Writing Contest
Medical Musings
Results of our seventh annual writing contest
Since 2004, Minnesota Medicine has been sponsoring a writing contest for physicians and medical students. Each year, a panel of judges struggles to determine which poem or essay or short story is best. And each year, we find ourselves thinking of the cliché about apples and oranges. How does one compare a short poem with a long essay? A story that has gripping imagery but grammatical flaws with a piece that is more precisely constructed but has less impact? This year, more than ever, we struggled.
In the end, we decided to name a winner in our medical student category. That is the essay “Fear and Wisdom, Blood and Time” by Trahern Jones, a student at Mayo Medical School who is profiled on the next page and whose winning entry appears on p. 35. In the physician category, we decided not to select a single winner. Instead, we named three honorable mentions. They are the essay “No Reasonable Explanation” by Diane J. Horvath-Cosper, M.D., and the poems “In Memory” by Nancy J. Baker, M.D., and “Treating Gautama” by Tim Ramer, M.D.
We are pleased our contest spurred so many thoughtful Minnesota physicians and medical students to put their ideas into words and share the results with us. Over the next few months, we hope to share more of their work with you as well.—the editors
Student Category Winner
By Trahern Jones
Physician Category Honorable Mention
By Diane J. Horvath-Cosper, M.D.
By Nancy J. Baker, M.D.
By Tim Ramer, M.D.
Our winner in the student category found inspiration in India.
Long before he double-majored in chemistry and biochemistry and before he thought about going into medicine, Trahern Jones knew he wanted to write. As a high school student in Mesa, Arizona, he hoped to major in English in college.
Jones might have proceeded with that plan had it not been for his participation in the U.S. Academic Decathlon during his senior year in high school. The program pits teams of high school students against one another in a test of their knowledge in 10 areas. Jones was tasked with becoming his team’s biology expert. “I really got into it,” he says, admitting that until then he had done poorly in his science and math classes because he felt disengaged.
After a year of community college, Jones transferred to the University of Arizona in Tucson, where over the next four years he excelled in the sciences that had once bored him. To ensure that his focus would not be limited to what could be seen through the microscope, he became involved in the school’s chapter of Engineers without Borders, raising funds and organizing teams to work on water projects. That experience ignited his passion for volunteering. A trip to India in 2007 to work with a nonprofit called the International Alliance for the Prevention of AIDS sparked his interest in health. “It’s where I developed my first taste for medicine,” he notes. Jones started at Mayo Medical School in July of 2009. As a first-year student, he has continued to travel and to write.
Jones says his desire to help the less fortunate stems from hearing his father tell about his own activism. During the 1970s, for example, he helped elect the first black student body president at the University of Tennessee and protested against supermarket chains that were charging higher prices in poor neighborhoods. “You can’t grow up hearing these stories from your dad without applying them to yourself in some way,” Jones says. In a blog, he describes the impact of such stories: “I can only say that my father and mother raised me to hold a great deal of respect toward the written word, knowledge, and art, and a great deal of disrespect towards authority, wealth, and narrow minds.”
His disregard for narrow minds is revealed in his winning essay “Fear and Wisdom, Blood and Time,” which explores the consequences of prejudice toward people with HIV in India. Jones’ inspiration for the piece was his most recent trip (last February) to India, when he visited the Selvi Memorial Illam Society’s home for HIV/AIDS patients and learned that people with AIDS were feared and shunned. “That was the fire behind it. It was extremely upsetting to me to hear about patients who are discriminated against because of their HIV status,” he says.
Jones says HIV is misunderstood by people in all levels of Indian society. He notes that the Selvi residence is situated in a relatively affluent suburban neighborhood of Chennai populated by educated people. “These neighbors have petitioned multiple times to shut it down, to close the house because they claim their children will catch something from these people,” he says. “They would prefer this nonprofit was moved to a less visible part of the city, a place where they didn’t have to think about HIV on a daily basis. For a lot of people in Chennai, HIV is not merely a disease. It’s a problem with these people’s moral fiber.”
Jones says he decided to write this essay and submit it to the contest because he knew he had a story to tell. “I don’t think a lot of people would [otherwise] hear these stories about these places in the world. I thought I had one people could take something away from.”
He says his writing is done these days in fits and starts. When he’s traveling, he might write about an observation; when he has a free moment at home in Rochester, he might explore an idea. He likely will have more stories to tell when he returns from his latest trip. This summer, he’s working at an orphanage for mentally handicapped children on the Indonesian island of Sumatra.
Jones expects to continue his trips to underserved and needy areas, making full use of Mayo’s block plan, which enables medical students to fit their own selective experiences into the curriculum. He says each new experience abroad furthers his passion for volunteering and opens doors to more overseas experiences. “The more involved you are, the more you meet people who are also involved and who can help you find other places to learn from,” he explains.
Just where these experiences will ultimately lead is uncertain. For now, Jones says he is thinking about specializing in tropical medicine or infectious disease. And he plans to keep on telling stories. “Writing is definitely a craft I want to keep improving on,” he says. “It’s something that I can bring to medicine.”—Carmen Peota
Fear and Wisdom, Blood and Time
Dawn comes in Chennai with an engine-rattle along the road. The dark silence of sleep lights up with the sound of a thousand hands against the street garbage, and I wake up and I believe in the gods of India. I believe in the gods of India while the Brahmins sweep the altars clean beside the line of sweating, armpit-stained, white-shirted information technology and telecommunications workers waiting to buy their tickets at the train station, and I believe in the gods of India while the electric lines sputter above the manifold squatters’ rambling, tin-roofed invasions below the elevated track.
I believe in the gods of India while their stone brows are painted red by the pigment-thumbed hands of passers-by, the stains a reminder that blood is what defines the lives of many HIV patients here. It is the content of their blood that makes the doctors turn men and women and orphans away. Afraid to touch these patients, they refer children with ear infections or shy away from performing essential surgeries. Some hospitals are reported to burn seropositive patients’ bed sheets.
On the outskirts of the city, shaded by the looming figure of an old tuberculosis sanatorium, you can find the Selvi Memorial Illam Society’s house. The air is fresh out here; the courtyard is lulled by the sound of birds and wind. Here, beyond the slums, rivers, and roads, restless engine motors, and puttering rickshaws, Selvi’s ghost walks the hallways like a protector saint. She was once a prisoner of mistrust and hatred. One of the original six HIV-positive sex workers first identified in 1986 (India’s own patient zeros), she was sent to jail in a misguided attempt to stymie the epidemic. Yet she agitated; she told the truth about this new disease—and she was hated for it.
Selvi died several years ago, and this organization was named in her memory. I believe in the gods of India when I look at her picture above the front door, where, frozen in film, she lights a candle in perpetuity.
The counselors at the house speak in the clichés of social work: peace and quiet, trust and hope. Patients journey from villages and towns throughout southern India to stay here and to obtain a life-saving regimen of protease inhibitors and nucleoside reverse transcriptase inhibitors offered by doctors who speak an obscure language of biochemistry and viral evolution. Patients travel so far not because they cannot obtain treatment nearer to home but because they cannot obtain it secretly. There are too many pharmacists, too many doctors, too many friends and family members willing to spread rumors about them. HIV is a dirty secret, a wellspring of darkness in many minds. Like many others, India’s morally prescriptive society cannot abide the reality of extramarital sex. Sex between men is outlawed; sex between women does not officially exist. Thus, in the old manner of law and propriety, lies are fashioned into a bizarre reality that, despite its underlying falseness, warps lives and ruins families. Most of all, it kills.
In the courtyard of the Selvi house, I met a female patient who, at first glance, appeared to be a young girl. Her tiny frame better evoked the spirit of a bird than that of a young woman. She was 20 but appeared to be only 12 years old, and at her full height she barely reached halfway to my chin. The patient’s salwar was draped over her thin shoulders as if it were hanging on a clothesline. Her bony arms clutched a bundle of notebooks.
Last year, her mother had been overwhelmed by a litany of opportunistic infections, and as the woman died, the doctors identified AIDS as the responsible syndrome, the diagnosis like a wreath placed on a tombstone. They turned to her daughter and realized what had stunted her growth. She had been born infected with HIV. In all probability, she ought to have died more than a decade ago; by some fluke of the statistician’s calculator, she had survived to encounter this devastating reality.
She was shy. She averted her eyes when I looked at her. But most of all, she was incredibly strong. It is not easy to undergo antiretroviral therapy. Every medication applies its own peculiar effects, disruptive to the patient’s life and often resulting in a startling loss of flesh and color. Many patients abandon ART because of these side effects; they cannot pretend their lives are normal while experiencing these symptoms. They also cannot believe that the specter is not eating them away from the inside. But this young woman carried on; and not only did she carry on, she continued her college studies. In fact, she had homework to finish on the day I met her.
Most interestingly, she had the strength to volunteer at the Selvi house. Every day, she visited other HIV/AIDS patients in the community. She taught and cared for these patients despite the side effects of ART, despite her own tragedies, despite the fact that her grandparents, her only remaining family, still didn’t know she was HIV-positive. She worried what they would do when they found out.
And this is why I say I believe in the gods of India.
The suffering of HIV patients stands out because of stigmatization, fear, and ignorance. The Bhagavad Gita, a sacred Hindu scripture, offers sublime insight into confronting these issues. They say that many years ago, the hero Arjuna faced the terrible reality of seeing his family members, his servants, his warriors, and his enemies dying needlessly, tragically. He begged his charioteer, Krishna, for an explanation. Krishna, a divine being, showed Arjuna a vision of terrifying, wonderful truth of cosmic scale, indescribable in words. This vision left Arjuna shaken and trembling. Krishna said:
Knowing wisdom, not again will
delusion so torment you, pandava;
With this, all creatures, without
exception, you will see in yourself,
and in me.
In their daily struggle against suffering, HIV patients, caregivers, and health workers in India have learned this lesson well. They look beyond the biomedical surface of the epidemic and recognize its deeper facets—the misunderstanding and fear that dehumanize patients, that silence the discussion about the spread of the disease, and that ultimately abet the contagion.
In the rhetoric of blame, AIDS is still spoken of in terms of a scourge, a curse—a scarlet letter sewn into the flesh of patients. In reality, it is a biological entity, a virus that through the currents of natural selection, wove its way into the largely uncharted courses of human sexuality, behavior, fear, and wisdom. It has taught us about the darkness of the universe and the misunderstanding and the fear within ourselves. We see visions of historical plagues resurrected. We see visions of whole villages, regions, nations denuded of their inhabitants; and thus we see how urgent it is to comprehend the many ways of being human, the weaknesses of our moralizing, the truth about our human society.
The young woman continued her antiretroviral therapy in spite of the obstacles she faced, in spite of the hatred and fear of her. But her first-line medications were not working—the virus was evolving within her blood and her infection was devising new ways to evade the chemical onslaught brought against it. Her immune system was failing, and if it did not improve, she would be put on other, more brutal drugs to stem the multiplication of HIV in her arteries, veins, lymph nodes, and flesh. Those drugs would further savage her body, and they would exhaust her. I asked her if she had a plan to improve her immune system before it weakened to the point when second-line drugs became essential. She coyly answered that she would try to eat better; she knew that a good diet might help improve her chances. But I knew it was not going to save her.
I want to speak to her again. I want to ask her, Why aren’t you afraid? But I know the answer—that she is afraid and that it is human to be afraid. But I see that it is the point at which fear meets wisdom that counts—that edge of experience where deities speak with mortals, where visions overwhelm, where truth rather than lies begin to guide our choices and passions. Who knows when she will tell her grandparents her HIV-positive status, if ever. I believe she will; but nevertheless, I see she has committed herself to a beautiful thing—to care, to teach, to attend college, to multiply wisdom in the face of clinical progression.
I want to say to her, You taught me how a human being may begin to face uncertainty and fear, blood and time. And you taught me that only strong souls may pass here. You tell the truth, and in your ways find the brim, that place where a human life meets the universe, that point where the red-stained thumbs meet the brows of stone gods, under the train tracks and above the tin roofs, between the roar of the street and the quiet poverty that paws through the refuse of richer men. In this society, in this experience of humanity, you, as many others, still tell the truth. You make the edge against darkness. You carry fire against the night.
I was groggy when I returned the page to the resident work room. Two hours into what I had hoped would be a long post-call nap, I wondered which of my continuity patients had been admitted for labor. I was caring for six women who were all near term.
“Hi Liz, it’s Diane. You paged?”
“Oh, hi. I have some bad news. Your patient Ms. P is here with a dead baby.” Instantly, I was completely awake. Oh my God, what happened? Liz related Ms. P’s history of absent fetal movement since Wednesday, her arrival at triage today (Friday, her due date), and the ultrasound that confirmed that her baby girl was gone. Ms. P refused to believe the first ultrasound and had requested a second. Following that, she demanded an emergency cesarean, insisting that her baby would be born alive if she were delivered immediately. She was angry that we wouldn’t attempt an emergent surgical delivery. She was angry that she hadn’t been delivered a week ago, though there was never any indication for an early induction. She was angry that she had waited so long to come in.
“Does she want induction? Does she need some time to think about it? Will she still be there if I leave my house in 15 minutes and come in? Does she even want to see me?”
“Yes,” Liz replied. “You should come. She says she wants to see you.” My first visit with Ms. P had been 30 weeks prior, when we embarked on her pregnancy journey together with an office ultrasound that confirmed her 10-week gestation. I remember her glowing smile when I gave her the grainy black-and-white ultrasound image to show her boyfriend. She attended every prenatal visit faithfully, read every book and brochure she could get her hands on, and asked insightful questions that made me understand the depth of her commitment to this unplanned-but-wanted pregnancy.
She revealed her personal history more gradually. The product of a substance-abusing mother and an absent father, Ms. P made her own foray into drugs and alcohol at the disturbingly young age of 14. By 15, she had landed in rehab, then juvenile detention. By 17, she was clean and sober. And by 19, she had met a caring young man, fallen in love, and conceived this pregnancy. She was delighted to learn that she was having a girl.
This baby was a new opportunity for Ms. P, the impetus for reconciliation with her mother. She was the reason to maintain sobriety. She was another chance to be part of a happy childhood, years after Ms. P’s painful childhood had ended. She represented all that Ms. P’s life could be. She was hope for the future.
And now she was gone.
I sat with Ms. P for a long time. She went through the stages of grief in front of my eyes, experiencing anger, denial, and despair within a matter of minutes. She decided to begin induction of labor that afternoon, and at 3 a.m., I helped her deliver a perfectly formed, lifeless baby girl. The nurse and I wrapped the baby in a flannel blanket, put a little pink hat on her head, and lifted her up into Ms. P’s arms. The floodgates opened, and Ms. P and her boyfriend were engulfed by the tears that they hadn’t been able to cry until now. I felt my chest tighten and my breath catch. I excused myself to the work room, where I cried until I had nothing left. There were many hugs and kind words, as senior colleagues who had had similar experiences offered emotional support.
Since then, I’ve gone through the prenatal record dozens of times, reviewed all the ultrasounds, the negative cultures, the autopsy report. I haven’t been able to identify any reasonable explanation for why this happened. I thought through each of the last several office visits. Did I tell her to come in right away if the baby wasn’t moving normally? Did I remind her at every visit? I’m sure I did. And I don’t know that it would have made any difference. It’s still unclear to me why Ms. P waited those two full days to be evaluated.
When I’m asked to define myself, I usually describe my many relationship roles—I’m a daughter, a sister, a wife, and a friend, among other things. But when I think about what really makes me who I am, what gives the most meaning to my life, it’s my vocation as a physician that provides me with my strongest sense of self. My entire adult life has been a journey to this point, and I would gladly do it again. All the school, the sacrificed time with family and friends, the emotional and financial burden have been worth it if I can believe that I have the power to make a difference.
When I held Ms. P’s dead baby girl, the foundation of my self-concept crumbled. All my accumulated knowledge and training hadn’t been enough, and there was absolutely nothing I could have done differently. My best had not been good enough. It became a challenge to be the daughter, sister, wife, and friend I once was. In some ways, I’ll probably never be the same. Part of me will likely grow stronger and maybe a little harder, knowing that this will happen again and that I’ll need to call upon the things that I’ve learned while caring for Ms. P. But part of me will always mourn the memory of that sweet, perfect baby girl who never took her first breath.
I haven’t seen or heard from Ms. P since then. I called all three telephone numbers on file, and they were either incorrect or disconnected. Periodically, I check her chart to see if she’s been seen in another department. She hasn’t been back to that hospital. I worry that she’s slipped into depression, gone back to drugs and alcohol, or worse. I wonder if she and her boyfriend are still together and if she continues to see her mother. I wonder if she might be pregnant again. I want to talk to her and tell her again that I am sorry and thank her for allowing me to be with her in both wonderful and terrible times. I want to promise her that she will never have to go through anything like this ever again, but I know I can’t promise that to her or anyone.
Diane Horvath-Cosper is a fourth-year resident in obstetrics and gynecology at the University of Minnesota.
Petite and poised,
she pirouettes
on the high wire.
Arms outstretched,
she stands angelic—
an acrobat balanced
on the head of a pin.
Decades later, grounded,
she totters as she turns.
No longer working in tandem,
limb cogwheels lock.
Clown-like,
she trips
on the edge of the step.
Nancy Baker is a family physician at Smiley’s Clinic in Minneapolis. She wrote this poem about a patient who suffers from dementia.
My first patient is Mr. G. Buddha. His chief complaint: “How few here see clearly!”
I ask if he is having trouble with his vision. He replies that freedom from desire is the way to end suffering.
I nervously inquire: “How long have you felt this way? Does anything make it worse?” He smiles and says, “Only the experience of nirvana makes it comprehensible to the wise.”
I review his vital signs, notable for low blood pressure and slow pulse. The record shows no fixed address, no occupation, and no cell phone number, I tell him.
He reports that he has been traveling, searching for truth and the meaning of suffering. I note that he is homeless in the chart.
I ask him what he hopes to accomplish today. “How can you find delight and mirth?”
“Yes, Mr. Buddha,” I say. “I, too, like a good joke, but how can I help you today?” “To keep the body in good health is a good task. Otherwise, we shall not be able to keep our mind strong and clear.”
Ah, you are here for a preventive health exam—good for you, I think and then ask, “Do you have any concerns?” “Few are the people who make it to heaven unaided,” is his unnerving reply.
I begin to feel alarmed and ask if he has thoughts of harming himself. “Death is not to be feared so much by one who has lived wisely,” he says.
I mentally review the DSM-IV criteria. Is his speech evidence of hyper-religiosity? Is he suffering from delusions, psychosis, or paranoia? He seems to be calm—I am not, I am worried. Should I call a psychiatrist, a social worker, the police?
“One should understand according to reality and true wisdom. Be greatly aware of the present,” he says to me in the midst of my consternation.
I return to the familiar ritual of history taking I learned in medical school. I ask whether he has any headaches, dizziness, double vision ... rectal bleeding ... sexual dysfunction. He laughs and says, “Of all the worldly passions, lust is the most intense. Make proper use of it.”
“O.K. it sounds like you are doing well in that department,” I say. I ask how I may help him—and find that his reply both confuses and consoles me. “Let us rise up and be thankful, for if we didn’t learn a lot today, at least we learned a little, and if we didn’t learn a little, at least we didn’t get sick, and if we got sick, at least we didn’t die; so let us all be thankful.”
He thanks me for my time and my concern, and he bows with his hands together. “You can search throughout the entire universe for someone who is more deserving of your love and affection than you are yourself, and that person will not be found: You, yourself, as much as anybody in the entire universe, deserve your love and affection,” he says in parting.
He slips out the door, and I am alone. I sit down to document the visit. Was he crazy or holy? What is the diagnosis? How can I record this visit in a way that will make sense to anyone?
Then I pause,
breathe,
smile,
and for a moment feel singular confusion and joy.
Tim Ramer is medical director at Smiley’s Clinic in Minneapolis. He wrote this piece after a patient described feeling close to God after starting on fluoxetine. The quotations are translations of Buddhist writings.