29 September, 2014

{this moment} 117

{this moment} is a Monday ritual that my father started in May 2011, and that I have maintained since May 2014. He described it as "A single image - no words - capturing a moment from the past. A simple moment along my life's Journey - but one over which I wish to linger and savor each treasured aspect of the memories it evokes." When he passed away in February 2014, he left a folder containing images that he hoped to share in the months and years ahead. For some, I share my perspective of the story behind the moment on Thursdays, in a companion ritual called {this memory}. For others, the story is lost in the ocean of time, but I welcome flights of imagination and speculation from readers.

{this moment} was adapted from cath's wonderful blog ~just my thoughts. She, in turn, borrowed it from Pamanner's Blog. My dad suggested, "Check out their blogs, and if you're inspired to do the same, leave a link to your {this moment} in the comments for each of us to find and see. If you are moved or intrigued by my {this moment}, please leave a comment." I encourage the same.


28 September, 2014

Confessions of the hidden curriculum

Hidden curriculum - a term coined in the 1960s to describe the idea that education is a process of
Source: https://drkevincampbellmd.wordpress.com
socialization; currently in vogue to describe the many things medical schools teach medical students that are not officially part of the curriculum, i.e. the ways in which American medical students are socialized into becoming physicians.

Although this term, and the concern about the unintentional and often negative lessons that medical students learn on their way to becoming licensed physicians (who then maintain the status quo of American medicine), greatly precedes my medical education, I never heard it directly discussed or addressed when I was a medical student (2003-2008, minus a stint as an anthropology graduate student). And for a long time, I focused my recollections on the non-traditional educational experiences that I was lucky to have and that profoundly shaped the kind of doctor I wanted to be - an undergraduate summer spent studying how medical mistrust affects African-American women seeking prenatal care in an inner-city neighborhood; first-year encounters with hospice care and lessons in "breaking bad news" from the awesome Tammie Quest, who now directs Emory's palliative care center; and impassioned discussions of structural violence early in my training (what is now called structural competency, or a recognition inequalities in health affecting individual patients and influencing the relationship between patient and provider arise from social structures and institutions). 

I have never forgotten the day a lecturer used the term "white privilege" and a (Caucasian, socially and economically privileged) female student walked out.

That is not to say that I would claim to be unaffected by the hidden curriculum. In fact, as I sat down to write this, I wondered whether I'm writing now because my new role, teaching medical ethics and social responsibility to medical students, involves shining a bright, bright light on the hidden curriculum and reflecting deeply on these experiences...or because, as a licensed-board-certified-fellowship-graduated-attending-physician-faculty-member (pick your choices of adjective and noun), I may not be tenured but I am indubitably beyond the reach of those who inculcated me into the hidden curriculum.

On my first day of medical school, one of the deans told a fairly devastating story about a recent graduate who died (I think in a mountaineering accident) the day after his graduation. The point of the story was to remind students to make the most of each day and not postpone "life" until the end of medical school (four years later). I thought about that advice nearly every day and tried my damndest to practice it, but after all was said and done, I hated medical school. The closest I came to succeeding was when I took a leave of absence to study medical anthropology at Oxford. 

Most of the time, I felt like I was being taught by old white guys who had neglected their families for years in favor of their careers (hopefully, their patients got a little of the spoils, but I was doubtful) and who wanted to smugly tell us how they had finally learned the importance of work-life balance but secretly, bitterly hoped we'd make all the same mistakes.

That is a terrible overgeneralization - I also had many extraordinarily gifted teachers - but it was an overarching theme.

During my first semester, I was in a long-distance relationship. The leader of my "problem-based learning" small group had offered to move our required session to help me make a surprise visit to my then-boyfriend's town, several states away, over a long weekend. I filed a request to book a room for the new time slot. At the gym that evening, two days before the scheduled trip - my heart is racing remembering how stunned and livid I was - I received an e-mail from one of the associate deans saying that we were not allowed to reschedule our small groups, nor was I allowed an absence. 

I met with this dean the next day, and he had the nerve to tell me "too bad" and "I want to get home to my family on Friday afternoons too." I can't remember what I replied, although I know we came to some sort of compromise, because I went on the trip (and blessedly broke up with the guy), and I know that after I walked out, I cried. Looking back, I want to say something very rude, followed by a more articulate statement of my incredulity: He wanted to get home to his family on Friday afternoons? His family on the other side of our city? My boyfriend and all of my closest friends lived 500 miles away; my entire extended family lived at least 1000 miles away. Seeing someone - anyone - I loved on a weekend wasn't a matter of leaving work an hour early on a Friday afternoon; it required careful budgeting and plane tickets or several full nights of sleep and a grande quintuple latte. 

But there was already a lesson there - don't dare to suggest that family is more important than obedience. (a.k.a. I say "Jump!" You say, "How high?")

Playing on natural rock slides in Sacsayhuamán
Cusco, Perú, July 2004
Life went on. I got good grades and a good Step 1 (the first of the three-part general licensing exam) score. I edited the literary journal and spent the summer in Peru, made new friends and explored the local restaurant scene. I rented the first apartment that was completely mine (on the top floor of a 100-year-old building, with gorgeous crown moulding and hardwood floors, a French balcony and a wall of built-in bookshelves in the bedroom) and painted the living room a questionable mix of bright yellow and dusty violet, to complement a Federico Coscio painting I'd hauled back from Cusco. 

I started my third year and was mostly disappointed. I was expecting to find intense personal satisfaction from regular interaction with patients, as well as opportunities for interprofessional growth, collaborating with colleagues across many levels of training and disciplines, including nurses and other support staff. (I am fairly certain anyone who has attended medical school is laughing at the degree of my naïveté.) And like many people before and after me, I instead discovered that doctors spend very little time at patients' bedsides; that there is a seemingly enormous amount of "scutwork" that is unrelated to learning and frequently apparently unrelated to patient care; and that medical students earn good grades in the clinical years (traditionally, the third and fourth, with the first two spent in the classroom, though this is changing) by quickly identifying "scut" and getting it done. 

Some people got depressed. I filled out applications for graduate programs in foreign countries. Before I could flee across the ocean to figure out what my real calling in life was supposed to be, my father had an implantable cardioverter defibrillator (similar to a pacemaker) placed. It was intended to help his heart beat more effectively and also to restart his heart if it ever stopped. Several months later, he was hospitalized again after it became infected. One night, when I was on-call for the labor and delivery ward, my family called and asked me to come home. Near tears, I called the course director, the physician who was in charge of my rotation (a block of time, usually four to six weeks, but sometimes longer, devoted to studying the same specialty - e.g. obstetrics and gynecology - and seeing patients in that specialty's clinics and in the hospital). 

Some background: I was not always the perfect third-year medical student. I knew when I applied to medical school that I wanted to be a pediatric oncologist, and so I sometimes struggled to feign interest in specialties that had little relevance to my goals. (Most medical students quickly learn not to admit their true passions, but to pretend that they want to do whatever it is that the physician they are working with that day does. I am a terrible actress.) But I was a solid OB/GYN student. In college, I volunteered as a peer health educator, helping to prepare students before their first gynecologic exams and weigh birth control options, and accompanied sexual assault survivors to the ED. I really cared about women's health (and still do). I had also done well on all of my rotation-specific exams, and there was every reason to think, in this the second-to-last week of the rotation, that I would get a well-deserved A. 

So you might expect that my course director would have expressed concern, reassured me about my anticipated absence, and wished me a safe journey home. 

Not quite. 

I explained the situation as succinctly as I could, trying to accurately summarize 35 years of medical history while conveying our real fears that my father might die. After a pause long enough to qualify as awkward, she said, "Well...you need to do what you think is best." 

Once again, the incredulity with which I recall her words has blurred any recall of my real response. Eventually, I must have told her that I planned to leave the next day but would attend clinic in the morning, as my sister had been unable to find an early flight. To my continued astonishment, she told me that I was allowed to miss two days and, if I needed to be away longer, we would discuss how I would "make up" my absence when I returned. 

Yes, that is how a physician, a healer, a woman with young children (and, presumably, parents of her own), whom I previously respected and admired, responded to a dedicated young student who had just told her that her father was gravely ill. 

The next morning, my resident, a kind and gentle young man whose wife was nearly nine months pregnant, sent me home after a couple hours, shocked that I would try to see patients while wondering if I would ever see my father again.  That night, my sister and her best friend picked me up at an airport two hours away and took me straight to the hospital. And over the next few days, my dad slowly improved. His pacemaker was removed and the following weekend he was discharged home. (His infection lingered and recurred at least twice more, leading to the prolonged intensive care stay that he described here.)

I returned to school, completed the rotation and earned an A on the exam. My course director brusquely informed me that my grade would remain an "incomplete" on my transcript until I presented myself to the gynecologic oncology service for two additional days, and I explained that it would have to wait, as I was leaving as soon as I finished my required third year rotations, first for an away rotation (a rotation at another institution) in pediatric neuro-oncology (brain tumors) at St. Jude Children's Research Hospital and then for my leave of absence at Oxford University. 

This is how I like to remember Oxford - 
deep conversations over good wine.
Linacre College, October 2006
You would be wrong if you thought this demonstration of intellectual passion and commitment to scholarship fazed her at all. You would also be wrong if you thought that she'd wave her hand and send me on my way when I contacted her a year and a half later to announce my impending return from the UK. 

So one sweltering morning in August, I stumbled bleary-eyed from a friend's air mattress (my new lease hadn't started yet) in order to make my required appearance. My bag contained a jumble of references for my unfinished master's dissertation on hope and uncertainty in treatment choice for childhood cancer, as well as scribbled notes for the personal statement that would accompany my application for pediatric residency slots. 

The next two days spent holding retractors (devices that pull back flesh during surgery) and having residents and attending surgeons ask me detailed anatomic questions (the answers to which I had forgotten within seconds of finishing the Step 1 exam) were perhaps two of the most meaningless of my life. 

When I wasn't pondering the metaphysical impossibility of ever getting those 48 hours back, I begin to develop a sort of personal creed of work-life balance, further refined over the next seven years of medical education. It goes something like this:

If what I'm doing is NOT (1) directly improving the health and well-being of my patient or my community; (2) educating myself, so that I can improve the health and well-being of my patients or society; or (3) directly helping my colleagues, so that they can go home sooner, see their families, or just take a deep breath, then I should be doing something else.

A few months later, I had an elective, which I chose (emphasis on choice) to spend in the surgical intensive care unit. At one point, I was asked (mockingly) if I would like to remove a patient's Foley (urinary) catheter. ("Jump!") I responded with, "Yes, ma'am, I would love to!" ("How high?!") Afterwards, I thought, Once I graduate, I will never fake enthusiasm again. 

Life is too short, and there is too much about which I am so deeply and genuinely passionate, to pretend.
Sunrise over Mount Hood, seen from the tram to OHSU
(I was interviewing for residency and thought, I'd get up at 5 AM every day to see this)
Portland, Oregon, November 2007
I was lucky in medical school in a lot of ways. I have never had a supervisor curse at me. I did work with a surgeon who had a knack for choosing borderline-inappropriate positions in which students were expected to assist with retracting, but I never had anyone demand sexual favors for grades or privileges. I was never asked to do anything blatantly unethical, immoral or illegal. (If you have access to an academic library and are interested, I suggest reading Jim Dwyer's paper, "Primum non tacere: An ethics of speaking up.")

And I had an inoculation of sorts: I arrived at medical school profoundly influenced by my mother, a child life specialist who had been teaching me to see the whole person first, and to advocate for him or her, since I learned to talk, and affected by my father's hospitalizations. Because of them, I will always be a family member (a daughter and now a mom) first, and a doctor second, and a better doctor for it.

I want to believe that.

And most of the time, I really do. Because of that conviction, I can't dismiss my experiences as a minor. How we as educators treat our students, how we acknowledge their personhood outside the classroom, outside the clinic or hospital, matters. Doctors who are stressed, depressed, burnt-out, or bitter cannot provide good medical care...not for very long, anyway. We can't ask medical students to respect the struggles of a patient with diabetes trying to afford healthy food on minimum wage, or teach them to respect their nursing colleagues and pay attention when a nurse comes to them with a patient safety concern, if we are also teaching them that we don't respect them, their loved ones, or the fact that sometimes their loved ones need them the most - more than their patients and certainly more than their books.

To teach a future doctor to see the whole person in their patient, we have to see the whole person in our student.

This is something I still have to work to reconcile with the myth of the good doctor, who is always on call, always at the patient's bedside, a figure who is barely recognizable in modern medical practice, but still ingrained in our collective medical psyche. 

This summer, I had the opportunity to attend a workshop for young doctors who are interested in developing new treatments for cancer. On the last day, I hiked up here and stopped to remember and thank the world and all the people in it who helped me get to this point,  by being nothing like the people I've written about here.  Most especially my dad.
Vail, Colorado, August 2014

I will live so as to embody 
(i) an open-minded receptivity toward creation and creativity; 
(ii) a celebration of life and all that is good in humankind; 
and (iii) a caring hand extended toward the least of my brethren. 
- Gregory W. Schneider

26 September, 2014

Blue Lily, Lily Blue: My first full ARC!

Before I start my complaining, let me say:

I adore Maggie Stiefvater's writing. I didn't love the Shiver (Wolves of Mercy Falls) trilogy when I first read it, but I think I need to give it a second chance, because her next three books, The Scorpio Races, and the first two books in The Raven Cycle (The Raven Boys and The Dream Thieves) were brilliant

There is something delightful about her writing, a charm woven into the simplest sentences that makes you want to read them over, and over, and over again. (There are better examples but, off the cuff, "Tonight, the music was already loud enough to paralyze the finer parts of her personality.") Her characters are vivid, physically and emotionally - even minor characters. ("Ashley's mouth didn't make an O so much as a sideways D.) I also like that her characters seem to find humor and sarcasm even in the darkest and most dramatic moments. That's how I approach life, so it feels real even when the events are supernatural. 

The Scorpio Races is exceptional for being a perfectly contained stand-alone novel. Sure, you want there to be another two (or ten) books when you finish reading. But there aren't and there shouldn't be. The story is complete just as it is. The book is set on a remote island that seems to be part of the UK in the recent-ish past (all really perfect strategic choices) with a single magical element - the presence of quasi-mystical, dangerous water horses, who the island's inhabitants risk their lives to race every November. The narrator is a teenage girl who enters the race (usually a male-only pursuit) in order to try to keep her siblings together and save the family farm (but in a totally less cheesy and more awesome way). A second protagonist appears in the form of a young man who trains horses and frequently wins the race. The book's heart and soul is in the blossoming of their relationship (I'll come back to this in a bit**) and their relationship with their horses. The language is beautiful and the setting is extraordinarily drawn. 

On to The Raven Cycle... This series is set in rural Virginia, so the general landscape and culture is very familiar to me. When the characters joke that the fictional town, Henrietta, is Gansey's (one of the protagonists) "girlfriend", because he so loves the area, I know exactly what they mean. I used to stop in Washington on the way back to college and meet my friends who grew up there, before driving down Route 29 to Charlottesville, and I would quite literally sigh with contentment when the Blue Ridge Mountains came back into sight. I also frequently referred to them as "my mountains", separate and distinct from all the other mountains that I played on. After I showed a visitor around and he mocked them as being mere hills compared with "his" mountains (the Rockies), I told my dad about the conversation. He said, "You should have told him that your mountains are ancient creatures compared to his - his are barely out of infancy."

As with The Scorpio Races, the soul of The Raven Cycle is in the characters and their relationships, and in that sense, I think Maggie Stiefvater is unparalleled among contemporary authors. Although Blue, a teenage girl in Henrietta, is at the center of the story, there are really three other protagonists, all teenage boys attending an all-boys private school in Henrietta. The boys, led by one in particular, are obsessed with the myth of a Welsh king, Glendower, who they believe is buried under a ley line near the town, and they draw Blue, raised in a family of psychics, into their quest. All four have well-developed back stories and families, but Blue's mother and her mother's two closest friends are written with as much care (if less story time) as Blue and the three boys. 

I absolutely loved the first two books in what I thought was a trilogy, so of course, I had October 21 prominently marked on my calendar, anticipating the release of the third book, Blue Lily, Lily Blue. And then yesterday, I received my ARC!

Here is my one-line recommendation: Go buy The Raven Boys

Here is my four-line recommendation: Read it. If you like it, go buy The Dream Thieves and Blue Lily, Lily Blue. Read them back-to-back. Think of Blue Lily as a really, really long epilogue to The Dream Thieves. Or a long prologue for the fourth book, due out next year. I think you'll love the series and probably be less disappointed that I was.

The main problem is that much less happens in Blue Lily than in the first two books. It is a beautiful work of character development, and after I invested so much in the characters reading the first two books, I did appreciate that aspect. All four protagonists grow, push their boundaries, and discover themselves (as teenagers should), and their relationships with each other change and grow in ways that seem natural, almost elegant in their inevitability, not just in service of the plot. 

But the events are anticlimactic. Some seem uncomfortably similar to the events of The Dream Thieves, with different (new) characters serving the same essential functions, going through the same essential motions, and this makes them less heart-pounding and spine-tingling than their predecessors. Still, I'm willing to give the author the benefit of the doubt and trust that she sincerely thought she needed 416 pages to develop the protagonists to the point where they are psychologically ready to find their sleeping king - because I still think she is brilliant, and I have every confidence that she'll come through in the fourth book.

**A side note on relationships! As previously discussed, I think a kind of attraction or chemistry with characters is a crucial part of a good book, and I fully admit this kind of chemistry is as personal and unique as any real-life attraction to a new friend or lover. In my real life, I have never been attracted to people who are aggressively protective of me. I don't do well being told what to do (sometime we'll talk about how my 16-year-old self wanted to join the Navy ROTC like my dad...). In my life, there are two levels of protectiveness - how I feel toward my son, and how I feel toward the other adults that I love. I recognize that for many other people, there is a more traditional "men-protecting-women" level that they either think is key to a functioning society or simply find attractive in their own relationships. I just...don't. Beyond political or philosophical statements, the fundamental core of my being doesn't find that kind of protectiveness attractive. So I very very much value books that show relationships outside that context. (A counterexample: I loved the historical settings - and contemporary Oxford, of course - of Deborah Harkness' All Souls Trilogy, but I found the lead male character incredibly irritating.)

Maggie's books really stand out in this regard. She shows male-female relationships based on mutual respect, and she also clearly respects the importance of same-sex relationships (whether they are friendship, family/parent-child or romantic). It's also delicious to see authors who are potentially influencing young readers going beyond stereotypes and taking the opportunity to show female friendships in a positive, constructive light, and young men who sincerely care about their friends. I keep a shortlist of books I'd want to share with Finn and especially any daughters I might someday have, and these definitely make the cut.

23 September, 2014

A little early birthday present and a tribute to the power of fantasy writing

I love books. Love to read them, hope soon I'll actually finish writing one. And for the last few years, I have loved young adult (YA) and fantasy literature (yes, literature) more than any other genre.

This weekend, I signed up for NetGalley, a website that helps connect "professional readers" (reviewers, bloggers, educators, librarians, etc.) with publishing houses who have advance reading copies (ARCs) of soon-to-be-published books to distribute. I had just learned that the release date for a book I had been eagerly awaiting, Samantha Shannon's The Mime Order, had been pushed back from October 21 to January 27. I was disappointed but learned that a sampler of the book (the first nine chapters) was available for request through NetGalley. I decided to take a chance and request it, and was thoroughly surprised and elated when I received a link to download the sampler just a few hours later. (Scroll down to the **** to skip right to my review.)

I've always read a lot. I can read very fast, and I like to read fast, which explains a lot about the kind of book I like. First, I want a book that draws you and wraps you in a different world. It could be an ambitious, expansive, shockingly different reality, or it could be a tiny fragment of a place, breathtakingly close to our world...either way, world-building, on any scale, is important. Second, I need chemistry, a kind of attraction (not necessarily romantic or physical) between my reader-self and at least one and ideally several characters. I don't need to always like them but I need to be drawn to them, either because I identify with them, or because I'd genuinely like to know them better, and preferably both. Third, I want mystery - or better yet, a mystery wrapped up in a quest and tied up in a bow of social change. I want to turn pages rapidly, heart pounding, eager to find out what happens next. I want to take a deep breath and force myself to close the book (or painfully-but-exquisitely be forced to close the book and wait for the sequel) to speculate and ponder and analyze and wonder.

And fourth, in a perfect book, when I get to the last page, I go back to the beginning and start all over, this time reading slowly, savoring perfect turns of phrase, noticing and dissecting nuances of story and character that I missed the first time around.

If we get to (4), I've found a book that I will love and re-read perhaps a dozen times. Maybe more. It's a book I'll return to when my Books to Be Read shelf has emptied, or if I have it on my Kindle app, when I can't sleep or am waiting for an appointment. This group includes the Harry Potter books, Philip Pullman's Golden Compasses, the Daughter of Smoke and Bone trilogy, Tana French's mysteries, and a few select others.

If one of the first three is missing, but (4) is in place, I've usually described a book that I will always admire, that will have a place of honor on my bookshelf and that maybe, if something really resonated, I will come back to re-read every year or two. Many books in this group are perhaps more widely regarded literature, or have more layers of depth and meaning to probe. The best example for me is Haruki Murakami's The Wind-Up Bird Chronicle, which I usually cite as my favorite book of all time, or China Miéville's books, especially The City & The City. 

My love affair with fantasy started off slowly, during winter break in 1999, when my father brought home the first three Harry Potter books. Before Harry, I read widely and voraciously but self-consciously. Jane Austen (agonizingly dull). Carl Sagan (mercifully less dull). Edith Hamilton (genuinely loved classical mythology). Frank Herbert's Dune books (brilliant). Shakespeare (most enjoyable when performed improv-style at CTY). Foucault and Nietszche and so on.

After Harry, and particularly once I started medical school, I no longer cared what other people had labeled as "classics" or "canon". Elsewhere, I've read critiques of the adult readers who push YA books to the top of bestseller lists, concerns that this represents the death of adulthood. As someone who spent all of her twenties working intensely long hours, who works in a life-and-death field, I say... Meh. I don't care.

I spend large chunks of time reading serious nonfiction and academic journals. I want my literature escapist and immersive. I appreciate the beauty of the sentence, but I want that appreciation to be a lightning strike of insight, like the feeling of hearing a song, maybe for the first time, maybe for the fourth time, and having it pierce my soul. I don't want to have to study each sentence in a work of fiction the way I'd study a painting, trying to find the beauty in the deeper meaning.

At the beginning of my third year of medical school, Harry Potter and the Half-Blood Prince was released, and my dad was diagnosed with heart failure. I was scared, sad and lonely, far from my family, as well as severely sleep-deprived on my surgical rotation. Most days, I didn't fall asleep until 2 AM and my alarm clock went off at two hours later, at 4. I started re-reading Harry, and every time I got to the end of the sixth book, I'd go back to the first book and start all over again. I began to really appreciate the nuances, the incredible attention to detail, the hints carefully - and naturally! - introduced in earlier books, the threads of theme and plot woven throughout the series. Regardless of how wholly novel any one aspect of plot or setting was, the finished product was extraordinary. At first it was fun, like marveling at a Escher drawing, and then it became therapeutic. So much of the story was really about coming to terms with mortality, our own and that of those we love. At that point in my life, I think I found Dumbledore as comforting as Harry does in the books. I was also touched by the morality, by the lessons that were not a preacher's afterthoughts but an essential part of the plot - lines like (and I paraphrase), "It takes a great deal of courage to stand up to our enemies but just as much to stand up to our friends."

Over the years, I sporadically tried to make this case to friends and fellow parents but rarely found a sympathetic, much less equally passionate, ear, so you can imagine how vindicated I felt when this appeared in the Journal of Applied Social Psychology:

"Recent research shows that extended contact via story reading is a powerful strategy to improve out-group attitudes. We conducted three studies to test whether extended contact through reading the popular best-selling books of Harry Potter improves attitudes toward stigmatized groups (immigrants, homosexuals, refugees). Results from one experimental intervention with elementary school children and from two cross-sectional studies with high school and university students (in Italy and United Kingdom) supported our main hypothesis. Identification with the main character (i.e., Harry Potter) and disidentification from the negative character (i.e., Voldemort) moderated the effect. Perspective taking emerged as the process allowing attitude improvement. Theoretical and practical implications of the findings are discussed in the context of extended intergroup contact and social cognitive theory."

In the spring of 2007, as a graduate student in Oxford, I walked into Blackwell's and casually picked up Northern Lights, the first book in Philip Pullman's Golden Compasses trilogy (the U.S. title is The Golden Compass). The experience of discovering a new favorite book is nothing less than real magic. The following summer, the last book in the Harry Potter series was released. I read all day and into the night, and then experienced a crushing letdown, as I wondered if I would ever experience that "real magic" again.

Back in medical school for my last year, someone recommended a series that shall not be named here as the "next Harry Potter." It was not. It was too young for me, sloppily written and sloppily plotted, and ultimately offensive to my personal beliefs. (If you're curious, you can read my review here.) But I kept looking, not for the "next Harry Potter" but for the magic of falling headfirst into another world, of falling in love with characters, of trying to solve the mystery in an author's head. During the next few years, I discovered Haruki Murakami and China Miéville, as well as Tana French, Kate Atkinson and John Hart.

And then I met The Hunger Games, via my cousin Megan's blog. I was so quickly hooked that I read it in Kindle form on my iPhone while waiting for babies to be born (the pediatrics team is sometimes called to deliveries well in advance of the actual birth). I literally COULD NOT STOP reading it. I also could not stop searching for new books in this exciting and vastly cooler new form of YA that did not exist when I was a teenager. As a new pediatric oncology fellow, I discussed my love for The Hunger Games with a 12 year old patient who had received a bone marrow transplant and was strikingly thoughtful and introspective. He recommended a handful of YA books that he thought I would like, including Elsewhere, by Gabrielle Zevin. When my son was born several months later, I began reading constantly on my iPhone to keep myself awake while he nursed (every two hours, until he was a year old...). In a matter of weeks, I zipped through dozens of books and fell in love, in rapid succession, with Laini Taylor, Maggie Stiefvater (Scorpio Races, not Wolves of Mercy Falls, however), John Green, Daniel Handler, and Sarah J. Maas.**

Several of the authors had started trilogies and series, and so I started pre-ordering sequels in Kindle edition on Amazon. They usually automatically downloaded at 10 PM mountain standard time, which meant many a night's sleep was lost when I couldn't resist starting the first chapter... And naturally, when my fellow Oxford alumna (then student) Samantha Shannon was tagged as the author of the "next Harry Potter", I heard about it and decided to pre-order The Bone Season, the first in her seven-book series. On my first attempt, it didn't draw me in and so I quickly forgot about it, until my father passed away and I was searching for something to read. And there it was on my phone, just waiting for a second chance.

I should just say now, before we go any further - I am not a critic. I am a book lover, an avid reader, an occasionally gifted writer who aspires to be a novelist someday, a teacher, a perpetual student ... everything but a critic. I did not take a single English literature course in college (the closest I came was a fiction writing workshop and a Spanish lit survey). But I do read book reviews, mostly in the New York Times. I am vaguely aware that there are definitions for fantasy, science fiction, speculative fiction, etc. and controversies over genre. I am also aware that certain complaints pop up regularly in reviews of more mainstream and YA fantasy, which to me seem to center on whether the plot and/or world-building are truly original or seem pieced together from other sources. For me, the non-critic(al) reader who wishes to be a writer, this criticism often seems beside the point. Very few writers are writing in the absence of inspiration, and even fewer of those are going to be any good. No one can imagine a world from scratch, without some sort of influence from the world we know and those who have tried to imagine alternatives before us. Moreover, while I appreciate the fictional world that seems brilliantly novel, clearly, the novelty depends on what else I've read...if some of the elements appear to have been inspired by a book published 200 years ago that I've never read, or published four years ago and I started it but hated the narrator...well, it's not going to affect my experience of this book.

When I gave The Bone Season its second chance, after the first few chapters, I pitched headfirst into the alternate future Oxford (and I admit, I do love a book set in a cityscape familiar to me) that Shannon has created. It met all my requirements - I cared about the narrator/protagonist, Paige, her friends and colleagues in the clairvoyant crime syndicate, and her mentor/maybe-nemesis, Warden. It sets up a conflict that has epic, fate-of-the-world proportions, without reducing the players to good vs. evil. It has the "mystery wrapped up in a quest", in that Paige understands very little of what is happening in her world.

Of course, there were flaws. With many bestsellers in this category, I sometimes think the editors got so overexcited about the apparent blockbuster on their hands that they became careless with little details of characterization. A few scenes are awkwardly written. But those flaws never get in the way of the story and so - to bring us back to where we started - I was still very excited to read The Mime Order. I was also excited because this is a multipart (seven books, I think) series, rather than a trilogy, and that gives a young author (and editor) time to mature. While there are several trilogies I've loved, the middle book often is weak, and recently I've noticed several authors (ahem, Divergent) seem to have produced a trilogy for marketing reasons, without really having a story that naturally warranted three books.

****The Mime Order Sampler****
This probably won't make a lot of sense if you haven't read the first book. Just FYI.

The first several chapters are promising! The writing is tighter and more polisher. The progression of action is nicely paced. Then - cliffhanger! And I'm left in agony until January... January! Not even in time for the Christmas holiday. :-(

A few concerns that probably won't lessen my enjoyment of the full book, but I going to throw them out here now as a prayer to the gods of publishing:

(1) I hate stilted recaps of previous books. I logically understand that publishers want to be able to capture the reader who picks up the second or third book in a series accidentally and pull them in so they will go back and buy the earlier books. But it's uncomfortable to read those recaps when they are clumsily inserted into the latest sequel. With a little more effort, I think most plots allow for a more natural exposition. For instance, early in The Mime Order, Paige summarizes her experiences for her friends Nick and Eliza. Instead of writing realistic dialogue for how Paige might actually try to relay her incredible story, the text summarizes it. Disappointing!

(2) My second wish is for the continued mystery to be justified by the plot. I admit, it's terribly difficult to plot a good mystery so that the main characters logically discover the answers, piece by piece, but I hate when authors are intentionally vague just to create a sense of mystery, that wouldn't otherwise seem to arise from the plot. I rapidly flip through those books just to get the answer for myself. (For instance, J.K. Rowling justifies much of what Harry has to figure out for himself by having Dumbledore withhold information to protect him.) At the end of The Bone Season, there is a ton that Paige does not know about the real identity and goals of her captors, the Rephaim, and the terrifying, flesh-eating monsters, the Emim, although many intriguing clues have been dropped. However, she also has a Rephaite ally, Warden, who clearly chooses not to reveal everything to her. It seemed, to me, that Paige would be in less danger if she had more information, and that someone trying to protect her would want her to be well-informed. So I have my fingers crossed that the secrecy will be explained, even if it is as simple as the truth being so awful that Warden didn't believe Paige would work together with him if she knew it.

Finally, if anything I've written here has resonated with you, please tell me what else I should be reading! In the last few weeks, I finished Sarah J. Maas' third book, Heir of Fire (best one yet), Tana French's fifth mystery, The Secret Place (my favorites are still the first two, In the Woods and The Likeness)Sheri Fink's Five Days at Memorial, Kim Barker's The Taliban Shuffle and Kathryn Joyce's Quiverfull (it's been a nonfiction kind of summer...no wonder I'm happy to get back to fantastic worlds). Kameron Hurley's The Mirror Empire is next up on my Kindle app.

**A probably-not-comprehensive list of YA, YA-fantasy, and mainstream-fantasy authors whom I've read and may review at some point:

  • I like you a lot. (runners-up to my best-loved books, for various reasons) Kami Garcia and Margaret Stohl, Leigh Bardugo, Diana Gabaldon, Michelle Hodkin, Neil Gaiman, M.R. Carey, George R.R. Martin
  • I want to love you, but there are issues. (it's complicated but writing quality is definitely an issue) Richelle Mead, Tahereh Mafi
  • You started out strong and then what the hell happened? (plots that jumped the shark, or just didn't live up to their potential) Veronica Roth, Deborah Harkness, Gayle Forman, Alma Katsu
  • It's not you, it's me. Really. (really. amazingly gifted authors whose work I just didn't have that chemistry with) Kendare Blake, Lucius Shepard, Ransom Riggs, Jay Asher
  • I'm just not that into you. (missing one and probably more of the four elements above) Rae Carson, A.G. Henley


freedom expanded.
freedom constricted.

22 September, 2014

(this moment: then and now} 5

{this moment} is a Monday ritual that my father started in May 2011, and that I have maintained since May 2014. He described it as "A single image - no words - capturing a moment from the past..."

{then and now} is a twist on that ritual. People often ask me if my son looks like his father, because he is blonde and blue-eyed, while I am dark-haired and dark-eyed. In fact, aside from those features, we are very much alike in looks (and, for better and worse, personality). Even more so, my son strikingly resembles my father as a young child. He has the exact same shade of steel blue-gray eyes that his grandfather had. Every so often, I stumble across a photo of myself as a child that seems like an echo of one I know I've taken of my son. {then and now} is a space to revel in the sometimes surreal elements of the passage of time.

{this moment} was adapted from cath's wonderful blog ~just my thoughts. She, in turn, borrowed it from Pamanner's Blog. My dad suggested, "Check out their blogs, and if you're inspired to do the same, leave a link to your {this moment} in the comments for each of us to find and see. If you are moved or intrigued by my {this moment}, please leave a comment." I encourage the same.

18 September, 2014

{this memory} 116

This is the story behind last Monday's {this moment}

It's December 2013 and we're at my parents' house in upstate New York.

Having just finished a quiet family dinner, my sister's fiancé Matthew is teaching my son, then 21 months old, to get out of a headlock. Finn is beyond delighted...he thinks this is quite possibly the most fun game ever invented. (And, in general, he thinks Matthew is the funniest person alive.)

I really think this deserves a poster-size reproduction.

15 September, 2014

{this moment} 116

{this moment} is a Monday ritual that my father started in May 2011, and that I have maintained since May 2014. He described it as "A single image - no words - capturing a moment from the past. A simple moment along my life's Journey - but one over which I wish to linger and savor each treasured aspect of the memories it evokes." When he passed away in February 2014, he left a folder containing images that he hoped to share in the months and years ahead. For some, I share my perspective of the story behind the moment on Thursdays, in a companion ritual called {this memory}. For others, the story is lost in the ocean of time, but I welcome flights of imagination and speculation from readers.

{this moment} was adapted from cath's wonderful blog ~just my thoughts. She, in turn, borrowed it from Pamanner's Blog. My dad suggested, "Check out their blogs, and if you're inspired to do the same, leave a link to your {this moment} in the comments for each of us to find and see. If you are moved or intrigued by my {this moment}, please leave a comment." I encourage the same.


13 September, 2014

A tree grows in Snoqualmie

I can't replace Saturdays with the Tree, but being pretty fond of trees in general, I have more than a few favorite photographs of them. 

I took this one on a hike with another medical student. We were both living in Seattle for a month to do elective rotations at the children's hospital there (mine was with the pediatric infectious diseases service). Because it's a really small world, we met again six years later during a medical education course when we were both fellows in Denver and realized our children were about the same age.  

Snoqualmie, Washington
November 2007

11 September, 2014

For 9/11/2014

A Brave and Startling Truth
by Maya Angelou

We, this people, on a small and lonely planet
Traveling through casual space
Past aloof stars, across the way of indifferent suns
To a destination where all signs tell us
It is possible and imperative that we learn
A brave and startling truth

And when we come to it
To the day of peacemaking
When we release our fingers
From fists of hostility
And allow the pure air to cool our palms

When we come to it
When the curtain falls on the minstrel show of hate
And faces sooted with scorn are scrubbed clean
When battlefields and coliseum
No longer rake our unique and particular sons and daughters
Up with the bruised and bloody grass
To lie in identical plots in foreign soil

When the rapacious storming of the churches
The screaming racket in the temples have ceased
When the pennants are waving gaily
When the banners of the world tremble
Stoutly in the good, clean breeze

When we come to it
When we let the rifles fall from our shoulders
And children dress their dolls in flags of truce
When land mines of death have been removed
And the aged can walk into evenings of peace
When religious ritual is not perfumed
By the incense of burning flesh
And childhood dreams are not kicked awake
By nightmares of abuse

When we come to it
Then we will confess that not the Pyramids
With their stones set in mysterious perfection
Nor the Gardens of Babylon
Hanging as eternal beauty
In our collective memory
Not the Grand Canyon
Kindled into delicious color
By Western sunsets

Nor the Danube, flowing its blue soul into Europe
Not the sacred peak of Mount Fuji
Stretching to the Rising Sun
Neither Father Amazon nor Mother Mississippi who, without favor,
Nurture all creatures in the depths and on the shores
These are not the only wonders of the world

When we come to it
We, this people, on this minuscule and kithless globe
Who reach daily for the bomb, the blade and the dagger
Yet who petition in the dark for tokens of peace
We, this people on this mote of matter
In whose mouths abide cankerous words
Which challenge our very existence
Yet out of those same mouths
Come songs of such exquisite sweetness
That the heart falters in its labor
And the body is quieted into awe

We, this people, on this small and drifting planet
Whose hands can strike with such abandon
That in a twinkling, life is sapped from the living
Yet those same hands can touch with such healing, irresistible tenderness
That the haughty neck is happy to bow
And the proud back is glad to bend
Out of such chaos, of such contradiction
We learn that we are neither devils nor divines

When we come to it
We, this people, on this wayward, floating body
Created on this earth, of this earth
Have the power to fashion for this earth
A climate where every man and every woman
Can live freely without sanctimonious piety
Without crippling fear

When we come to it
We must confess that we are the possible
We are the miraculous, the true wonder of this world
That is when, and only when
We come to it.

© Maya Angelou, 1995

09 September, 2014

Light For The Navigator, VII

Wednesday Without Words

Bodie Island Lighthouse
First Lighted in 1872
Outer Banks, North Carolina

Originally posted three years ago, my father planned to revisit this series of lighthouses this year. Although he never did, I have chosen to repost these monthly on the day of his passing, in his memory and in celebration of his love for lighthouses.

See: Birth of Salvation
Digital scan of 35mm color slide
Copyright © 2011 Thomas G. Brown

08 September, 2014

{this moment} 115

{this moment} is a Monday ritual that my father started in May 2011, and that I have maintained since May 2014. He described it as "A single image - no words - capturing a moment from the past. A simple moment along my life's Journey - but one over which I wish to linger and savor each treasured aspect of the memories it evokes." When he passed away in February 2014, he left a folder containing images that he hoped to share in the months and years ahead. For some, I share my perspective of the story behind the moment on Thursdays, in a companion ritual called {this memory}. For others, the story is lost in the ocean of time, but I welcome flights of imagination and speculation from readers.

{this moment} was adapted from cath's wonderful blog ~just my thoughts. She, in turn, borrowed it from Pamanner's Blog. My dad suggested, "Check out their blogs, and if you're inspired to do the same, leave a link to your {this moment} in the comments for each of us to find and see. If you are moved or intrigued by my {this moment}, please leave a comment." I encourage the same.


05 September, 2014

1 in 330

I don't write about my work very often, largely out of concern for the privacy of patients and standards of professionalism.

But I do have one of the best jobs in the world.

Like everyone else in my field, I've had the awkward airplane conversation with the person who says "I don't know how you do it" or "I could never do that." Maybe those are honest statements, but I know I am in a position of incredible privilege. I was born in a time and place where a girl could get an education, in a family where having a career and being a mom was a completely respected and supported choice. I had parents who were able and willing to financially support my dreams, including large chunks of my quarter-million dollar education (no kidding). They never pushed me to become anything (much less a doctor) but always advocated for what I wanted to do. They were patient when I took time off from medical school to study medical anthropology. They didn't bat an eyelash when I gave up increasing amounts of future salary to follow my calling (I now spend 50% of my time in teaching, research and advocacy at a medical school). They have always been there to listen, whether I needed to bitch about an administrative issue or grieve for a family. I am blessed to be doing what I'm doing.

There are many days that my work is difficult, intellectually or emotionally, but when it comes to caring for patients, I always, always, always feel privileged to be able to experience that difficulty, to walk this road with children and families who are experiencing it much, much more intensely.

It is an extraordinary privilege to take care of children and their families during the most challenging times of their lives.

Many of their parents have taught me more about being a good mother than I ever imagined. I have been blessed to know them.

It is the greatest joy to watch them grow up. And it is also an honor beyond words to be with someone at the end.


Some things you might not know...
Children with cancer can be cured even in the poorest countries.
In most high-income countries, 80% of children with cancer are cured...but 80% of children in the world live in low- and middle-income countries, where they have less access to life-saving treatments. In these countries, cure rates can be as low as 20%.

With support, resources and education through partnerships with government agencies, hospitals and doctors in more-developed places, many, MANY more children can survive cancer. Providing curative treatment for childhood cancer is well within the reach of many countries that you may think of as "third world." Guatemala, for instance, has a fantastic pediatric cancer hospital, Unidad Nacional de Oncología Pediátrica (UNOP), supported by the Fundación Ayudame a Vivir.

Access to good palliative care is just as important as access to curative therapy.
In addition, many more children can benefit from palliative care, to make them as comfortable as possible, for as long as possible, sometimes until they are cured! However, access to morphine is a major problem around the world. No child should die in pain because their country's laws prevent them from receiving it, or because their providers fear addiction or other side effects.

Adolescents and young adults are "children" too - sort of.
Biologically, many organ systems (you've probably heard this about the frontal lobes in the brain) are still developing and maturing into the twenties. Many adolescents and young adults (AYA) have cancers that are more similar to pediatric cancers than to adult cancers and many do better if they are treated on pediatric protocols. For young adults with ALL, this is true up to at least age 30.

For several types of cancer, younger children actually do much better than older children and AYA.

Cancer can be cured, but the treatment is still "barbaric." (to borrow a quote from my dad)
The most common kind of cancer in children, average-risk acute lymphoblastic leukemia (ALL), now has a cure rate higher than 90%. This is thanks to decades of research comparing new treatment regimens and studying long-term side effects from treatment. Doctors now try very hard to minimize late health effects and give children the best possible quality of life, whether that is for eight months or eighty years.

Somewhere between 60 and 90% of childhood cancer survivors develop a chronic health problem related to their cancer and treatment later in life. As some readers know, my dad was one of these. He had Hodgkin's disease as an AYA. In fact, he was in one of the first cohorts to have a good chance of cure. However, he had an early heart attack and developed heart and lung failure related to his radiation treatment. This is not unusual, and more research is desperately needed to better understand, prevent and treat late effects, and to develop new ways of treating cancer that are less toxic.

The government supports a lot of really useful research into cancer and cancer treatment.
Many other cancers, including acute myeloid leukemia and high-risk neuroblastoma, are very difficult to cure. The existing treatment don't work well or don't work for many people. Many doctors and scientists - my friends and colleagues - are devoting their lives to research into new treatments and into better understanding how cancer develops in the first place. They desperately need more funding, from nonprofits and from the National Institutes of Health.

The government is far and away the largest source of financial support for health research in the U.S., including childhood cancer. The U.S. is truly a world leader in health-related research.


When my dad was diagnosed with cancer, the vast majority of children, adolescents and young adults did not survive. Doctors didn't expect their young patients to grow up, much less graduate from college, get married and have children. Because of research over the past 70 years, the type of cancer he had and several others are now considered extremely curable, and my dad lived to hold his first grandchild.  

Most of the time, today, when I tell a family that their child has cancer, I can tell them that this is treatable, and it is curable. I can tell them that most children will go on to lead full lives. I want to be able to say that with 100% certainty. I want to be able to assure them, not only that their children will not die from this cancer, but that they will never have to face another cancer (many chemotherapy drugs carry a risk of causing a second cancer later in life) or struggle with the shortness of breath my dad experienced as his heart failed.

Until then, we need to people to care. To support financially, if you can, but equally importantly, to advocate - to tell your representatives that you want funding for this work to continue and expand, not shrink with budget cuts.

This post is dedicated to to the children and families I've met over the past nine years. You may not realize it, but you are supporting us and teaching us as physicians and providers, just as we try to support and educate you. Your patience with those of us who were still fellows, residents, or medical students, still figuring out what it means to be a good doctor, is a gift to every child and family we will care for in the years to come. Thank you. 

04 September, 2014

{this memory} 114

More catching up...

This is the story behind last Monday's {this moment}

It's September 2012 and we're picking apples at Ya Ya Farm and Orchard in Longmont, Colorado (about an hour north of Denver).

Finn is not quite seven months old here, so he didn't do much picking, but he did get to eat plenty of apples, after I turned them into homemade (sugar-lessly delicious) applesauce. I'm also partial to apple cider donuts and fall suppers of popcorn and apple cider.

It was a brilliantly sunny (hot, in fact) and I'd forgotten Finn's hat, so we borrowed this pink one from our friends' daughter Maddie. Pink is a good color on him, don't you think? 

01 September, 2014

{this moment} 114

{this moment} is a Monday ritual that my father started in May 2011, and that I have maintained since May 2014. He described it as "A single image - no words - capturing a moment from the past. A simple moment along my life's Journey - but one over which I wish to linger and savor each treasured aspect of the memories it evokes." When he passed away in February 2014, he left a folder containing images that he hoped to share in the months and years ahead. For some, I share my perspective of the story behind the moment on Thursdays, in a companion ritual called {this memory}. For others, the story is lost in the ocean of time, but I welcome flights of imagination and speculation from readers.

{this moment} was adapted from cath's wonderful blog ~just my thoughts. She, in turn, borrowed it from Pamanner's Blog. My dad suggested, "Check out their blogs, and if you're inspired to do the same, leave a link to your {this moment} in the comments for each of us to find and see. If you are moved or intrigued by my {this moment}, please leave a comment." I encourage the same.