Life under the quill

It's been a busy year, but I thought I'd briefly review the last two books I finished up last year, A Confederacy of Dunces by John Kennedy Toole and Things Fall Apart by Chinua Achebe (whom I really must stop confusing with China Mieville -- it's embarrassing!

Things Fall Apart is the story of a powerful tribal leader and how his life changes both through the good and ill luck of his traditional community and the impact of colonialist missionaries in the latter half of the book. It is an interesting exploration and gives significant tribute to the tribal culture before shifting to how colonialism altered it. However, overall I felt the book lacked. I feel it made a dent in 1959 because African nations at the time were bucking their colonial powers and not due to the nature of the writing or the plot. It feels like the book everyone hoped an African would write, and Achebe just happened to be the first to gain from a timely publication. Overall, an interesting exploration, but not compelling in the way of other books.

I'd had Confederacy of Dunces on my list for some time since it was also prize-winning, and yet I was sorely disappointed. Perhaps if I knew New Orleans better it would have some nostalgia for me, but as it is I had to satisfy myself with the characters. Per the cover, the main character Ignatius Reilly is an "obese genius" and "frustrated scholar" who lives with his mother and gets into all sorts of hilarious hijinks. From my perspective he is someone with an obsessive personality disorder that ends up the butt of jokes for the 400 pages of the book. I know people like him or at least with similar characteristics and the repeated offenses he gives his employers and family seem less funny than a product of his inability to understand social cues. I suppose you can write comedies about mental illness -- As Good As It Gets comes to mind -- but in that film the main character gets everything, and here the character is fired, yelled at, beaten, and generally ostracized. I finished the book feeling more offended than anything else. Do I lack a funny bone? Perhaps. But this just seemed like kicking the main character when he's down.

While I did hope that I might be able to participate this year, baby shows no signs of making an appearance today. In lieu of that, I wish a Happy Mother's Day to all those readers that are celebrating with their family in whatever way you choose to celebrate!

Today we said goodbye to my faithful car Beauregard! He was 15 yrs old and the first car I ever bought. He had his tough moments. Right around 2008 he had a period of recurrent and expensive issues, but gradually settled into a comfortable old age. I'd actually set a limit on what I was willing to pay in repairs this year with a "no more than $1000 all year or you're going to the dump!" Apparently he listened, and behaved very well after a little $200 tune-up last summer.

I never thought he'd last this long, but it was time to say goodbye with us moving to a much more urban area and real uncertainty that Beau could even make it on a long-distance trip. And what's more? After a shampoo and a wash we managed to sell him for almost as high as I'd hoped and well more than I expected! Especially given he's 15-yr old manual transmission with a scrape down one side from a Boston nighttime hit and run (with my car parked).

Goodbye Beau. You served me well for ten years. Rest in Peace!

This week A and I hit Boston to find an apartment. Little did we know it would be the worst search in history.

To sum up, there were two main factors: the current rental market, and my pregnancy -- yes, that's right, my status as pregnant.( The obstacles )

With those two features in place, it eliminated 95% of the 1% of apartments that were vacant. What was left were "splits" (two bedrooms, one bathroom, NO common space), a one bedroom for $2100 a month with no flooring and the refrigerator in the living room, and an apartment that was 45-60 minute commute but decent. After 14 brokers and very few apartments we seriously worried we'd be living in a box. We went with decent.

...and we almost didn't get it. On my salary, we can afford $1800/mo. There is nothing in that range that is remotely appropriate for us. A is going to look for a job, but his start date cannot be until the baby is 3 mo old, since I haven't yet run across a daycare that will accept infants younger than that and I can't take maternity leave. After that point it must be a job paying enough to cover daycare AND the amount our loan payments will increase with increased income. Until that point we will be underwater with our $2000 apartment, but it is a nice apartment near our friends and the commute may not be that bad if I bike half of it or drive every day. The realtor looked at my employment and said "you know, usually we like to see no more than such-and-such a percentage of income go to rent." There I was thinking "no s*** Sherlock, we can add" but I'm stuck between being underwater for a few months or having an even longer commute (3 hrs/day) on top of my 12 hr average day.

The solution? We're buying a house. There was simply not enough time between Match Day and my start date, especially given my requirements for finishing med school, the pregnancy, and our not living in the city we were looking to buy in. But according to Zillow we can easily find a 2 or 3 bed condo or house with shorter commute and cheaper mortgage. Our new place is listed as having an estimated mortgage of $1200 if sold in the current market. I know there are property taxes and other fees, but that singular rent/mortgage difference is jaw-dropping. It sounds wrong to spend $20k in closing and fees and such in order to save $500 a month but between our resources and a special physician loan loophole in my pocket, we could be earning equity on a significantly nicer place instead of pouring >50% of our collective pre-tax income down the drain. We will start looking once we get back on our feet after a few months of the new baby, new job, and the move.

So, many tears later and with much emotional exhaustion, we really do have a place. It's overpriced, poorly placed for my commute, and has little natural light BUT it is unleaded (built after 1978), doesn't put us too far underwater, is quite spacious for Boston, and is near many of our friends (Ball Sq). May we never have to do this again.

Although my absence from Holy Week (to attend Passover) has put a crimp in my church gig, the director still called me in for a lovely Compline service last night. We sang to a small crowd from the balcony of the church just as the sun was setting. We were six singers, myself, two altos, one tenor, and two basses, but given the acoustics of the room our voices soared throughout the hall. We sang Palestrina's Te Lucis Ante Terminum (to thee before the close of day), Gibbons' Nunc dimitis, and Byrd's Ave verum corpus, our voices intertwining in delicious polyphony. It was rejuvenating, perfectly in my range, and allowed my voice to relax after its brutal treatment in Beethoven's 9th.

Beethoven's 9th is a very exciting piece, granted. However, like Handel's Hallelujah Chorus, it's murder on soprano vocal chords. You stay in your high range and punch out note after note as loudly as possible. Now, Beethoven actually explicitly calls for some very quiet passages, but like many conductors, the guest conductor of the Orchestra that day decided to keep everything loud and "exciting". It felt to me like live audio compression. Are audiences so accustomed to recorded music that they can't appreciate the range anymore? Levine would never have stood for that. I still have a lingering cough after raking my vocal cords over the coals two weeks ago.

... and Palestrina was a wonderful balm.

I don't expect to be able to pursue music next year. My goals will be to survive internship, serve my patients well, give my new babe a loving home, stay healthy myself, and maintain my marriage, not necessarily in that order. But when I do return, I have to consider where I want to take my voice. Chamber music or orchestral? Early or Romantic? Solo or ensemble? We shall have to see.

We all know we could do without that extra latte, or cable television, or a car. But lets get medical here. What can we actually do without, and still live a more or less normal life?

Let's start with what's really just a tube, your gastrointestinal (GI) system. What is NOT needed?

Esophagus: Really it's just a conduit from your mouth to your stomach. Without it you'll have wicked heartburn, but you'll be just fine.

Stomach: Gastric bypass does just that -- bypass most of the stomach. And if you have stomach cancer they'll just take it right out. You end up with "dumping syndrome" which is the technical term for when you dump food right into your intestines. You'll have bad cramps, but you'll live.

Appendix: Need I say more? There are arguments supporting that it may have a function in immunity, but "we might be able to come up with something" doth not make it essential!

Colon: Convenient, but definitely not required. People have it out all the time. Your poop will be runny, but you'll still get all your nutrients, since the small intestine does all the important food processing.
( More things you can do without! )

What do you need?

Heart: The heart's just an electro-mechanical pump but you do need something to move that blood around. Since it's so simple, we can fix an electrical malfunction (pacemaker) or a mechanical defect (valve replacement) or even clogged pipes (bypass surgery) but we still haven't found a good complete replacement. Dick Cheney was on one for almost two years which is pretty great, but he still looks like he was hit by a truck. We should be close on this one though. Just give it time!

Liver: Oh, sweet liver! This is why you are my favorite organ! You are irreplaceable. You filter toxins. You are the central energy distributor. You even regenerate! So you could go without most of your liver... and it will grow back. Cool, eh?! Just don't insult it too much. The liver can quit on you.

Pancreas: While we can replace the insulin (which is what usually craps out), it does so much more. It produces all those digestive juices that allow you to make the most of your meal. The stomach may mash it up, but the pancreas does the heavy duty.

Small intestine: We have some extra yardage in there, but you gotta have some. Otherwise that food will just pass right through you. Only alternative is TPN (total parenteral nutrition), i.e. food by IV. Trouble is bacteria LOVE tasty sugary stuff in the blood stream, so people on TPN are prone to infection. You want to keep your small intestine.

Skin: Underappreciated, but TOTALLY necessary. Without your skin you are not only missing an important barrier to all the nasties in the outside world, but you would dehydrate in hours. That's why it's so important to cover up burn wounds. Our bodies are bags of water and without the skin we might as well just evaporate in a day. NOT good!

Brainstem: the brainstem and top of the spinal cord (to about mid chest) are pretty vital to coordinating all that keeps us alive -- breathing, heartbeat, digestion -- all in about 18in of important nerve tissue.

Enough lung, kidney, and cortex to get along (as mentioned above in "duplication")

So there you are. See how much we can do without these days?

With expectations set appropriately low, we went to see the Hunger Games last night. It proved to be a serviceable adaptation of the popular young adult series. I did not mind the cuts, and while it never truly captured the desperation of the districts, it was a reasonable teen rendition. The only thing that left me feeling a bit guilty is that here we were watching the Hunger Games. Somehow reading the book and remaining in the mind of Katniss throughout the narrative allows you to be aligned with the rebels. Watching and enjoying the Hunger Games with a bag of Twizzlers seems a bit too close to being a Capital citizen glorying in the gladiatorial combat.

This is bound to be a trilogy. I will await the next few and see where they go with this. Overall, well above Twilight but below X-men.

P.S. I know that Google Plus killed Livejournal (or at least made it moribund), and now Google Plus seems to have failed as a social networking site. Does that make it a murder-suicide?

A happy equinox to all! I know astonomically it was technically yesterday, but I generally celebrate on the most common day since I can't be bothered to check the charts each year.

Today the Land of Cleves celebrated with weather of 80 degrees?!! The trees are all in bud and several are blooming, people are walking their dogs in shorts and T-shirts, and generally all the signs of the apocalypse are upon us. Seriously. This should be snowmelt season!! Eighty?!! We had to go get ice cream in order for my internal thermostat to reach an appropriate temperature.

In any case, it's given me a taste of summer which I would gladly give back for a few more days of spring. May your day be bright and your spring be long!

It is with great joy and regret that I faced Match Day.
I got the program I liked best, one that I feel addresses what needs to be addressed in this crazy world of healthcare.

It emphasizes ambulatory (outpatient) care, with one week out of four devoted to it. This is unlike most training where you get half a day a week and most graduates go on to fellowship or become hospitalists (inpatient only) because that's all they know, inevitably driving healthcare costs higher and higher.

It has a strong dedication to service, with a very diverse patient population (racially, globally, etc) including training at two city hospitals and a VA hospital.

I will have the opportunity of doing some of my outpatient work in a women's clinic, becoming comfortable with the basics instead of most interns who wouldn't know where to start with a pelvic exam, so I won't have to send off my patients to a specialist to get a Pap smear.

The school of public health, very well-regarded, is located on the quad between the two main hospitals and there are close research interconnections between all three.

I personally know the program director who is both very sharp and a wonderful human being who will care about resident life balance.

Unlike many places, BMC truly seemed to want me there.

As an added bonus, we'll be near many friends, many of whom have small children. We know the city. BMC campus is walking distance from Symphony Hall. WGBH is one of the top content producing NPR stations in the country and ideally A might get a job there.

But I was also filled with regret.

Boston is the furthest location from most of both my and A's family. And we're bringing a new family member into the world. Will they ever know their relatives?

I don't fit the mold. I didn't publish as an undergrad. I don't plan on fellowship. My stats aren't that great. I had to leave a section essentially empty for research then condense ten years of work into "undergraduate career" because the frickin' application form does not allow for anyone who has HAD a job. (My "research" at Abt is both unpublished and most of it classified under Homeland Security.) As an older student, most places threw out my application in the first pass. I felt the doors close before I even started interviewing.

I see my classmates who've been groomed since birth for med school taking a year off to do research and beef up their resume, or going into radiology (does 16% of the class really love reading scans or do they just want the money and do they realize how soon it will all be outsourced?), or going to Stanford and Northwestern and the Brigham when I never got a chance to say hello. Neither of my two favorite programs (Brigham & Women's and Northwestern) even offered me an interview. Same goes for programs in San Francisco.

I feel the same way I did applying to med school where I had a mediocre school reject my application and request I retake remedial premed courses at a community college because my Caltech courses were too old. Or being told that because I didn't have a story to tell about a patient with cancer or a dying relative they didn't understand why I was applying to med school. Or having 75% of the schools I applied to cash my $100 check and immediately reject my application.

I believe I will be a good doctor. I believe the system is broken and I want to fix it. And I believe that old school medical education and the self-serving lobbyists of the AMA are partially at fault for the healthcare mess we've gotten ourselves into. And I'm terrified that my choice of the best program for me will be deemed inadequate by someone somewhere later in my career because it doesn't have the most NIH funding or because they haven't maximized their profits by doing the most heart caths and MRIs.

I'm also terrified of living in Boston on less salary than when I left, but now supporting three people with three times the rent.

My path has been chosen for me and I will make the best of it. But it won't be easy.