam Jones | MD Student, Class of 2018 Photograph John Moon | Research Technician Poem Peter Hung | MD Student, Class of 2018 Photograph Composite

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The Eternal Exile

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Dog Sledding in White River National Forest

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Cousin Fred and the Laws of Thermodynamics

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Montmarte

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Dimples

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June

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What is the Hospital for?

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Brooklyn Bridge

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Fighting for his Life

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Fall n Angel

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Memory

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Hope Is, Hope Ebbs, Hope Surges

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Benet Pera-Gresely, PhD | Postdoctoral Associate, Medicine Prose Anthony J. Choi Photograph

Jeffrey Fisher, MD | Clinical Professor of Medicine, Department of Medicine Prose Scott Breitinger | MD Student, Class of 2015 Oil on Canvas Lara Wahlberg, DNP, RN, OCN | Registered Nurse, Medical Oncology Poem Elen Gusman | MD Student, Class of 2018 Photograph Caroline Pinke | MD Student, Class of 2016 Prose Yoshiko Toyoda | MD Student, Class of 2018 Photograph Ngozi Monu, PhD | MD Student, Class of 2018 Poem Elizabeth DuPre | MD Student, Class of 2016 Photograph Fabiana Kreines | MD Student, Class of 2018 Prose Madeleine Schachter, JD | Faculty, Department of Medical Ethics Watercolors

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Time Travel

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In the Rain, In the Train

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Icarian Sea Gall

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Breathing Memories

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Waiting

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Waiting

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Michelle Lee | MD Student, Class of 2018 Poem Qiaochu Bernice Qi | MD Student, Class of 2018 Photograph Elizabeth DuPre | MD Student, Class of 2016 Photograph James Wang | MD Student, Class of 2016 Poem Natalie Wong | MD Student, Class of 2018 Prose Priya Gupta | MD Student, Class of 2017 Pencil Drawing

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Chief Complaint Peter Hung 15 y/o girl presents with acute onset aphasia and right-sided hemiplegia.

A chief complaint… How am I supposed to write just one sentence for a case like this? A case this stunning, this tragic? Something’s missing.

S.C. is a 15-year-old girl with no significant medical history who presents with a sudden inability to speak and complete right-sided motor paralysis.

No significant medical history. Yes, we’ve all seen strokes, but never in a person like this. She’s a young, healthy girl. No clotting disorders. No heart disease. No diabetes, history of infections, or precipitating events. One nice summer day, she’s walking down the street and suddenly she’s fallen to the ground half paralyzed.

S.C. is a healthy 15-year-old girl who had an unexpected stroke that paralyzed the right side of her body.

Even that doesn’t do her story justice. I know who this girl is. Everyone in our town knows Sandra. She’s our star, the brightest kid in years, the nicest and most generous person you’ll ever meet. She was growing up to be a beautiful young woman. So much promise struck down.

Sandra, a healthy 15-year-old girl—a loving daughter and sister, a high school sophomore, a varsity tennis player, an award-winning calligraphy artist, and a star student, on track to becoming valedictorian—had an unexpected stroke that paralyzed the right side of her body. She was right-handed.

Now this starts to hint at the tragedy of this case. She was right-handed... she won’t be anymore. Do you know how much she will lose to this stroke?

Do you know what trials she must endure to reclaim a fraction of her life?

Sandra, a previously healthy 15-year-old girl, was struck by an unexpected stroke that paralyzed the right side of her body. She survived, but she will need brain surgery to place a stent, then open-heart surgery to cleanse her heart of the infective endocarditis. Due to the severity of the infarction, she will have permanent damage to her motor cortex. It will take a year of focused physical therapy just to relearn to walk but not run or jump;

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to move her right arm but not her fingers. She will have to become lefthanded. Her enunciation and voice will never be the same. She might try to distance herself from this, but she will be forever preoccupied with hiding her injuries from her friends and acquaintances.

No‌ no...The chief complaint is supposed to be abstract and concise, so the next doctor who reads it can learn the important parts of her history and treat her effectively. I should delete all this. I should write it properly.

15 y/o girl with no significant medical history presents with acute onset aphasia and right-sided hemiplegia.

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Coping Chaos Pastel on Paper

Lara Wahlberg, DNP, RN, OCN

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Three Reasons Medical Students Should Read Poems Tony Sun

“Why should I read poems!?” some people ask me. Others tell me: “Possibly, but only when I have time!” These common responses from medical students give me reason to share in this article how I think reading poetry can help me, and you, become a better doctor. Here are three reasons: 1. Reading poetry reduces stress in medical school.

Reading reduces stress in general, not just during courses and clerkships.

Certain combinations of words have a soothing effect, and poets and songwriters have long kept this in mind. Consider Shakespeare: “I know a bank where the wild thyme blows, / Where oxlips and the nodding violet grows.” Read those lines slowly, taking care to imagine the scenery being described, and note how calming the effect can be. Then imagine visiting this “bank,” and use this moment to be at peace, much like in meditation. The effect, at least on me, is soothing and stress-relieving.

Now you might wonder why reducing stress is useful in the first place, and to that, I would cite a lecture from medical school that mentioned chronic stress as an inhibitor of both logical thinking and creativity—not things you want happening before, say, a major exam or during rounds.

But aren’t there other ways to reduce stress, maybe even more effective ones? Googling “how to reduce stress” produces nearly thirty million results, and yes, it’s entirely possible that poetry might not be the best way for everyone to reduce stress, but how will you know without trying first? There is little to lose, for example, by reading a sonnet during a short break. But if you already have a routine for curing stress, fear not, because reading poetry can help your medical career in other ways, which brings me to my next reason.

2. Reading poetry improves your thinking skills.

Well, what do I mean exactly by “thinking” skills? Many things, honestly, but I’ll focus on one for this discussion. In medicine, one challenge is thinking about how to connect seemingly unrelated dots to make a

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cohesive story. Getting to a diagnosis requires doctors to weave facts gained from a patient history into a unified story. How does one get better at doing this? Malcolm Gladwell might cite his 10,000 hour rule, but he doesn’t tell you how to fill those hours. Yes, I do think spending more time in the clinic helps, but let me suggest that reading poetry can also help, because the same skill sets are being practiced. Poems are patients in the sense that seemingly unrelated ideas are thrown together, and you as the reader or doctor must complete the puzzle. Shakespeare’s sonnets, I think, offer a great way to start practicing this skill, because his sonnets are short enough to be time-practical and substantial enough to be challenging. Reading his sonnets is like weight lifting for the brain. Of course, I’m happy to offer more options should anyone want to increase the weight after reading several sonnets. So for any aspiring or current physician, I enthusiastically suggest adopting the slogan: A sonnet a day saves the day!

3. Reading poetry improves your ability to interact with people.

Now you might object, and you’re right to disagree, if you take my advice to mean entirely replacing social interactions with private poetry marathons. No, that’s definitely not what I mean. I’m suggesting that adopting a habit of reading poems and poetic dramas can enrich and complement your interactions with other people. Many of the skills used in social exchanges are also used when imagining how characters in a play interact with each other. Similar questions, for instance, run through our minds when chatting with friends and when hearing characters speak—questions such as: Is this person being serious? Or sarcastic? For example, how are we to take Hamlet when he remarks: What a piece of work is man! How noble in reason, how infinite in faculty! In form and moving how express and admirable! In action how like an angel! In apprehension how like a god!

Is he saying that with conviction, or sarcasm? Can we take his words seriously? In context, most readers interpret Hamlet’s words ironically, but there is not one absolute way to read his words. For instance, one can imagine these same words being delivered with conviction in praise of humanity, perhaps at the Nobel Peace Prize ceremony. Recognizing

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context is only one of many subtleties involved in interpreting social exchanges, whether that be between characters in a play or patients in a clinic.

So, here are my three reasons why doctors should make time to read poetry: reduced stress, improved thinking skills, and enriched social interactions. Finally, for those (myself included) who might unpleasantly associate Shakespeare and poetry with term papers and exams, gone are those classroom days and gone should be those associations. Poetry and drama can very much be enjoyable to read, not just useful!

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Physics Photographs

Lindsay Smith

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On Adequacy It was the eve of new year’s eve, the eve of her wedding anniversary I sat next to my sister as she lay resting beside me (even fighters take a break sometimes).

Our mother was there too struggling to contribute to heal to not let go my sister’s feet in her hands.

We did not know then what we know now (that there would be no more miracles) (no more surprise batches of cookies) as she looked at our mother and said Don’t feel inadequate You are good at loving You are good at taking care of people’s needs You are good at praying for people you care about I need you to be you, mom.

I stopped and wrote it down unsure whether our mother had heard her thinking that she really needed to hear it to take it in.

I need you to be you, mom.

And then she said, No one is more inadequate than me right now.

I cannot remember now if she had stopped walking by then I returned to New York City the next morning The plane full of new year’s eve revelers.

— Mary Simmerling, PhD

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Fire

Photograph

Peter Hung

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No Events Overnight Jack Levy cheers…

“Tonight, Jessica Chastain, Golden Globe Winner Patricia Arquette, and music from Childish Gambino. With Cleto and the Cletones. And now, look at this, here’s Jimmy Kimmelllllllllllllllllllllll…”

Where is that nurse?

I think I’m due for my meds now and this pain is unbear.. AHH. Where is that damn remote?

“Yes.” “Hi, can I speak with my nurse?”

“What do you need, I’ll tell your nurse.”

“I’m in pain. I think I need my pain medicine.”

“Okay. I’ll let her know.”

-clickShoot, it’s been half an hour, why hasn’t she come yet? Maybe I shouldn’t have told them I was in AA. They probably think I’m just playing the system. But this pain is real, man. First they stop the gabapentin and that was barely touching this pain. I’ve been dealing with this for years and now my gout is acting up cause they stopped the colcrys…They gotta know this is real. Where is she…

“Yes.” “Hi, I’m still waiting for my nurse” “This is your nurse.”

“Oh, you didn’t come by and I need my medication” “You got your medication already” “What medication?”

“Your antibiotics, it’s hanging right now” “No, I mean my pain medication.”

“It’s not time yet.”

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“Well, I’m in pain…Can you please come by as soon as it’s time?”

“Okay, I will.”

-click“… The people are real. The cases are real. This is Judge Judy.”

What is going on here, it’s been over 5 hours since I got any medications.

I’ve barely slept an hour all night. Why hasn’t that nurse come yet? This is bull----. I hope they get me out of this damn hospital tomorrow. Wait, tomorrow is Lisa’s recital. I can’t ruin that for her. Maybe I’ll stay until Friday. Unless they have to keep me longer…I’m not sure they know WHAT they’re doing. First they tell me my kidney’s injured, then they say they’re giving me medicine that can destroy my kidney… For all I know it could be failing again from all these antibiotics I’m getting, and I can’t afford to lose this kidney too. Shit, no way I can ask anyone for another kidney…They might not have anywhere to put it. Four kidneys in one body and they got me loaded up on all these drugs. Maybe Rhonda was right. Maybe I’m just using all these medical problems as a way to get my fix. Maybe I shouldn’t even be taking all these pain meds they’re giving me. Lord knows I got- oooh. Where is that damn nurse!!

“Nurse!”

“Yes.” “I know it’s time now, where are my damn pain meds.”

-click-

“Nurse, I think there’s something wrong with my IV.” “Someone will be right there.”

-click“What’s going on Mr. Thomas?”

“I’ve been sitting here in pain all night. Where have you been?”

“I’m sorry, but you’re not my only patient tonight!”

“Well I’ve been waiting and…nevermind. There’s something wrong

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with my IV.” “Let me take a look. Yes it’s infiltrated. I’ll have to take it out.”

“What about my pain meds?”

“I’ll have to tell the doctor to change it to oral until the IV team comes in the morning.”

“What time will that be?”

“I’ll do it as soon as I’m done here.”

“Change the IV?” “No the IV team does that.”

“That’s what I’m saying, when do they get here?”

“I told you. They come in the morning.”

“What time because I’m supposed to be getting my medications and I can’t…”

“Mr. Thomas, I can’t tell you an exact time. As soon as they come by, they look at the list and they come to the rooms that need to be seen.

There are other patients with IVs.” “Well then can I get the pill form of the medications?”

“Yes, when I’m done here I’ll talk to the doctor on duty.”

“Thank you.”

“Coming up next, a fatal car accident leaves two people dead and one critically injured…”

I can’t take this anymore. I gotta get out of this place. How can I go home when I can’t even stand on my own two feet? After everything I already put Rhonda through, I can’t go home like this…And if she catches shingles from me…No, I better stay here until this goes away. Or at least until Dr. S tells me it’s ok. They got me in here for 6 days now…

It’s driving me crazy being in this double doored room, the doctors and nurses coming in here covered in masks and gowns and shit…like I’m some kind of a leper. I can’t even get any help, can’t get up and stand, can’t walk out of here if I wanted…”

“Nurse, I asked for my meds!!”

-click-

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Tap tap tap..

“Good Morning, Mr. Thomas. How are you feeling today?”

“I had a horrible night. My IV infiltrated again, I couldn’t get my pain meds, I was in pain all night, barely slept an hour all night.”

“I’m sorry to hear that. I’ll see what I can do to get you your medications as soon as I can. In the meantime, it looks like your rash is healing nicely…”

“Mmhmm.”

“Have you noticed any new rashes anywhere or feeling of burning, itching, or tingling anywhere other than your forehead and scalp?”

“No, not that I noticed.”

“Good. And any shortness of breath, chest pain, or palpitations?”

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Untitled

Cut Paper

Evan O’Dea

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A Body to Serve Others Natalie Wong To the families of our Anatomy donors: Even before I knew its anatomy, my body served me quite faithfully. I have laughed; I have cried; I have devoured food. I hope my body continues to serve me well in the years to come.

And while I hope that my body serves me well, I also hope that it serves others. Perhaps my hands will perform important operations, or maybe my ears will listen to stories that desperately need to be heard.

After all, the body is truly a gift-giving vessel.

This semester, we learned the anatomy that allows our bodies to give.

We were, over and over again, stunned by the complexity and beauty of the human body.

What a privilege it has been to learn from faces that have smiled, arms that have hugged, and diaphragms that have laughed! We studied hands that prepared dinners, feet that climbed mountains, and backs that carried the weight of generations. We learned from incredible people who understood that their bodies could continue to give gifts and serve others, even after those bodies stopped serving them. We are in awe of these individuals.

We walk away from this experience with an understanding of the human body that will serve our future patients. We are so, so grateful to you and your loved ones for your generosity. Know that we will use the gifts you have provided us to become caring and competent physicians.

Thank you.

This speech was originally given by a first year medical student at Weill Cornell Medical College Gross Anatomy Program’s annual memorial service in honor of donors (December 2014).

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Legs

Chalk Drawing

Liana Greer

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One olfactory, two optic, three oculomotor; four trochlear, five trigeminal, six abducens; seven facial, eight vestibulocochlear, nine glossopharyngeal; vagus, accessory, hypoglossal; [cranial] nerves complete.

Tour of the Cranium Pencil Drawing

Sarah Schrader

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Visual Art and the Frontal Lobes Matthew Schelke Is there a place for visual art in the brain? If so, what does that area do besides just the mechanical aspects of sculpting, painting, drafting, and looking? Earlier this century, the Russian neuropsychologist A.R. Luria described a group of patients who offer some oblique insight into these questions. The patients had damage to the anterior regions of the brain’s frontal lobes—the large prominences just behind the forehead that are most developed in humans—and all demonstrated a peculiar deficit when looking at pictures. Luria had the patients analyze a scene depicting a man falling into the icy waters of a frozen pond, with townspeople and policemen crowded on the banks to save his life. Whereas a normal individual would glance over each element to assemble a coherent explanation for the scekne, the frontal patients would blurt out a characteristically premature explanation for the entire scene. One patient, seeing the policeman, described the scene as a “war;” one, whose eyes happened to land on a sign by the pond with the word “danger,” exclaimed that it was an “infected area.” Instead of holding these immediate impressions at bay and interpreting each object in light of the others, the frontal patients merely reacted reflexively to the first item they saw.

The core of a work of visual art is that it forces the viewer to do precisely what these frontal patients could not—to hold immediate impressions at bay and to reconsider the content of a work in light of everything on the canvas or in the marble. Pablo Picasso created a striking instance of a work that depends on this resistance to immediate interpretation in his Bull’s Head, in which the artist welded together a bicycle seat and a pair of handlebars to create the head of the eponymous animal. A year after its creation, Picasso noted how the essence of the work depends on the viewer seeing the object as both scraps of a bicycle and a sculpture of a bull: “If you were only to see the bull’s head and not the bicycle seat and handlebars that form it, the sculpture would lose its impact.”1 The ability to see both the everyday nature of the bicycle parts and their new function as the head and horns of a bull simultaneously is precisely the 1 Georges Brassaï, Conversations with Picasso. University of Chicago, 1964, p. 61.

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ability that Luria’s patients have lost.

Patients with these anterior frontal lesions display similar deficits in the broader context of everyday life. They behave in an unusual manner that the French neurologist François Lhermitte described in 1983 as “utilization behavior”: The patients felt compelled to use everything in sight, whether or not it aligns with their current task. Normally, for example, one enters a kitchen with a goal that unifies the situation: To make bread, one opens a certain drawer for a loaf pan, turns on the oven to 350 degrees, and runs the faucet to clean a spatula. However, a frontal patient entering into a kitchen may open all the drawers, turn on the oven, and run the faucet with little rationale or explicit plan. Just as Luria’s patients could not resist offering an explanation of a scene based on the first item they perceived, Lhermitte’s patients could not resist handling and using whichever object their eyes came across. The attempt to construct a cohesive narrative with a means-end structure to unify the situation was lost.

These two patterns of behavior—the failure to understand the meaning of an image and the failure to respond cohesively to a situation—are linked through the dual meaning of the term “culture.” Culture refers to both the artistic productions of a society and the kinds of behaviors that are acceptable. We think of the former as leading to the latter: The basis of an education in the humanities is an implicit faith that exposure to artworks, musical compositions, and books will inculcate behavior according to the goods of the culture rather than the whims of the individual. The patients of Luria and Lhermitte demonstrate that the frontal lobe is a basic biological link between the kind of perception necessary for artworks and the kind of behavior required of a culturally competent individual. To perceive an artwork is to inhibit immediate reactions to its constituent parts and to reinterpret them in terms of the overall goal of the work: To see, for example, that the bicycle seat and handlebars portray a bull’s head. Similarly, a culturally competent individual does not react to everything in sight but rather formulates an overall goal and reinterprets his surroundings in terms of that goal.

Both involve a certain distancing from the immediate colors, light, and emotions of the world in favor of a more longsighted perspective, and art develops the key frontal functions that are the foundations of this behavior.

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It is no accident, then, that the frontal lobes are the slowest to mature over the lifespan of the individual and do not reach their full size until well into the third decade of life. We define maturity as this ability to reshape our visceral reactions into plans of action that serve long-term goals rather than instantaneous whims. As soon as children learn to speak, this process begins: Children's earliest crib talk centers on narratives in which they try to explain the events of their day through a meansend structure and begin to acquire the critical interpretive distance that inhibits the automatic responses that are so characteristic of the frontal patients. Though they underlie artistic production and perception, the anterior frontal lobes are thus built not to perceive beauty or to identify the work of a particular painter or school, but rather to reinterpret, revise, and renew one’s perceptions of the world both in terms of goals of behavior and in terms of the overall construction of an artwork.

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Faith “In the interest of medical education, I wish to donate my body to Weill Medical College of Cornell University at the time of my death.”

After life, I trusted you With the remains of my earthly stint.

Now, your patients will trust you With what remains of theirs.  Did the thought of exposure not stall you?

Gloved green hands and eager eyes probing!

If beauty is found in the mind, Then yours lives still in the memories of those who love you.

If beauty is found in constitution Then we experienced it, too.

Your parts will live and speak inside us, As they once did in you.

But even as you gave us answers, we had more questions.

So I ask again: Did the thought of exposure not stall you?

It seems that mostly, beauty is engraved in existence, In your persistence here.

As we mastered your inner workings, we were faced with something even more monumental: In placing your faith in us You demand our future.

— Aaron Oswald

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Window Shopping Photograph

Marta Dzyadyk

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The Little Dancer Photographs

Alexandra Berman

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Axis of Growth The Unexpected Result “Although epiphyseal growth plates are obviously stimulated after GH is given to hypophysectomized animals, little or no stimulation of cell division … was observed when cartilage was incubated with GH.” H. M. Goodman, Basic Medical Endocrinology 2nd Edition.

A scientist labored like Sisyphus To study the plates of Epiphysis “GH failed,” she cried, “IGF kept them wide!

“NIH will say ‘Oh how amiss this is!’ ”

The Releasing Factor “…frequent measurements of GH concentrations in blood plasma throughout the day reveal wide fluctuations, indicating multiple episodes of secretion.”

H. M. Goodman, Basic Medical Endocrinology 2nd Edition.

“Your job,” said the brain to Pituitary, “Is to send lots of hormones and do it very Oft’ in reply To diverse stimuli And at intervals counter-intuitary”

The Hormone “It was entirely unexpected that a monomeric ligand such as growth hormone would cross-link its receptors, as it requires that the two identical receptors recognize different parts of the hormone” Alberts et al, Molecular Biology of the Cell 3rd Edition

There was a young hormone named Growth, Who to choose his life’s partner was loath.

“These receptors are twin, And although it’s a sin, I am tempted to mate with them both.”

— Lawrence Palmer, PhD

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We Were Children Once Jeffrey Russ, PhD We were children once, my patient and I, at the exact same time, born within months of each other. We were children once, and the idea of ever being twenty-nine, if it crossed our minds at all, seemed so far away, so abstract for both of us. When he and I were ten, I remember marveling even at the thought that one day I’d be sixteen and able to drive a car, let alone that I might ever be twenty-nine. Sixteen was as far into adulthood as my young mind could travel then, and driving a car was the most “adult” responsibility I could conjure. And maybe also when we were ten my patient imagined his grown-up self as well: where he might live, whether he might have a family, what it might be like to reach an age where he could also be a driver of cars. Of course it seemed a plain enough fact, if either of us thought of it, that we would someday turn twenty-nine, get behind the wheel, or handle numerous additional adult responsibilities, but these ideas were too vague and distant to ever be considered an eventual reality.

At ten, knowing that we would one-day turn twenty-nine was sort of like acknowledging the existence of another country that we saw on a map; knowing that it existed but not really fathoming that it was a place you could actually go, where people actually lived. Indeed, as a teenager, my limited concept of Mexico came mainly from a videotape my Spanish teacher once played that began along the lines, “Mexico is an exciting country with a rich cultural history and many diverse citizens...” And hearing such platitudes about Mexico, the idea that someone like my patient could be there, leading a similarly vibrant youth and progressing through development in step with myself, was far too distant and abstract to fully register.

Nevertheless, we aged together, unaware and far away. When at eight I sliced my knee on a metal landscaping divider, my patient was probably having his reckless scrapes patched up as well. And when I finally drove alone for the first time at sixteen, likewise he was enjoying his autonomy as he lurched down the open road. As I studied medicine, he studied finance. Most recently, as I enjoyed Valentine’s Day dinner with my girlfriend, he returned from his honeymoon in Africa, still aglow with celebration and passion, worrying slightly about why his stomach was

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bloated and painful and not getting better. We grew up together, distant and oblivious to one another, marching in parallel, while twenty-nine grew less far away.

We were children once, my patient and I. Twenty-nine seemed so far away, and death seemed so much further still, the very concept absurdly inapplicable to us. But now I stood in his hospital room, his new wife on the cot beside him so she wouldn’t have to leave his side. As it happened, the convergence of our trajectories found me wearing a white coat and him in a hospital gown. Our medical team was explaining that his “best” case scenario was that he had an aggressive lymphoma. He choked back tears. His new wife cried through her already swollen, red eyes.

His mother and sister tried to make sense of what they were hearing, tried to find hope in the potential for treatment. Somewhere a PICC was being placed, a PET was being scheduled, and Reproductive Medicine was discussing sperm banking in anticipation of chemotherapy so that this new couple, in the most optimistic of outcomes, would still have a shot at conceiving. I watched the scene unfold, watched the full tragedy of his diagnosis register within him. And all the while I was aghast that my adult responsibilities, previously inconceivable at age ten beyond the complexities of driving a car, now at twenty-nine included informing my peer of his impending demise. And with this responsibility of frantically trying to steer the wreckage in front of me from total emotional catastrophe, I myself faced the additional challenge of maintaining a professional demeanor and not betraying that I was just as terrified for him as he was for himself. Such were the unanticipated responsibilities that I took on at twenty-nine; his was to cope with being newly married and facing a premature death.

That my twenty-nine years had somehow given me any extra authority to help pronounce his illness upon him felt fraudulent. To invite myself into his room, as the one of us who still had time, felt sickeningly arrogant. “How was your night?” I would ask. He and his wife, curled on the hospital bed, would muster composure and force halfhearted smiles.

One particular morning he had difficulty finding a comfortable position in bed since his stomach had become so distended so rapidly from his lymphoma proliferating viciously within. “How dare you ask,” I would scold myself for him, though not once did he himself ever imply as much. After growing up together, albeit unknowingly, at our intersection

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he was to be the sufferer and I was to be the observer, and he played his role as graciously as one could. He forced himself to be positive; he tried to stay strong in front of his family. If this was how he was going to approach the burden he was dealt at twenty-nine, then all I could do was take up my yoke alongside him and help him as best I could.

While reflecting on this patient, the memory of a dream I had forgotten suddenly resurfaced and became forcefully salient. Once I dreamt that Death, faceless and hooded as he tends to be, stood over my bed and began to suffocate me, though somehow I knew that he was not actually ready to take me right at that moment. He simply wanted to remind me that he could at any time. Helping reveal to my patient, the one who had led my very same life in an alternate universe—or else I lived his life in a universe unknown to him—that at twenty-nine his time may now very well be up, transformed that dream into an immediately sobering reality.

My patient’s life was about to conclude just shy of three decades with a honeymoon punctuated by an aggressive cancer attacking him out of the blue.

We were children once, my patient and I, and twenty-nine had seemed so old, but now it seemed so young. As I continue to look forward, fifty, eighty, and a-hundred-and-one now seem so far away, to me. But for him, I wonder if thirty suddenly seems remote, as close and unreachable as the city right outside his hospital window.

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Stone Soup Oil on Board

Natalie Wong

Ascensus

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After Work I washed the blackberries at the kitchen sink, lazy to let late night soften some long hospital day until tomorrow.

There were the faucet’s drops to steel below and the window opened at the city, quiet for a moment.

I watched the berries blacken under cold water and smiled at the color. — Samuel Woodworth

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Untitled

Oil Pastel Collage on Paper

Kim Overby, MD MBE

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Pro Re Nata Nicholas F. Maston During a small group session in our second year of medical school, we were discussing prescription-writing when a student asked the group, “What does PRN stand for?” Another student, with more clinical experience than most, who was respected by the group for his unique and informed perspective, replied, “per the RN.” I frowned, knowing that PRN does not refer to a registered nurse and is in fact an acronym for the Latin phrase pro re nata, used in clinical medicine as prescription shorthand for as needed. Surprisingly, I realized his interpretation worked remarkably well in the world of 21st-century American hospital medicine: when a medication is prescribed in the hospital to be given on an as-needed basis, the acronym PRN is picked from a drop-down list in the electronic medical record. The nurse then administers the medication at allowed intervals, either by his own judgment or by patient request. This alternate meaning for PRN works in the world of hospital medicine, where orders are entered electronically and doses are later logged by a hand-held scanner. This is a disconnect that did not exist in the days when PRN was first used as time- and confusion-saving shorthand by handwriting-challenged physicians equipped with a pen and paper prescription pad.

The changes that hospital medicine have brought are many: When I enter an encounter note for a patient, I choose a pre-formed template from a list that contains a cursory review of systems and generic physical exam. I then go through the motions of deleting questions I didn’t ask and parts of the physical exam I didn’t perform and adding those pertinent questions and exam findings that are not already in the template. When finished, I review the note for completeness, submit it to the electronic database, and re-type my password to ‘re-authenticate’ the work as my own. My note then gets added to the growing portmanteau of notes from nurses, students, residents, physicians, physical therapists, nutritionists, and other healthcare professionals that together comprise the patient’s written medical record. Sometimes an attending physician or consultant will challenge a dangerous omission (e.g., “Why didn’t you address the patient's serum bicarbonate level in your assessment?”) or compliment a thorough note (writing “reference medical student’s excellent note for

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complete patient history” in their own daily note).

In this maelstrom of acronyms, notes, and fragmented feedback I still struggle to determine what exactly I am supposed to be learning. The intent of the third-year of medical school is to learn the basic practice of clinical medicine in core specialties, including internal medicine, surgery, psychiatry, obstetrics, neurology, pediatrics, and primary care. I am being trained in the mechanics of medicine, the whys and the how-tos of the practice of caring for patients. But when I see a seasoned physician at a patient’s bedside casually conversing while subtly incorporating the questions and exam tricks that will allow him to fine-tune his assessment of and plan for that patient, I become acutely aware that there is more to medicine than covering seven organ systems in my review of systems, or addressing all abnormal lab values in my assessment and plan.

When will I learn how to enter the room like that seasoned clinician, ignoring the sometimes distracting cues of slightly low serum sodium values or medications that have to be re-ordered on a daily basis, and clue into what is right for that patient at that moment? When will I move past the mechanics of the history, physical exam, notes and acronyms and become a physician who knows what is needed and when, and who delivers that needed care with grace and dignity and compassion? PRN, it seems, has a meaning far beyond “per the RN” or the pharmacologic “as needed”: To me, PRN’s meaning sits somewhere in the space between clinical decision making and the very human connection between physician and patient—doing what is needed, as needed, and knowing the difference between the important and the mundane.

The Serenity Prayer comes to mind: God, grant me the serenity to accept the things I cannot change, The courage to change the things I can, And the wisdom to know the difference.

One day I hope to become that physician: wise and smart, respected and loved. However, my task right now is simple: Keep grinding through the notes and the acronyms, the daily hustle of hospital medicine, keeping in mind that this is not the end of the road but rather a necessary and probably indispensable leg of an unending journey toward excellence.

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Winter Storm Photograph

Lia S. Logio, MD

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Tuning Attention and Focusing on the Moment Peng Kate Gao A few years ago, my friend and I took a road trip to the Blue Ridge Mountains. It was a typical mid-fall afternoon, when warm autumn colors began to paint the pastoral landscape of the Appalachian Highlands.

The drive was not a difficult one; we had little fear of tumbling over the few cliffs we encountered. Nonetheless, the road was often winding and torturous with plenty of unexpected curves. As the drive and the scenery captured our full attention, all of our worries and work issues faded away.

Suddenly, the vibrant foliage became much more lively, the afternoon sun shone more brightly than usual, and the air was sweet with the smell of fall. Years later, the colors, sounds and smells of this experience still play vividly in our minds.

Looking back, my memory of that distant afternoon seems so much clearer to me than many more recent Saturday afternoons I’ve spent aimlessly roaming the streets or watching TV. Recent psychology and neuroscience research helps to explain why this is so: Our experience and memory is shaped by what we attend to. It is, therefore, tempting to think that if we can consciously tune our attention and focus on the right things, life will feel less like a series of random acts and more like a work of art that we create.

Unfortunately, tuning attention is not always easy. Do you remember a time when you knew you were supposed to be working on a project or assignment, but somehow your mind started to wander and you felt the urge to check email or Facebook? Focus slips, time melts away, and work is left undone. If this lack of focus becomes a habit, we face the real danger of drifting along in life—passively reacting to circumstances or whatever that happens to us. This is certainly a life that most of us try to avoid.

Psychologist Mihaly Csikszentmihalyi, in his widely influential book Flow: The Psychology of Optimal Experience argues, “The best moments in our lives are not the passive, receptive, relaxing times… the best moments usually occur if a person’s body or mind is stretched to its limits in a voluntary effort to accomplish something difficult and worthwhile.”

He named this fully engaged state “flow,” during which the person feels “strong, alert, in effortless control, unselfconscious, and at the peak of

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their abilities.” We usually associate flow with creative endeavors of scientists and artists, but Csikszentmihalyi argued that in fact it could be achieved in everyday life too, such as reading a book or tending a garden.

Those moments lift our spirit and make us feel life is worth living. The key to living an engaged life, then, is to find a way to maximize our time in flow and minimize drifting.

Is it possible to reign in our attention? Writer Winifred Gallagher in her book, RAPT: Attention and the Focused Life, proposes that we can deliberately train our ability of concentration and focus, “like physical fitness, the mental sort that sustains the focused life can be cultivated.” In other words, attention is like a muscle, the more we use it, the stronger it becomes. Gallagher referred to work by mid-twentieth century psychologist Nicholas Hobbs, who stated that the way to ensure calm but heightened attention and focus is to choose activities that push you so close to the edge of your competence that they demand your absolute focus. “If an activity is too easy, you lose focus and get bored. If it’s too hard, you become anxious, overwhelmed, and unable to concentrate.”

This theory is supported by many subjects in Csikszentmihalyi’s research, who reported “least happy” when they were at “leisure,” for example while watching TV. This seems counterintuitive, but the fact is, our mind only comes alive when it is engaged in the activity at hand, and at those moments we feel more fulfilled and happier. When we lose focus and the mind wanders, it often turns inward. Before long, we find ourselves ruminating about our worries, troubles, and other negative thoughts. To avoid this trap, Csikszentmihalyi suggested spending leisure time on a challenging and engaging hobby, such as playing a musical instrument, which simultaneously expands our horizon and exercises the mental muscle of focusing.

On the other end of the spectrum, when the task is too difficult, we feel anxious and frustrated, and also have a hard time focusing. In these cases, we may try to break down the overall task into smaller, more manageable parts and focus on solving one at a time. In accomplishing each smaller part, our brain is energized and we start to think, “I can do this,” and thus start a positive feedback loop that propels us to go further.

In a way, it is like climbing a mountain: If the summit seems daunting and out of reach, it helps to have intermediate goals along the way, which eases our worry and makes us focus on the climbing business under our

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feet. The ability to tune attention and focus on the work itself rather than being consumed by anxiety and frustration seems to be the key here, and is certainly a capability worth cultivating.

In a world that is overflowing with so much information and stimulation and filled with uncertainty, sometimes life can feel out of our control. In those moments, please remember that attention is a muscle that each of us possesses, and by tuning our attention, we can choose to focus on things that are worthwhile and valuable. What we attend to becomes the thin slice of our universe as it shapes our experience and becomes imprinted in our memory.

I often think of this quote by botanist Liberty Hyde Bailey: “A garden requires patient labor and attention. Plants do not grow merely to satisfy ambitions or to fulfill good intentions. They thrive because someone expended effort on them.” Our life is a garden; let’s take very good care of what we choose to grow there.

This piece was originally published in the April 2015 edition of Natural Selections, a newsletter of the Rockefeller University.

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My Empire State

Photograph

Elen Gusman

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Healer, Doer, Mover, Shaker I am neutral grease.

I am without traction – I am powerless.

In the heat of jungle trouble, I might fester, rancid, Like a delicate olive oil.

We need sustenance, We need justice, WE NEED EQUALITY, We protest.

Some use me to lubricate pistol barrels and tank innards.

Some use me to fry cicadas and to warm their hearths.

Complicit, forever yielding – I am used, too, to shapeshift silhouettes.

I give you me.

I must believe that something good will come of us – We have the means.

— Neal Parikh, MD

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Art that Smells Good

Candle wax, acrylic, and magazine paper on cardboard

Priyanka Vijay

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A Physician Travels and Observes Paul Miskovitz, MD “Fightertown, USA”, as the former Naval Air Station was known, is now a Marine Corps Air Station, in Miramar, California. Popularized in the 1986 action film “Top Gun” starring Tom Cruise and Kelly McGillis, among others, it played the backdrop for the United States Navy Fighter Weapons School. It was not the military that brought my wife and me to this arid locale north of the city of San Diego early in the month of July but rather Bell’s palsy.

A Manhattan-based physician, I had developed facial nerve paralysis over a twenty-four hour period four weeks earlier. Sometimes viral in etiology, sometimes the initial presentation of Lyme disease, and often idiopathic, this temporary cranial nerve inflammatory condition results in facial paralysis. Named for Sir Charles Bell, a 19th century Scottish surgeon (distantly related to Dr. Joseph Bell, the inspiration for Sir Arthur Conan Doyle’s character Sherlock Holmes) who was the first to describe the condition, it can be mistaken for a stroke. Drooping of the eyelid and the corner of the mouth on the affected side, drooling, dryness of the affected eye and mouth, impairment of taste and vision, and excessive tearing in the affected eye often occur. Antibiotics, antiviral therapy, and corticosteroids are often prescribed in an attempt to eliminate the cause of the nerve damage. Bell’s palsy can interrupt the eyelid’s natural blinking ability, leaving the eye exposed to irritation and drying. Therefore, keeping the eye moist and protecting the eye from debris and injury, especially at night, is important. Hence the need to leave town, to seek out a vacation spot removed from the daily stresses of medical practice where one could wear an eye patch and not have to constantly talk on the telephone or deal with patients face to face while having to explain one’s altered appearance, but also not be too far from medical care if needed.

After careful planning we selected a motel near the confluence of I-805 and CA-163 in the Clairemont/Kearny Mesa area of San Diego just south of the military base. With our rented car (my wife doing the driving) we were able to visit and walk the beaches of the Silver Strand State Beach in Coronado, enjoy the famed San Diego Zoo, and relax at poolside while enjoying the mild climate of Southern California. We were to discover

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that the nights were filled with the sonorous rumble of nearby jet aircraft engines.

One morning, while having breakfast in the motel dining area, I observed a Marine Corps officer sit down, alone, at a table for two at this off-base venue. Perhaps it was the effect of the neurological condition or the steroid treatment or seeing the world through one good eye (“In the land of the blind, the one-eyed man is king!”) that heightened my sense of awareness, but I took in details that would have otherwise gone unnoticed. The “high and tight” haircut, the two highly polished silver bars on each shoulder, the muscular forearms, the black large-bezel aviator watch, the razor-sharp creases of his officer service uniform, the aviator wings, the chest full of ribbons, and the spit shine of his shoes did not escape my attention.

I watched as the waiter politely poured him a glass of orange juice followed by a cup of black coffee. Both went untouched as he reverently bowed his head while looking down at his lap. Here was one of America’s warrior breed—possibly having just returned from the battlefields of Fallujah, Mosul, Kandahar Province, or perhaps Okinawa, Guantanamo Bay, Diego Garcia, liberating some besieged US embassy in Africa, duty at sea, or who knows where? Perhaps he had passed the necessary background check and security clearance to pilot Marine One, the helicopter that ferries the President of the United States. Yet before partaking in his morning meal, he felt compelled to pray! How different from the usual Manhattan restaurant or coffee shop scene I was used to.

As I reveled in my Holmesian-like powers of observation and deduction I noted that seconds, then minutes, passed with no change in his ramrod-seated posture and downward gaze. What train of thought could be taking him, this embodiment of American apocalyptic “Death from Above,” so long to contemplate? It was only after several minutes that I realized the object of his intense interest was not prayer but his BlackBerry® Smartphone being used to check his email!

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Le Catedral

Watercolor and Pen on Paper

Natalie Wong

Ascensus

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Innocence Abroad Jonathan Huggins, MD Medical schools cast the term “global health” out into their swollen rivers of applicants as an almost irresistible lure. For my own part, as I am sure is the case for many others, I bit without knowing what the phrase actually means. I had been enticed by glittering images of myself toiling under the unforgiving rays of some foreign sun. My clothes ragged and hair unkempt, I would bring aid to throngs of the poor and sick in forgotten parts of the world. It may be an exaggeration to suggest that I thought I had something unique to offer as a fresh-blooded medical student, but it would be hard to overstate my yearning for the adventure and romanticism I saw in these opportunities. Certainly these sentiments did more to propel me toward other continents than any commitment to social justice or toward righting inequities in health care provision. How could it be otherwise? I had never suffered the way victims of war, famine, or disease suffer. I had never lived, I mean really lived, among them. I would like to have thought that I had considerable exposure—academic exposure, that is—to the sorts of injustices afflicting millions around the world, but that counts for little when it comes to producing action. The longing to enrich my own views, to add inches to my measure of myself was real, and so that, as much as I would like to write about my passion for erasing suffering from the world, is what drove me across oceans.

Though I can without hesitation declare that I was internally-focused when I embarked, I would not call my designs entirely selfish. There is something to be said for worldviews developed through observation rather than intellectual extrapolation. In what is considered a seminal work of American travel writing, The Innocents Abroad, Mark Twain documents the misadventures of an American as he makes his way through Europe and the ancient cities of the Holy Land. Reading it, I was struck by how closely my own aspirations in traveling abroad were encapsulated in prose now almost one hundred and fifty years old. In the book’s final pages Twain writes, “Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one’s lifetime.”

This sentiment, the assertion that we grow both intellectually and

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personally through a wealth of experience receives remarkable emphasis in medical school global health programs. Even the term, “global health” invites us to envision providers whose commitment is limitless. And with unbounded devotion, our beliefs and ideologies ripen. That’s how I saw it, anyway. It seemed an inexhaustible spring. I believed that the more lives with which my own became entwined, the more countries I could put pins through on a map, the more fulfilled I would feel and the more impact I would have. By stretching myself as widely as I could, I would find myself endlessly enriched. 

Dr. Salins’ office is cold and austere. The white tile gives it the feel of a repurposed operating theater. We sit in two uncomfortable chairs before an ornate wooden desk. Behind us, on the other end of an entirely too large unfurnished space, is a small sitting area. To our right, two serpentine bookshelves are as sparsely furnished as the rest of the room.

Salins walks in, eyes gleaming and voice booming. His commanding appearance and pointed stare make him a fitting choice for medical director of the Mazumdar Shaw Cancer Hospital on the south eastern outskirts of Bangalore.

“Peter and Jon, is it?” he bellows baring his white teeth under a graying mustache. He drops into a chair behind the desk.

The conversation flows like the dialogue of an absurdist play, and in retrospect, the analogy is fitting. So much of my experience over the two months I spent in India was characterized by exchanges with fleeting moments of mutual understanding before they again assumed a trajectory along tangents of unshared meaning. Things seemed to lose purpose. Peter and I were like corks set adrift in a seething ocean that was undulating to some erratic, but cohesive rhythm. We were subject to its whims, but distinct from it. We hadn’t the mastery of the elements to set a course nor the stubbornness of character to establish a mooring.

And so like Vladimir and Estragon or Rosencrantz and Guildenstern we floated through an indecipherable landscape endeavoring in vain to make sense of it and our place in it.

“Peter, you are the immunologist, is it?”

“I’m Jon,” I tell him, “He’s Peter.”

“And I’m not an immunologist,” Peter protests.

“Right,” he says, not looking up from our resumes in front of him.

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“Well, Bharath will meet you two in the morning.

“When you are there I want you to learn what is a microfamily. You know this word, Peter?”

“No,” I tell him. “And I’m Jon.” “Well, I want you to learn this. And you must report back to me. This is very important. The model can be very useful. You will write me a report. It may even win you a Nobel Prize.” Peter and I exchange glances and a smirk, but then again the glittering images, the burning sun. Salins does not smile.

“Very well. Come in the morning to meet Bharath,” he says standing.

“Jon,” he says extending a hand toward Peter. They shake. “Peter,” he extends his hand to me. 

The sky is gray above the cricket field beneath our window early the next morning. We meet the hospital shuttle in the dirt road in front of our hotel and arrive to meet Bharath as the sun climbs above the trees.

Hosur road passes about two hundred yards in front of the gates to the Narayana Hrudayalaya health city. The space between is filled with hawker stands offering bananas, diced mangos, and papayas. Hospital workers and patients off the city buses have packed the earth running between the shouting salesmen. It’s in this muddy interval that we find Bharath. He is our age, but taller, backpack slung over his shoulder. He smiles widely baring the gaps between his teeth as he shakes our hands.

He turns and leads us toward the road where the bus throws up dust as it crunches to a halt in front of us. The door squeals open when the driver, in a brown uniform befitting of a UPS worker swings the hand lever beside him. We find seats together among commuters leaving the city, bags of rice propping up their sandaled feet. At the front of the bus a Tamil film plays, rife with slapstick. I begin to doze. 

When we arrive in Dharmapuri, Tamil Nadu, we climb with Bharath into his family’s jeep and drive through the teeming streets amid horns and the gravelly roars of mopeds. The town gives way to quiet dirt roads leading to Bharath’s village, Mukkalnaickanahalli. We climb a hill and pass through an iron gate in a stone wall plastered over with white stucco. There is a square lot surrounded by three flat-roofed buildings where pointed shoots of grass force themselves up through the rocky soil, threatening the

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intrepid barefoot walker. Beyond the empty lot is a grassy path running between several fallow garden beds. A brown cow with bony shoulders and ribbed flanks grazes nearby, two white geese at its feet. In the distance two green peaks stretch skyward cradling the village below.

Bharath leads us across the yard to a small office. A desk at the far end and behind it, low counters covered with countless figurines of the countless Hindu gods. Ganesh sits cross-legged over a bowl of flower petals, puja, an offering made in his honor. Others hold sticks of incense, whose vestige fills the room with a sweet closeness smoothed over by a breeze coming in through the open door. We take off our shoes and sit on a couch along the wall.

“Tea and biscuits?” Bharath asks, but before we can answer, he has sent the cook away. She steps barefoot through the doorway, bangles clacking as she clasps her sari and makes her way to the kitchen.

This is the post from which Bharath manages his organization, Agro Bio Care (ABC), that endeavors to educate students in agricultural science and encourages them to become advocates for farming techniques that avoid toxic pesticides, but maintain productivity.

Salins at Narayana had contacted Bharath about establishing a health screening program in the village. As with many rural towns in India, this one had been washed over by the ebbing and flowing tides of NGOs and microfinance schemes, an alphabet soup of do-gooders trying to fill the void that had been left when manufacturing plant shut downs left many of the village’s men out of work. At the hospital in Bangalore, Salins had warned us in rather blunt terms, “The men are all alcoholics, you understand. They are hopeless. They will not work so we must target the women.”

The microfamilies that Salins had so proudly espoused were groups of women to whom combinations of government and private funds were granted to finance causes the group saw fit. In most cases this meant extra money to cover each family’s individual expenses, but those who put the funds to use as capital in building small businesses or to cover the expenses of developing a productive skill were rewarded with new grants and more robust support. Narayana Hrudayalaya envisioned these regular gatherings of community members as an opportunity to perform health screening and education. To this end, Salins had emphasized the importance of individuals with minimal healthcare

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training in performing these screens and advancing health education in the villages. Their shortcomings in knowledge would be smoothed over by the integration of technology. The hospital had invested in equipment that required onsite technicians to do little more than apply electrodes or a blood pressure cuff, and the data would be transmitted to computer screens miles away where experts could interpret the results.

To me the idea fit nicely with the impression of India I had built from books and had subsequently superimposed on the place I had come to know since I had been there. In the weeks leading up to my departure, I had read about the country’s lopsided progress toward becoming a powerful world player; its importance to the technological and pharmaceutical industries was juxtaposed with the persistent problems of poverty and corruption. Standing before the Infosys campus only a few miles northwest of Narayana, I saw the dichotomy incarnate. The gleaming glass buildings of one of the world’s largest IT conglomerates rose on grassy mounds above shanty towns of corrugated tin and crumbling concrete as if foisted by the potential held by India’s future onto some of the most unpleasant circumstances of its present. The congruence of Salins’ proposal with my own limited understanding of the country’s dynamics in that moment fortified my yearning to take action.

I wrap the cuff around Peter’s arm. It tightens and Bharath reads the results from a laptop across the room, “It says one hundred and fifty and another number, ninety.”

“Well, there’s no way that’s right,” Peter says.

An argument ensues between Peter and me, Peter emphasizing the importance of the technology working properly in assessing the success of the screening program, me the value in demonstrating proof of concept. Bharath looks on as Hamlet watching one of Rosencrantz and Guildenstern’s circuitous and ineffectual exchanges, unperturbed by a debate with no bearing on the development of his own reality.

We drink the tea, eat the biscuits, and make our way to our room. 

We take the motorbike into the village the following morning. Bharath at the handlebars, Peter sits behind him with his thighs straddling Bharath’s and mine straddling his. The motorbike often substitutes the minivan in India. Riding the bus to and from Bangalore, we would pass entire families packed onto the things. The father standing and steering the

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bike among honking drivers like some sort of domestic daredevil with a toddler or two sitting cross-legged between his legs. The mother, baby in arms, is sitting behind him, the loose end of her sari wafting the faces of a few school-age kids behind her. Three men stacked like open books is familiar enough for me.

We are jostled and bump one another along dirt roads through flat fields of rice paddies spotted with women in brightly colored saris wading in the shallow water. They give way to a wide grassy expanse and beyond it a clump of trees with stone buildings crowded at its base.

We dismount and avoid eye contact with one another as we stretch our inner thighs in a paved square at the village’s center. In a damp building, we open a laptop and unfold a manual blood pressure cuff. Children crowd the windows to catch a glimpse of Peter and me. Soon they are flooding the room jumping and giggling as Peter takes pictures and lets them review them on the digital display. They perch themselves on a pyramid of rice sacks in a corner whispering and giggling as we begin to interview the members of the community.

Over the next several days, we hear the same story related over and over: the men farm for a few months out of the year, but the work is temporary and pays little. The money granted to the women by NGOs helps cover some of the expenses, but does little to provide the financial traction needed to allow them to consider more lasting employment.

Then there’s the corruption. Government programs to provide rice to impoverished villagers are notorious in this regard. The money is siphoned off by middle men and government employees all the while cultivating dependence among the poor and disincentivizing would-be workers. It’s an ugly circle of circumstance fashioned over years, further tainted by alcohol and disease. The NGOs sprinkle well-intentioned volunteers in several month stints on top of it all, but if one thing is clear about the situation, it’s this: How can something built by generations of misfortune be broken by temporary measures that do little more than tidy the surface without ever digging for the diseased roots?

The approach we have unwittingly selected, and the one which I envisioned when I first began to familiarize myself with the field of global health, is one tailored to the remediation of disasters and acute humanitarian crises, but what I saw in Tamil Nadu was something entirely different. Diabetes, cancer, and alcoholism require years of

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commitment on the part of providers who understand the societal and cultural components particular to the context in which these diseases manifest themselves - the so-called social determinants of health. And this is excluding the background structural issues in India that complicate the implementation of change. Slowly, I began to realize that the efforts that succeed will be led by people who understand the problems in a way I never can, people who have been born and raised in their midst and who can grasp nuances that are invisible to someone like me. 

Under a tree in the center of the village, one man waves his arms furiously, the bulb of the blood pressure cuff swinging wildly, evading my grasp. The veins in his neck bulge as he gestures toward the home of a government official and bemoans the corruption. In the midst of his tirade, a woman approaches us. She says something to Bharath in Tamil.

“Her daughter is sick. She wants you to see her. She is there, only.”

Bharath nods toward a small house at the end of a dirt path. We find the little girl sitting on the front steps. She is malnourished and perhaps as a result, was never able to walk. The mother looks at Peter and me expectantly, but we are both ignorant and at a loss as to how to react in the face of a problem that started years before we got here and whose end will arrive in one form or another long after we leave. I feel the transience of my presence and am forced to confront the fact that when I leave this place, I and whatever menial contribution I might make will be forgotten. For all the significance their circumstance had to them, in the end Rosencrantz and Guildenstern are unceremoniously dispatched as Shakespeare ties up his play’s loose ends. Almost as an afterthought, the English Ambassador relates their fate to the audience: “Rosencrantz and Guildenstern are dead.” 

Smiling and bobbing his head, Bharath’s father dips his thumb in the red powder and then presses it to the center of our foreheads. He ties a thin string coated in turmeric around our wrists. It is the day of a water festival in which Hindus give thanks to the gods. Up we walk to the ridge above the family’s well behind the kitchen. At its edge we place a silver tray laden with fruit and flowers as an offering. Bharath’s father, next to me extends his hand and nods toward mine. I take his and there we stand in observance of ancient rites older than any tradition I have known,

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observers to the unfolding of a story thousands of years old, but also in some way a part of its unfolding. Guildenstern on his and Rosencrantz’s predicament: “Wheels have been set in motion, and they have their own pace, to which we are… condemned. Each move is dictated by the previous one—that is the meaning of order. If we start being arbitrary it’ll just be a shambles: at least, let us hope so.

Because if we happened, just happened to discover, or even suspect, that our spontaneity was part of their order, we’d know that we were lost. A Chinaman of the T’ang Dynasty […] dreamed he was a butterfly, and from that moment he was never quite sure that he was not a butterfly dreaming it was a Chinese philosopher. Envy him; in his two-fold security.”

In the Vedic texts, Rta refers to the pervasive order that governs the unraveling of the universe and everything in it. It is the sacred duty of the individual to assume his place in this order and to fulfill those tasks to which he is cosmically relegated with a quiet grace. Perhaps my coming to India was a spontaneous act, an attempt to break free of any imperceptible order by which I was bound. Perhaps the sense of romanticism and adventure I had felt before leaving was my own anticipation of the perturbations in this chain of events I believed my activity had the potential to produce. But now, standing with Bharath and his family, having heard the stories of the villagers, so far away from anything I knew, I understood that the wheels that had been spinning for thousands of years prior to my arrival would continue to do so regardless of my actions, as they ought to. I had broken the fragile uncertainty to which Guildenstern alludes, compromising the security it provided. But if I am a fixed spoke in a turning wheel, devoid of anything but illusory autonomy, I did not feel condemned or lost because of it.

Rather than leaving me with a ruptured sense of myself, bearing witness to the evaporation of my global health fantasies left in its place a deeper appreciation for those things over which I did have control and that mattered most to me: My power to shape the way in which I engage the world and the relationships I build with others in doing so. Anything bigger seemed a distraction. (continued on page 54)

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Tigers After the Circus Photograph

Sam Jones

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(continued from page 54)



Before we left Mukkalnaickanahalli, Peter and I sat with Bharath on the patio to discuss the implementation of a community health program in the village. I had ideas having seen and read what I had, but Bharath seemed to find nothing new in my suggestions. Instead, he asked us a question that I was ashamed to be unable to answer.

“How do you fix these problems in your country?” Something became clear in that moment. I had tried for years to educate myself about the conditions in places around the world believing that this would make me an effective agent of change. But in talking to the villagers, I had come to see that there is some essential element to the equation that comes with laying down roots in a place and cannot be expressed using language. I will never have this intuition about a village in rural India, but sitting with Bharath, I recognized that perhaps if I more fully commit myself to my own community, a deep understanding of the places we come from could be an effective foundation on which to build a mutually beneficial relationship. Ironically, the most helpful advice I could offer to a community abroad is an intimate understanding of my home. I am embarrassed at my naïveté and remember Twain: “[One] will never know what a consummate ass he can become until he goes abroad.” 

When I returned from India, I came across a 2009 article by Wendell Berry called “Faustian Economics.” In it, Berry cautions against an idea of limitlessness that has characterized much of the American experience.

Our nation came of age during a time of seemingly endless westward expansion and though resources are becoming strained, our culture of limitlessness persists. This doctrine has, according to Berry, led to the “minimization of neighborliness, respect, reverence, responsibility, accountability, and self-subordination,” because each of these principles by necessity requires the individual to impose limits upon himself.

I wonder if global health, as it is presented to medical students, has suffered a similar fate. I believe that insofar as this principle is applicable to the individual, I had become one of its victims. In seeking to expand myself through travel I had unintentionally loosened my ties to those things that are essential to long-lasting improvements in any community:

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neighborliness, respect, reverence, responsibility, accountability, and self-subordination. I suppose I had done what I had set out to do: stretch myself. But I had stretched myself thin. I found myself less attracted to the sort of global commitment I had dreamed about before my trip. I had decided that though global health, as it is traditionally rendered, with skilled personnel parachuting into a war zone to provide relief from disease and famine will be necessary as long as these atrocities occur, the noncommunicable diseases and societal shortcomings that afflict growing numbers of people around the world, are not amenable to this approach.

I began to think that by limiting my focus, by offering complete devotion to my own community rather than fractional devotion to someone else’s, I would find more complete fulfillment. I was disappointed in my personal desire for limits at first; perhaps I was just intimidated by the demands of the field, but I found solace in Berry’s words: […] our human and earthly limits, properly understood, are not confinements but rather inducements to formal elaboration and elegance, to fullness of relationship and meaning. Perhaps our most serious cultural loss in recent centuries is the knowledge that some things, though limited, are inexhaustible.

And as I had come to see in my discussions with Bharath, cultivating the earth within our self-imposed limits can yield universal benefits. I can say that Bharath’s commitment to his village has compelled me to commit myself more fully to whatever place I will come to call home. As our network for global communication tightens, as channels open over which ideas for local development may be shared and filtered, perhaps we will see truly sustainable progress in quelling the chronic ailments that threaten the well-being of so many around the world effected by the those that understand them most intimately. 

Munnar, Kerala, set high in the Western Ghats, looks as if it were taken from a child’s storybook. The inroads twist along the sides of rocky slopes moistened by the streams of monsoon water that creep languidly down their faces. Brightly painted buildings are interspersed with tortuously trunked trees within the tea hedges that stretch like carpet across the hills and disappear into the fog.

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On our first day there, Peter and I leave our host’s home to explore the surrounding hills. As we traipse through the jungle, it begins to rain. It comes down in great beads quickly overwhelming our cheap umbrellas and lands on the plump green leaves flanking our path with fat splats. We continue along the path and as we round a turn, a mechanical grumbling rises at our backs. We stop and turn. A school bus. It stops at the turn and opens its doors. Laughing uniformed children leap from the bottom step and a waiting father takes a girl’s hand. They start up the path behind us as Peter and I turn back toward the road.

“Hey!” shouts the father behind us. “Hey! Wait!” We turn again.

“Where are you from?” he asks us.

“America,” we tell him.

“Ah, do you like tea? Come.” He says, passing in front of us with his daughter, sandals flopping against the wet earth, his dhoti brushing his knees. Peter and I follow.

“I live here, only.”

“What does someone do up here for a living?”

“Me, I grow spices. Pepper, cloves. Come, I will show you. It is here, only.”

Their home is a small cinderblock building of a few rooms. The little girl takes Peter and me around back. She leads us into her room, it’s small with a tiny chair and bed. There are wooden shelves stacked with medals and a few trophies. We remark on her awards, and she runs back out into the yard among the azaleas showing us the pink and purple flowers. Her father returns with two cups of tea and we sit on a small porch at the back of the house, drinking and talking. How strange, I think, that something so foreign can be so familiar.

Since I visited India, I have wracked my brain for some succinct conception of the idea of global health. I have struggled to reconcile a term that seems to encourage exposure to myriad conditions with my belief that change is most meaningful if implemented by individuals with a personal interest in its success. Perhaps the lesson is this: there are certain things that define the human experience the world over. Devotion to and pride in our communities, our families, and our friends are things that speak to us whether we live in New York City or on a hill in southwest India. So it would behoove the internationally minded health care provider to remember that “global” does not refer to the universality of our commitment, but to the universality of those things to which we are committed.

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Elephant Butt Oil on Canvas

Priyanka Vijay

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Comfortable Courtney Haviland We are crammed into this windowless, tiny room where our desks face the walls and our backs face each other. We wouldn’t know if it was daylight, but it’s not, anyway. I swish my coffee in its cup, drum my fingers on the keyboard, the clicking joining that of my residents as they pound out their daily notes.

My participation in the din reminds one of the residents that I’m here, and he half-turns in his chair to see me, “We got a new admission overnight. Elisa Tam. 32-year-old with metastatic breast cancer comes in with two weeks of nausea and abdominal swelling, likely progression of disease.” I feel my face draw into a wince. I’ve been a third year medical student for one week, but even I know what this means.

“Yep,” the resident smacks his lips, agreeing with my face. He twirls his chair to go back to his typing. “She’s gonna die.”  When we get to her floor for rounds, the resident points to a woman ahead of us in the corridor. “That’s her,” he says. She is gliding slowly toward us with her mother and an IV stand, one hand on the pole and the other cupping an enormously swollen belly.

“Are you coming for me?” She asks. She says something in Mandarin to her mother, then, “It’s okay, I’ll take my walk after.” She smoothly maneuvers the IV stand so that she can turn around, to lead us back to her room. The group of us, we hesitate, watching her deftly keeping her lines slack and ordered.

She is out of place here, dressed in clothes, not a gown, shoes, not hospital socks. I feel a little hysterical about it. She looks like the type of pregnant woman my friends and I have joked about wanting to be. “The kind you don’t even know is pregnant from behind,” we say. “The kind who just looks like she has a beach ball under her shirt.”

But, of course, she’s not pregnant, though her legs are swollen, and she takes a wide, waddling gait. She’s not pregnant, though she sits on the edge of her hospital bed with the fingertips of one hand resting lightly on her taut belly, as if to protect it from what we are saying about it.

“We think there’s fluid accumulating in your abdomen,” the attending

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tells her. “We think it’s from the cancer.”

Elisa nods and presses her palm flat to the swelling, testing it.

The attending continues, “We want to do a CT scan, to see if we can tap it— to see if we can put a needle in to remove some of the fluid. Make you more comfortable.”

Elisa regards us for a moment, says, “It doesn’t feel like fluid.”

“Sometimes it’s hard to tell,” the attending assures her.

Elisa translates this for her mother, who says nothing.

“Whatever you think will be best,” she says.  We’re all at our desks again, the next day, when the scan comes back. The resident calls us over and pulls it up. He and the intern collectively groan as her abdomen comes to fill the screen. They scroll through her from top to bottom as I cock my head, frustrated, looking for something to orient myself in the anatomy. A kidney, bowel gas, anything. But instead, mottled, patchy grey fills the ellipsoid cross section of her body.

“She’s all liver,” the intern says.  “It’s bigger today,” Elisa says on rounds. She does not look solemn so much as serene, in bed with her feet planted on the mattress, her back supported by a pile of pillows. Her body is folded into a little boat, a cradle, beneath the mound of her liver.

“Unfortunately, from the scan, it looks like there isn’t any fluid for us to tap,” the attending tells her.

“My stomach, is it bigger? Is it because I couldn’t have the chemo for the past few days?”

The attending looks chastised. “From what we can see on the scan, it doesn’t look as though the chemo was working.”

But Elisa only questions, “So do I switch to a different one? Maybe back to the taxol?”

The attending explains that we’ll have to work out a new plan, that we’ll want to keep her in the hospital for a few days. “While we try to get your pain under better control,” she says, putting a hand on her knee.

“While we try to make you more comfortable.”

Elisa says this to her mother, who says nothing.

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 “So who’s going to tell her?”

“It should be Martin. It’s supposed to be the primary. You know. They have the relationship.”

“We’ll have to see if we can get him in this week to see her. She should know before we send her home.”

“She’ll know. She’ll know when we send her home with morphine and miralax if she doesn’t know already. I keep thinking she’s going to make me tell her when I pre-round on her in the morning.”

“He should really be the one to tell her. Martin. It’s better to wait, so they can get the news from the person who they’ve known the longest.

I’ll email him.”

“Okay.”

“Now tell me about Ms. Pine.”  The next day, her mother is standing in the doorway when we come in.

The curtain is drawn between Elisa and her roommate and in the small space of the half room, her mother has arranged a semicircle of chairs facing the bed where Elisa is propped forward on her careful stack of pillows. Her mother ushers us all in and gestures for us to sit. She stands behind us, where she was, in the doorway.

“I wanted to talk to you,” Elisa begins. She looks around at each of us, and we look at each other.

“I want you to know that I understand, because this is happening so fast now.” She gestures once, jerkily, toward her belly, takes a breath, then brings her hands down on either side of her on the bed. “I understand that everything has changed.”

There is a long pause as we realize there will be no waiting for Dr. Martin. Then the attending nods, “Yes.” Elisa sighs, balls her hands into fists. “I just. I’m wondering if you could tell me if you think I will be alive at the end of this week.”

The attending lets out a burst of air, almost a laugh. “Yes! Yes! Goodness, yes. We think you have weeks!”

Elisa looks up and nods and keeps nodding. She closes her eyes, opens them again, breathes, “Weeks.”

She is quiet again for a moment.

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”I, um. I understand that the focus is now on making me feel… comfortable.”

The way she says the word, it has four syllables. It tumbles down stairs.

“I understand that that means using my PCA and taking the water pill to try to lessen the swelling in my legs.” She looks from one of us to the other. We are quiet. The intern is looking at the ground.

Elisa opens her mouth to say something else, then she stops, and she looks at the ground too.

“Yes,” the attending encourages her, soft.

“I’m wondering why, if it’s my liver that’s failing. Can’t you do a transplant?” she asks quietly, studying her feet where they are planted on the floor.

“We cannot,” the attending explains.

“What about. There was a procedure they talked about. Before. Where they could inject the parts of my liver… ” “It’s too late for that now,” says the attending.

“The best thing we can do now— “the attending begins, but stops when Elisa looks up.

“So that’s all that is left?” she asks, very quietly. She looks past us, and I remember again that her mother is back there, watching. “Just to be comfortable?”

I look back at her mother, who is very still, except for her head which is making little nods. As I watch her, she smiles a little, and her eyes fill, and she nods faster, faster.

“Yes,” says the attending. “That’s what you do.”

Elisa is nodding too now, looking at her mother who stays standing in the door. She keeps nodding and they keep looking at each other, through us.

“Okay,” she says. “Okay.”

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Descartes in Medicine “[S]o also the human body may be considered as a machine so built and composed of bones, nerves, muscles, veins, blood and skin that even if there were no mind in it, it would not cease to move in all the ways it does at present when it is not moved under the direction of the will.”

René Descartes, Meditation VI, Meditations on First Philosophy

Pain, riveting, blood-pulsing, hearts screaming Jumping towards the hands of light embrace, caressYearns as stars for their unlatched pasts No—Descartes, Nay—René You may not philosophize, mechanize, reduce by enlargingFor what you see is but the Hooke For we often believe far more than in what we see Doubt all visible for those invisible Stay distanced and hold yet from smoldering the plasma Of our lucent hearts That lights, guides, passes A warmth and touch unseen Giving meaning beyond the components sum Imbuing our disembodied pain and blood-ethereal With a reach far beyond the scope Of our glass covers — John Moon

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Four Days of Thawing Photograph Composite

Peter Hung

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The Eternal Exile Benet Pera-Gresely, PhD From the stern of a rusty liner, the Austrian humanist observes the ocean swallowing Downtown while he sails away heading to Brazil. It is 1941, and Europe has been immersed in its second fratricidal war for over two years. In his heart, the writer stores an infinite sadness accumulated after having seen the best and the worst of humankind. In his memory, he reminisces about his happy childhood when he furtively wrote poems during math class, and the son of the theater janitor was the most admired and respected by his classmates. That was the Vienna where he was born and raised. A two-thousand-year-old supranational metropolis, capital of a great and mighty empire, about which the author would say in 1939: “Do not look for it on the map; it has been swept away without trace.”

A melancholic smile appears on his face when he recalls the days of his youth traveling to the four corners of the world, learning from the cultural richness that surfaced at that time. In 1901, when he was only twenty years old, he published his first poems. His first novel and a doctorate in philosophy would come just three years later. Unfortunately, when humankind decided to betray all reason during the summer of 1914, the humanist was drawn to participate in the madness. Nevertheless, his friendship with the future Nobel Prize laureate Romain Rolland, together with the ludicrous amount of spilled blood in No Man’s Land, opened his eyes to the nonsense of war, and from then on he would embrace pacifism. As he would write some time later: “Before the war I knew the highest degree and form of individual freedom, and later its lowest in hundreds of years.”

A tear rolls down his cheek while he stares at the horizon. The skyline has disappeared now and only the blue desert of the ocean stretches in front of his eyes. The intellectual recalls then the years that followed the defeat. He remembers having to write in bed during the winter due to the lack of fuel for heating; he remembers paying an extortionate price for just a piece of bread because of the huge inflation; he remembers the hunger and the misery. However, in the words of his friend Albert Einstein, whom he visited during exile in Princeton in 1930: “Creativity is born from anguish, just like the day is born from the dark night. It’s in crisis that inventiveness is born, as well as discoveries made and big strategies.” Thus, it was during the interwar period when the writer

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achieved his maximum creativity and international recognition.

The pacifist contemplates the sun hiding behind the horizon, plunging into the ocean at twilight; just as in 1933, the heart of Europe was covered with the darkness of a nonsensical ideology, born from an irrational hatred. A shiver runs down his back. He buttons his coat and goes to his cabin while he recalls with inconsolable sadness how his books went from being loved by millions of readers, to being reduced to ashes over the Jewish origin of the author. He remembers how he had to run away from his homeland as if he were a criminal, and with a broken heart took refuge in England until the war started in September 1939. Then the eternal exile was forced once again to emigrate, this time because of his German passport. New York would be his next stop.

Defeated, the writer lies down on the bed in his small cabin and closes his eyes. Inside his luggage, his newly written memoirs travel with him.

In its pages, he wants to leave evidence of the uniqueness of the time he had to live. In his own words: “Against my will I have witnessed the most terrible defeat of reason and the wildest triumph of brutality in the chronicle of the ages. Never—and I say this without pride, but rather with shame—has any generation experienced such a moral retrogression from such a spiritual height as our generation has... But if we with our evidence can transmit out of the decaying structure only one grain of truth to the next generation, we shall not have laboured entirely in vain.”

A year later, tired and convinced that the evil empires would manage to conquer Europe and the Pacific, he decides to take his life together with his beloved. On the 22nd of February 1942, Stefan Zweig ceased to exist.

Now I walk down the same streets of New York that hosted the Viennese pacifist in what would be his last trip before leaving for Petrópolis, then leaving for eternity. I find him in libraries, in bookstores and sometimes I even think I see him walking down Fifth Avenue, always with a book under his arm. I will never cease to feel European, but, as he said, above all, I appreciate “the value of absolute freedom to choose among nations, to feel oneself a guest everywhere.”

It has been a long time since I chose to be a scientist. However, on the day of my thesis defense, my father gave me the memoirs of Stefan Zweig, The World of Yesterday, and after reading it, I understood that science and humanities should always go hand in hand. I understood that science makes us more human.

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Dog Sledding in White River National Forest Photograph

Anthony J. Choi

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Cousin Fred and the Laws of Thermodynamics Jeffrey Fisher, MD Cousin Fred was an automobile savant. In his bedroom were neat, chronologically ordered piles of Popular Mechanics, Autoworld, and his favorite, Under the Hood. When not “auto-reading,” Fred spent his free time in his father’s garage, tuning the family car and rebuilding his jalopy. Fred would stare transfixed at the motor block, stroking his chin, flaring his nostrils, and raising his ears for a telltale trace of disorder. Our family nicknamed him “Sherlock Holmes to Cars” and on his thirteenth birthday, my father gave him a deerstalker cap. Fred would jump from the school bus, pull his hat from his book bag, and race to the garage, shouting, “Quick, the game is afoot!”

Despite his parents’ misgivings, Fred attended automotive high school and became a school legend. While his classmates were there by default, Fred reveled in the art and science of automobiles. After rebuilding a distributor while blindfolded, an astonished instructor asked Fred what his personal motto was. Fred, a true-blue perfectionist, took no time in responding, “Good, hard work—the universal anti-entropy.”

Fred’s diligence paid off. Upon graduation, he surprised his family by obtaining a respected and lucrative position as the service manager at the most prestigious automobile dealership in the state. Customers grew to like the hardworking, pale, and pudgy kid with the deerstalker cap who treated them respectfully, got their cars serviced on time, and made their cylinders sing. Satisfied customers thought Fred was a hat collector and began to shower him with all sorts of headgear. Fred nailed his hats in a line around the service center and knew which customer had gotten him which hat.

Except for getting balder and bigger in the middle, Fred’s life remained fairly constant for a number of years. His boss appreciated his hard work and dedication and Fred got regular raises. However, things at the dealership changed abruptly when Fred’s boss retired and the sales manager was chosen to replace him as general manager. The “Chief,” as he now wished to be called, was tall, dark, and hairy. He was a former baseball player whose professional career was cut short by a Vietnam War injury. The Chief was his country club’s perennial golf champ and one of the reasons he was chosen for the top spot was that he was a “rainmaker.”

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It was said that the Chief could bring in more sales in one afternoon at a charity golf tournament than the entire sales staff in one week.

Fred thought the Chief cared more about appearances than performance and reliability, and he was correct. Under the Chief ’s management, the number of service employees was decreased regularly.

Despite grumbling from the union, senior mechanics were transferred to other dealerships and subsequently terminated, while unskilled junior mechanics were hired. Despite these cutbacks, there was enough money in the dealership to create new showroom façade, which gave the dealership the appearance of a cathedral. When the company’s new model was chosen “Car of the Year,” the Chief placed a huge banner across the front of the dealership, proclaiming, “Home of the Car of the Year.”

Despite increased sales at the dealership, Fred grew increasingly frustrated. The new mechanics did not have the same work ethic, were often late for work, and the quality of the work they did was poor. Fred made a habit now of arriving two hours earlier and often left two hours later, correcting their mistakes. Things really got out of control when Fred returned from a seminar out of town to find several of his crew having a party and not answering the telephone. Many of the cars placed in the “completed” bays had never had the proper adjustments made.

Fred, unable to control himself any longer, exploded, “Do you know you guys could kill somebody?” His pale face turned beet red as he ordered his workers out of the shop. He locked the doors and proceeded to do all the repairs himself, working the entire weekend. Fred called the union shop steward, who promised to investigate and get back to him. He never did.

Two weeks later, the Chief called Fred into his office and told him that the service department had filed a complaint against him with Human Resources, stating that Fred had been verbally abusive. Fred was shocked. He explained his side of the story to the Chief, who appeared very sympathetic. The Chief even seemed somewhat interested and smiled when Fred explained the second law of thermodynamics to the workings of the dealership. “Entropy or disorder,” Fred explained, “will occur unless energy or hard work is expended to control it. For us to produce mechanically sound cars, we need to have skilled mechanics who do quality work in a timely fashion.” Fred asked for a piece of paper.

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“You see, symbolically, if one applies the second law of thermodynamics from physics to corporations, businesses, or even hospitals, for example, then the change in entropy, delta S, equals added productive work minus mechanical work, the unproductive part of getting the job done.

Unproductive work, for example, is the time we spend apologizing for delays or returns.

“In this equation,” Fred continued, “productive work minus unnecessary work is divided by temperature, which is the climate, so to speak, of the business. We all want to work in a comfortable environment with a pleasant temperature.” Fred continued to write: ΔS = ΔU – ΔW T Where ΔS = change in entropy ΔU = change in productive work ΔW = change in non-productive work And T = temperature = ambient climate = work climate Fred resumed, “If you multiply both sides of the equation by T over one, then the equation becomes: ΔST = ΔU – ΔW “Hence,” Fred said, “if the amount of useful and useless work on the right side of the equation is constant, then increasing entropy or disorder will lead to a diminution, or even collapse, of the system. The only way T, the system, can be preserved with increasing disorder is to increase the amount of useful work. If our customers are to count on us for safe transportation, we must invest the time and energy to do proper analysis and repair. I must have time to be able to teach new mechanics the appropriate skills. Chief, I must have you talk to them and tell them the importance of a positive attitude in their work, of respecting clients, and the need for honesty about the time required for repairs.” Fred continued, “Right now, the service department is in chaos. It was never like this before. When we had hardworking, skilled, and honest mechanics who cared about their work, our customers appreciated us. Now, all I hear is complaints. And Chief, I, as one person, cannot fix all the mistakes and speak to the customers and apologize for all the others. I need your help.”

The Chief ’s eyes went soft and he smiled. “Fred, you are 100% correct.

I believe everything you have said and I promise you I will give all these

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matters the attention I think they deserve.” He shook Fred’s hand, patted him on the back, and wished him well.

Fred felt better—for a short while. Although he genuinely apologized to his crew for his outburst, they continued to be unproductive.

Absenteeism increased and work performance continued to deteriorate.

Despite longer and longer hours and spending his weekends in the shop, Fred could not control all the mistakes and complaints.

Six months later, Fred got his pink slip. In a letter from the director of Human Resources, Fred was cited as showing poor leadership skills as the reason for his dismissal. The Chief was very sympathetic to Fred.

“I don’t know what we’ll do without you, Fred,” he said. The union shop steward promised to investigate Fred’s dismissal but Fred never heard from him.

Two months later at an Elks breakfast, Fred bumped into one of the senior mechanics who had been fired from the dealership. They began to speak and within six months bought a garage and decorated it with Fred’s hats.

Three years later, they attended the Chief ’s retirement dinner at his country club. “This must have cost a fortune,” Fred said.

“Yup, and the dealership picked up every penny,” his partner replied.

The Chief was presented with a new set of golf clubs and got a standing ovation when he said that he would fondly remember everyone from his retirement home situated on a golf course in Florida. Doris from Human Resources, who had had too much to drink, confided to Fred on his termination, “Fred, it wasn’t personal. It was business. The Chief thought you were making too much money.”

A year later, the dealership went broke. “People are just looking for better performing cars, I guess,” said Fred, whose grateful clients still bring him hats. However, now Fred gives back two hats for each given, citing his oversupply and then launching into an animated lecture on the first law of thermodynamics.

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Montmarte Oil on Canvas

Scott Breitinger

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Dimples I don’t know why I can’t look at you without crying All du rag and dimples Animated meaty arms, Strong Telling me how now you can walk!

Two months ago I didn’t know you had dimples; Your gaunt face had flattened them ThenYour tumor sat like a basketball on your hip You couldn’t turn And now you walk!

The dressing there, now barely a bump, a small pillow, White and clean You tell me your plans And you pull out from the bedside drawer that moleskin notebook.

I had taken it from my bag and ripped out the first few used pages I wanted to give you something!

For you to write your rhymes And the blue Chase Bank ballpoint You hold that cheap plastic between your thumb and forefinger and say “I still have the pen you gave me” And I wipe my tears with the yellow sleeve of the contact gown — Lara Wahlberg, DNP, RN, OCN

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June

Photograph

Elen Gusman

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What is the Hospital for?

Caroline Pinke What is the hospital for? Before coming to medical school, I never considered this question. The answer was obvious: The hospital is a place where sick people come to get better. But throughout my Internal Medicine clerkship, all of my patients came to the hospital because they were sick and most left the hospital in stable condition, but many were still sick. Spending so much of my time in the hospital this past year has more directly taught me what the hospital is not for. ◆ The hospital is not for curing addiction. ◆ During my first month of Internal Medicine, I had two patients who suffered from alcohol dependence. They had the same underlying chronic disease but were admitted to the hospital for different acute issues. The first came in looking like a ghost—anemic and dehydrated after vomiting blood for days. We pumped the life back into her with blood transfusions and IV fluids. She regained the flush in her cheeks and moisture on her tongue. Once she was able to keep food down, her biggest concern was catching her flight back home to California. The best we could do at that point was recommend follow up with a doctor in California—which was made more difficult by the fact that she was uninsured—and with Alcoholics Anonymous, which she had tried and failed in the past. And then we discharged her, with little hope that she would heed our advice.

More than likely, she would start drinking on the flight home. She was stable for discharge, but she was still sick.

The second patient came in buckling at the waist, with crippling pain. This was his fifth or sixth hospital admission—he wasn’t sure—for alcoholic pancreatitis. We kept him from eating so his body could rest, gave him pain medication and fluids, and monitored him for alcohol withdrawal. Once his pain had subsided, he felt ready to leave even though we weren’t ready to discharge him. Because he was still at such high risk of going into withdrawal, we couldn’t yet deem him stable. But he wasn’t concerned about this risk, so he eloped from the hospital in the middle of the night. My resident joked, “At least we don’t have to worry about him going into withdrawal!”

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◆ The hospital is not for solving every diagnostic mystery. ◆ Two of my most interesting, and sickest, patients left before we had all the answers. The first patient came in with severe back and joint pain.

He turned out to have vertebral osteomyelitis, an epidural abscess, and multiple septic joints from an undertreated bacteremia. While we worked with our consultants of various specialties to treat his disease, I kept dwelling on the question of how he had gotten so sick in the first place. I was sure something must have predisposed him to such serious infection, and I desperately wanted to figure out the underlying diagnosis. But the patient just as desperately wanted to get out of the hospital and continue living his formerly active life. Once we set him up with a peripheral line for antibiotics, transitioned him to oral pain medications, and made his follow-up appointments, my curiosity was not reason enough to keep him.

The second patient had been dragged to the hospital by his daughter because his outpatient doctor was concerned, though he himself wasn’t interested in help. He had multiple worrisome symptoms: He had been vomiting after eating and was losing weight, his kidneys and heart were failing, and he had an incessantly runny nose, to name a few. The intrigue really began when his labs came back showing a very high eosinophil count, which we couldn’t easily explain. Over the next day, we sent off a long list of tests and pored over the differential diagnosis for multi-organ system failure with eosinophilia, hoping for a diagnosis that would tie together his complicated presentation. Meanwhile, the patient was getting antsy. He hadn’t wanted to be in the hospital in the first place, and now he was feeling left out of his own care. With many potentially diagnostic labs pending, my very interesting, and very sick, patient left against medical advice. I found this out the next morning when his name had dropped off my list, and I was overcome with selfish disappointment that I wouldn’t find out his diagnosis. This feeling was followed immediately by immense guilt and worry that he would probably keep getting sicker.

We may have been able to help him if we had focused more on his needs than we had on his symptoms. ◆ The hospital is not (always) for keeping people alive. ◆ I spent my last month of my Internal Medicine clerkship on the Geriatrics service, where “goals of care discussion” is a common item on the to-do list. Our oldest patient was a 110-year-old woman who was brought in

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from a nursing home because of worsening confusion. At her best, she was completely blind and nonverbal, but able to swallow small amounts of liquid, breathe on her own, and moan when she was uncomfortable.

We started treating her with broad-spectrum antibiotics for a presumed pneumonia, which may have precipitated her delirious state. She was still breathing on her own, but she was no longer opening her eyes or moaning. Her ever-devoted 85-year-old daughter was always at the bedside, raising concerns about her mother’s inadequate nutrition or asking questions about the specific antibiotics she was receiving and their potential side effects. She was intent on doing everything in her power to keep her mother alive. Then, her mother no longer seemed interested in, or capable of, eating or drinking. Three days passed during which her mother was not alert enough to swallow without coughing, so she started to ask about the option of putting a feeding tube directly into her stomach to provide nutrition. I couldn’t help wondering, to what end?

Later that month, another very sick, elderly patient was admitted to the Geriatrics service for confusion, with a similar non-interactive baseline.

Not only did this patient have a Do Not Resuscitate/Do Not Intubate order, but she was already receiving home hospice services. When she started to become more confused at home, her daughter decided to bring her back to the hospital—she had either not understood or had found it too difficult to accept the hospice terms, which strongly discourage patients from returning to the hospital for acute care. As I learned, these kinds of hospitalizations serve primarily as opportunities for end of life discussions with loving family members—who are sometimes blinded by their devotion—rather than as opportunities to save lives.

Unfortunately, patients and family members too often assume, as I had, that the hospital is solely a place where sick people come to get better. Things are more complicated than that. So, what is the hospital for? Through my futile search for a simple answer to this question, I was reminded that every human life is different, and every disease is different. The hospital is the common backdrop on which life’s extremes play out—miraculous beginnings and tragic ends—and it is also host to human experience that falls at every point between these extremes. The hospital is merely the context in which human lives intersect with, or are interrupted by, disease.

And as health care providers, we have the unique privilege of standing at this fragile intersection and doing our best to help in any way we can.

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Brooklyn Bridge Photograph

Yoshiko Toyoda

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Fighting for his Life I wanted to cry But my tears had to wait Because my tears would sadden him And make him think I had given up hope And he needed hope To fight for his life I wanted to scream But my shrieks had to wait Because my shrieks would scare him And make him think I had given into fear And he needed courage To fight for his life I wanted to break down and crumble But my weakness had to wait Because my weakness would break him And make him think I had given up faith And he needed strength To fight for his life Hope...

Courage...

Strength...

He needed them all...

To fight for his life — Ngozi Monu, PhD

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Fall n Angel Photograph

Elizabeth DuPre

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Memory Fabiana Kreines One year and two days ago, a stranger found me curled under the sink in the bathroom at work, sometime around 9:30 am. I know it was around that time because I looked at the clock when I saw that my mother was calling me, confused as to why she needed to talk to me at 9 am on a Friday morning. I remember that, instead of hearing a voice, I heard my mother crying on the other line and didn’t need any further explanation.

I don’t remember much of what happened after that, but I do remember the stranger grabbing me by the biceps and pulling me up and trying to get me to explain why I was crying hysterically. I remember screaming while I was crying, a type of crying I can’t remember ever doing before. I remember being totally unaware of how many people could hear my wails. I remember trying to tell the stranger that my best childhood friend was gone, a friend who was essentially my brother, who I had known for more than half of my life, and I remember getting angry when she asked how close we were, as if that were going to change how she dealt with me.

I remember choosing not to tell her that he died of leukemia. I remember not wanting her to think that I saw this coming, that any of us were prepared, or that he was somehow ready for what happened to him at 2:30 am that morning. I remember my friend finding me, presumably once the stranger decided there was nothing more she could do. I remember digging my nails into my calves while I stared at myself in the bathroom mirror, sitting on the floor for what must have been at least an hour.

For four and a half years, Ryan always hoped. We all hoped. When the chemo failed, when a bone marrow transplant suddenly seemed like a good option, when his minimal residual disease couldn’t go low enough for transplant, when Phase III trials failed and Phase I trials weren’t cutting it either. There was always another option. I was across the street in Zuckerman, in a lab studying bone marrow transplant and liquid tumors, always mentioning new ideas or studies to Ryan, as if he hadn’t memorized every option already. There was always something else, something that came next, another reason not to lose hope.

I remember looking at myself in the mirror, running through the

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options in my head the way I always had for the past five years, wondering what I was going to say to Ryan, because I knew he would be upset.

I remember that each of those thoughts lasted three seconds before I had to remind myself that there was no room for hope anymore, that I couldn’t talk to Ryan, that he was actually gone.

Hope was the reason I could refrain from crying for a few seconds, but it was also the reason I would devolve into hysterics a few seconds afterwards. Ryan knew how important hope was, and that was why he decided to let everyone hold onto it. I was one of the only people other than his parents who he expressed his fears to, who saw the hope dwindling, and it was only because he knew I would have figured it out myself anyway. Even still, it wasn’t until I read through his last text messages this past Saturday that I saw how he was sparing me, too. For those last few weeks, he knew what was coming, but didn’t want any of us to have to deal with that burden of knowledge.

Anger was the only thing I felt then, and it’s still a large part of what I feel now, even if it’s not as searing. Ryan was no more equipped to face his death at 23 than any of us are, and I hated to see people’s expressions change when they found out that he had his disease for almost half a decade. Obviously, losing a loved one to an accident is different, but losing Ryan was no easier or any more predictable. If anything, the hope we all clung onto for so long made it even more shocking, even more unbelievable.

Grieving hasn’t been about letting go of Ryan, because I refuse to ever let his memory fade. I hate knowing that we will no longer grow up together, no longer be able to update each other on the small and big changes in our lives. I hope that I remain this angry about that forever, that his memory will always be vivid enough for me to get upset every time I realize I can’t call him up. Grieving instead has been about letting go of the hope that kept teasing me that morning as I sat on the floor looking in the mirror, crying because I knew Ryan would never let this disease take him in the end.

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Hope Is

Hope Ebbs

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Hope Surges

Hope Is, Hope Ebbs, Hope Surges Watercolors

Madeleine Schachter, JD

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Time Travel Careful, if you nod against the hum of the night train you’ll slip past the glass— Take me past the buildings dabbed in soft lights across seas, bridges, cities Reconstruct my former universe The summers where my grandmother crouched down and told me that dying was easy The fields where an arm sweep would ring sweet whispers from the grass The church we’d go to escape the heat, a hundred speckled monarch butterflies gathered under the eaves The nights where my mother would hold up her thumb and carve out a constellation of synapses in the sky Falling asleep against her shoulder as she told me her dreams in a language I can no longer remember.

— Michelle Lee

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In the Rain, In the Train Photograph

Qiaochu Bernice Qi

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Icarian Sea Gall Photograph

Elizabeth DuPre

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Breathing Memories Is it true our lungs remember Each breath they have taken?

That they forget the air that gives them purpose I cannot fathom.

Look, now, Here I am.

Those walls look so familiar.

I spent my life within those crinkled ivy leaves.

Though my mind refuses to be tinder, My lungs obey the calls of the blood-red bricks From behind those vines.

With each breath, A frostbitten memory breathes too, Rekindling, for an instant, a whisper (Or a laugh, or a scornful silence) From a life long buried beneath frozen tundra, A godforsaken sapling withering in the cold sunlight. — James Wang

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Waiting Natalie Wong She is aware of it from the moment that she wakes in the morning, before she opens her eyes or looks in the mirror. Without a doubt, she still has those thirty pounds of new flesh and love hugging her abdomen. She’s groggy and just waking from sleep, but her little baby is wide awake. He kicks her in the stomach, hard, as if to make sure that she’s ready to start the day.

She opens her eyes.

Another day, pregnant. Another day, an almost mother. A day to walk around the house, pacing back and forth while folding her son’s clothes, waiting for the water to break and, with a burst of pent up excitement, come spilling out of her from behind that dam of anxiety. She is impatient, wanting to hold the baby that she’s carried and loved for nine months now. She’s awake, and she’s ready, but she’s still waiting.

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Waiting

Pencil Drawing

Priya Gupta

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Ascensus Volume IV

Ascensus is Weill Cornell Medical College’s annual journal of the arts and humanities. It was founded by a group of medical students in 2011 to provide a space for students to reflect on the practice of medicine. Since then, it has grown to feature work from all members of the Weill Cornell community, including faculty, house staff, medical students, graduate students, nurses, social workers, and more. Over the past four years, Ascensus has featured rich visual and written work by many members of the Weill Cornell community.

The editorial team takes pride in the quality and diversity of the work showcased each year and hopes to continue serving the community through this publication for many years to come. We believe that this journal provides an important voice for members in our community as we come in contact with patients and their stories, and think of our own.

The mission of Ascensus is to bridge humanities and medicine through publishing an annual journal, along with holding lectures and other events.

We would like to encourage all members of the community to continue creating artistic pieces and reflections on medicine and the human experience. We look forward to receiving submissions for next year’s journal! Please reach out to us at wcmc.lit@gmail.com with submissions or questions.

Lastly, we would like to thank our faculty advisors, Dr. Susan Ball and Dr. Randi Diamond. Ascensus is published with the support of Weill Cornell’s Office of Academic Affairs and the Liz Claiborne Center for Humanism in Medicine.