As the end of another year draws to a close, it seems only natural to take a moment and reflect on the last year.  I've often thought that the setting of our world can be an unfortunate combination of complicated issues that trigger political and emotional landmines while at the same time leaving little time for introspection.  As such, anytime I'm struck with the inkling of reflection, I try to embrace and grow it.

Reflection is important for emotional health. It's also imperative for personal growth. While many of my personal growth moments have been due to the generous patience and mentorship of countless of folks, I am also certain that self-reflection was a critical component.

I started my reflection with what would be best described as Hallmark thankfulness.  I have a loving and supportive family, a caring and inspiring partner, a community of friends, and a stimulating and fulfilling job. I have secure and convenient housing, access to education, a regular paycheck and I also have a steady supply of antidepressants. I'm grateful everyday. Reiterating why I'm thankful just because it's the year's end would be the easy way out.

So, I'm realizing, given my current situation, true reflection at this year's end is not just recounting what has happened or what I'm fortunate for, but really pushing myself to think about what I've been afraid to think about.  (Even beyond the typical "hard questions": Am I contributing enough to our global society? Have I been kind? Incidentally, a generous answer to both those questions would be, "sometimes.")

Even these past four paragraphs are probably longer than they ought to be because I'm reluctant to get to what I'm scared to say.

I'm anxious about having a wedding next year because I'm not totally comfortable with being queer. On top of that, admitting that I have discomfort with being queer is embarrassing for me.

It's not that my family and friends disapprove. They are incredibly accepting and supportive of me and my partner. I'm still anxious though. I think most of my family knows I'm queer, though I never really had a formal announcement; I didn't send an e-card. On the other hand, I've never hidden it either. Ultimately, the wedding will be the first time that I declare that I'm queer in front of my whole family.

I don't even know why I'm terrified. I've come out to crowds of strangers before. I've been put on display as the token queer. I've even been threatened before. This is my wedding where presumably all the people who come are only coming because they care and want to support me, and yet, I feel apprehensive.

I get so tired of being different sometimes. I get tired of psyching myself up to be unabashed and confident.

Maybe it's that I'm resentful that during a time that I'd just like to focus on celebrating that I've found someone incredible to spend the rest of my life with, it's also just as much about having a gay wedding. Even in a liberal city and a state that's passed gay marriage, we have to vet our venues and vendors and wedding planners. An unforeseen bonus to getting a wedding planner is that I no longer have to deal with hearing about it if someone doesn't want to do a gay wedding.

But maybe even more difficult is admitting that I still struggle with being queer.  I've been out for almost a decade and out to myself for even longer.  I like to think of myself as someone who's grown comfortable with being queer. I like to think that I've done all that soul searching and internal struggle and now I'm strong and proud. But I guess even after all that, I still can't figure out how to not let it get to me sometimes.  Every once and awhile, I still find myself wishing that I didn't have to be different.  And then right after that thought I wince because even more than that, I want to be the person that's ok with being different.

I hear my out and proud friends in my head.  I worry that if they find out that I have these thoughts they'll judge me and roll their eyes. Aren't we passed this? "Don't react with shame, react with pride!" "Don't let them disempower you!" And most of the time I can rise to the occasion, but sometimes I fail. Or I'm not strong enough. Or I'm tired. Or whatever.  And that disappoints me. But it is what it is and I can hear my same friends saying that I'm being too hard on myself.

Now that I've said it, maybe I can start to move on and enjoy my wedding.

Even I caught my breath.  For all 102 minutes of it my mouth hung open. I almost drooled on myself. Simply put, it was incredible.

It’s visually stunning.  It’s never-before-captured footage of holy rituals, like the Hajj from nearly 2,000 ft in the air. It’s technically meticulous, with the smoothest of camera panning and pushing all while shooting a time lapsed sequence.

It’s also infuriating.

Ron Fricke and Mark Magidson clearly have enormous talent.  Who else has gotten this access? Who else would come away with the same images?  But it’s been squandered.

We cut from households on the manmade islands of Dubai to people scavenging for food in the landfills of Manilla.  We follow the flow of weapons from bullet factories to a man buried in a casket the shape of a gun.  And there’s this machine at a factory farm that sucks up chickens as they cluck with panic and try to run away.

Their images have an astounding potential to move people, to leave us unsatisfied with the way that we humans treat each other.  However, all they do with the images is create what Fricke calls “a guided meditation on the cycle of life, death, and rebirth.”

That’s problematic.  By instructing us to use his images to meditate, Fricke wraps up all of the poignantly recorded suffering into a neat, pretty packages.  We’re free to view them without having to dwell on their complete significance.  We are absolved from the need to take action.

When asked to describe their own reactions to the footage and comment on the huge disparities that they witnessed, Fricke notes that he’s grateful for the life that he has.  Michael Stearns, the composer for the film, comments that Magidson has very strong opinions on the matter but after several away-from-the-microphone comments that none of us can hear, all Magidson can produce is, “There is extreme poverty in this world.”

Maybe it’s that they’re scared of being construed as political.  Maybe the only way that they can get access is by remaining neutral observers only interested in meditating.  I’ll always be curious what Magidson said off microphone.  Regardless, by the end of the Q&A session, one gets the impression that Fricke and Magidson are simply visual tourists with extreme talent and an interest in the spiritual.  I can’t help but wonder if some of the subjects of the film might feel exploited to have their suffering recorded for the sole purpose of helping two rich, white guys meditate.

Fricke and Magidson obviously recognize that compelling images require more than just visual beauty.  Most of their images are striking only because of the heartbreaking juxtapositions that they present.  For example, there’s a portrait of what appears to be a family holding their guns.  In the center is a young girl with a pink rifle.  An obvious interpretation screams at the viewer.  The young girl and the color pink is supposed to represent innocence and youth which is contrasted with a gun which is represents violence and death.  It’s a comment on the extreme level of armament of society today.  But if viewers of this film are truly supposed to meditate only on “flow,” then it’s not a profound statement at all, it’s just a gimmick to create a charged visual.

A tear drops from a Geisha’s eye.  It begs us to consider the price that some us must pay for the luxury of others. Initially moving, it’s all too appropriate and disappointing when Fricke explains that the tear was from the lighting, her heavy make-up, and the instruction “don’t blink.”  One begins to wonder how much substance is behind Fricke and Magidson.

Even as artists, a re-watching of Baraka, does make you wonder if they’re just repeating previous victories.  At one point an audience member asked how they decided to reuse footage and why.  Fricke visibly bristles and states that they didn’t reuse footage from Baraka.  Yet he does admit, “We just can’t seem to stay out of the Vatican.”

Some of the footage is so similar that it might as well have been reused.  Both movies have footage of Mecca, of Orthodox Jews at the Western Wall, volcanoes, the Vatican, the Tokyo subway, the Egyptian pyramids, factories on fast forward, industrial farms, and starry night time-lapses.  In such a beautiful and complex world, how could it be that things are repeated?

Ultimately it’s fitting that Fricke and Magidson fall short of perfection. Talent aside, they’re only human and thus capable of the same majestic heights and disappointing flaws that are portrayed in their film.  In many Buddhist teachings, Samsara is more than simply the cycle of reincarnation, but the world of suffering that we are trapped in before we attain Nirvana.  As my friend put it, “It’s like they’re stuck in their own little Samsara.”

But perhaps that’s too harsh - they’re only filming what we’ve all participated in creating.  As Fricke takes great pains to illustrate, we’re all connected: this is our collective Samsara.

At the very least, the film’s gorgeous and nonverbal medium is powerful enough to create messages that transcend the filmmakers’ intentions.  Go see the film, but please, do these images justice.  Do more than just meditate and passively experience.  Be inspired to do something about it.

Eid said! It's Eid, marking the end of Ramadan!  I can't help but feel a little nostalgic for Michigan.  Even though I'm not Muslim, it can be fun to be swept up in a community's special time.

I'm not Christian either, in fact, I don't even really celebrate Christmas commercially anymore like my family did when we were children, but I still love watching A Christmas Story on TBS. I'll even admit that I enjoy a good slice of fruitcake every once and awhile (I do have standards though... only high quality fruitcake and usually with rum).

Similarly, it was such a privilege to be living in an area with a high enough concentration of Muslims that I could get a contact high.  You're reminded to be thoughtful about one's behavior and thoughts.  You're inspired to come together as a Muslim community, a local community, and a global community.  You congregate around food.  These are all things that I support.

For those of us who are not Muslim, Ramadan's most notable aspect is usually the month long fast that occurs while the sun is in the sky. Though the fast is only one portion of a larger theme of abstinence and purity, it's definitely one of the first things that comes to mind for me when I think of Ramadan.  And medically, though I'm sure actively trying to reduce the number of negative thoughts in your mind can reduce stress and thus promote wellness, it's the fasting component of Ramadan that needs to be discussed with my patients who have Diabetes.

It can be hard to predict what will happen when a person's eating schedule is disrupted by external forces.  Some simple observational studies reveal that about 15% of people lose weight during Ramadan, 15% gain weight, and the rest keep on keepin' on.

Our patients with Diabetes, however, can be at increased risk for health complications, particularly those who are on medications that modify their body's insulin or are completely insulin dependent.  Regardless of whether you have type 1 or type 2 diabetes, the major goal (and frequently difficulty) of insulin therapy is to adequately match the amount of insulin that your body needs with the amount and timing that you take.  Even during periods of typical eating, it can be a challenge because your body's insulin needs fluctuate with time and depends on a wide range of variables including when you last ate, what it was that you ate, the time of day, how quickly your insulin works, how long your insulin lasts for, and how active you are.  The consequences of mismatching your insulin dosing with your body's needs can range from the minor (slightly elevated blood sugar) to the catastrophic (blood sugar so low or so high that hospitalization is required).

Ramadan does allow for folks to opt out of the fast for health reasons.  Women who are pregnant, women on their period, the elderly frail, the ill, are all exempt from the fast (though making it up later might be required).  Certainly there are cases where it's obvious that someone shouldn't fast.  But when it comes to chronic diseases like diabetes it's a hazy call that's entwined with all the complications of life.  How well controlled are they outside of Ramadan? How well do they understand diabetes and their medical regiment?  Even more relevant is how important it is to them that they fast. Is it a critical religious and spiritual activity for them? Is it a unifying cultural practice? Are they worried that they will be judged by others if they don't fast? Will they judge themselves if they don't fast?

As clinicians, our approach to medical decision making varies widely from being directive in what we think our patients should do to being completely patient driven.  It's a judgement call we make based on each patient and the particular clinical scenario.  The decision to fast during Ramadan, unless we think it's extremely dangerous, is really one that should be left to the patient.  Our job is to give them the relevant medical information in a way that they can understand and then partner with them to help them reach their goals.  To that end I'll conclude with a paper!

There hasn't been much research on the best way to change insulin and medication regiments.  During Ramadan one usually fasts for at least 12 hours and then breaks the fast with a large meal when the sun sets. It's hard to match such large and extreme fluctuations.  A co-intern of mine recently showed me a great review article on Diabetes management during Ramadan.  The clinical take home points are summarized in the table below:

Last week I began functioning as a real doctor.  I didn’t wear a long white coat because family medicine doctors are too counter-culture to wear white coats but, I did write a prescription without having to run around looking for a doctor's signature.  I filled out official medical paperwork and signed "MD" behind my name. When my patient addressed me as, “doctor” instead of babbling out the usual, “No, no. I’m a medical student, but perhaps I can still be of help. If not, I’m certain I can find someone who can,” I simply turned and said, “Yes?”

As excited as I am to be moving forward in my training, and as sure as I am that I learned many useful things over the past four years of medical school, I can't shake the feeling that when I say I'm a doctor, people have an image of what that means that is different from what I actually am.  As my co-intern said the other night at happy hour, "Is anybody else suffering from intense imposter syndrome?" Unanimous nods.

Acknowledging it out loud helped explain the thoughts that had been popping into my head the past few weeks.  Whenever I had a moment of downtime, memories that I hadn't thought about in years would seemingly randomly surface: the time that a friend in high school decided she didn't like me anymore and I never understood why or what I had done; the time at soccer practice when I was nine and I was chided for thinking I was better than my teammates; and the time a coworker told me that he didn't trust me.

What I fear is that somehow I've gotten this far despite of who I am. The litany of remembered failures and shortcomings, however small, are moments when people were able to see through to the truth of me. At any moment the smoke will clear and everyone around me will be able to see what they saw as well.  One ought to chastise me for even entertaining the thought that the people are around me could be so obtuse for so long, but the quiet fear remains, lurking in the back ground of my thoughts.

And then of course, being who I am, I thought about my own path with coming to terms with my own privilege and being a person of color. Maybe some of those lessons can apply to what it's like to be a new doctor.

Though Robert Jensen wrote this specifically from the point of view of a white person, it has always stuck with me.  He writes,

"A final fear... : The fear of being seen, and seen-through, by non-white people. Virtually every white person I know, including white people fighting for racial justice..., carries some level of racism in our minds and hearts and bodies. In our heads, we can pretend to eliminate it, but most of us know it is there. And because we are all supposed to be appropriately anti-racist, we carry that lingering racism with a new kind of fear: What if non-white people look at us and can see it? What if they can see through us? What if they can look past our anti-racist vocabulary and sense that we still don't really know how to treat them as equals?"

And another little pearl that comes to mind from my friend, Sarah.  As a white woman, she once described her college education and major in African American studies as a mediation on "growing comfortable with being uncomfortable."

I think what I like about these two ideas is that they remind me to accept (or even embrace) my own humanity.  When it comes to race and privilege, I've come to accept that I will never overcome my biases and reach "complete enlightenment."  I don't have any sort of confidence that I can navigate life without offending or disrespecting the people around me.  However, I do find self-assurance in striving for the humility to recognize my own shortcomings and in dedicating myself to self-improvement.

This is not to say that I don't have high expectations for myself and others. I would argue that a lack of expectation, a satisfaction with the low baseline level of discussion and understanding of privilege in this world is one of our biggest problems.  But having high expectations doesn't mean we can't be compassionate when we fall short of them.

We are all flawed.  Perhaps in those moments that I’ve been recently remembering I was unlikable, arrogant, and untrustworthy.  But that doesn't necessarily mean I'm solely those things. Even more importantly, I shouldn't spend energy on covering up those flaws when it could be better spent working on them.

Recently I was encouraged to watch Brené Brown's TED talk, "The Power of Vulnerability" as part of a training on giving and receiving useful feedback.  The entire talk is absolutely worth watching and there are pearls that can be applied to every part of living a more enriched life.  In it she describes her research on how human beings make connections.  One of the fundamental differences that she found between people who tend to have a strong sense of love and belonging versus those who tend to struggle with it is simply the “[belief that] they are worthy of love and belonging.”

Watching her talk was one of those wonderfully clarifying moments where someone has finally figured out how to articulate something you have vaguely perceived all along.

And that just might be the key to being a young doctor (or maybe even a doctor in general).  I will never master medicine in the same way that I will never master the internal biases that I carry.  But as long as I dedicate myself to self-reflection and self-improvement, I have nothing to be ashamed of because I have been adequately trained, I’m dedicated to my patients, and I’m committed to learning.  I am inherently worthy.

True strength is not having lacking any weaknesses, but being able to reveal the weaknesses that you do have. It’s cheesier than a Hallmark card and difficult as hell.  However, being more secure in my own worthiness makes it easier.  No matter how many times I say it, succeed at it, and fail at it, it’s always a struggle because perhaps the biggest catch 22 of all when it comes to “vulnerability” is that as soon as you get comfortable with revealing a certain part of yourself, by definition, it’s no longer vulnerable.

The culture of medicine, as a whole, is toxic. It's built on hierarchy and power.  Theoretically, patient care is supposed to be our highest value.  It is assumed that this is driven by increased knowledge.  Thus, we give the most power to those that can demonstrate the most knowledge.  In reality this creates a pressure to not necessarily know the most, but to conceal what you don’t know.  Mix in the usual amounts of pride, ego, and emotional baggage that colors all human interactions and it’s not surprising that in the end, this structure only vaguely translates to the best patient care possible.  This is the healthcare profession’s greatest shame.

It is also this culture that makes healthcare an incredibly difficult place to be human.  While it’s true that extensive knowledge is necessary, perhaps the framework shouldn’t be that the most knowledge makes the best doctor, but that the best learner makes the best doctor.  Having a doctor that graduated top in their class is less important to me than having one that graduated and continued to learn.

Overall, I think we’re moving in the right direction.  But progress is slow and is still the exception rather than the rule.  Not surprisingly, the shifts in culture that have had the most traction are also the ones that impact the financial bottom line in a positive way.

As I attempt to model my own behavior after my ideals and role models, I’m continually impressed with how hard it is to be vulnerable and confident.  Inherent worth is a dangerous phrase. It's a self-assuredness that can easily transform into over-confidence, arrogance, and entitlement.  Just as difficult is humility.  It is not the masking of arrogance with self deprecation.  Nor is it insecurity or a lack of confidence.  It’s not as simple as a one dimensional spectrum where “insecure” is on one end and “arrogant” is on the other.  There’s no balance, no “sweet spot” somewhere in between.  It’s a presence, it’s a genuineness, that’s on an entirely different scale.

Sometimes it can be hard to figure out how to be a medical practitioner and contribute to society beyond the one-on-one interactions that you actually have with your patients.

I'm super proud of my sister, Emily (and pictured to the right), who has been part of team that just opened up a community garden through their medical school in the middle of the Bronx.  While it might not produce enough food to support a community of patients, it is an area of green space, quiet, and perhaps, most important, a focal point for healthful eating and getting back in touch with real food.

BODY stands for Bronx Obesity, Diabetes, and You. Check out the rest of the short blurb on them here!

Hey folks! For those of you who are curious, I've posted the speech that I gave at graduation this past Friday. It was a huge honor to be chosen by my classmates.  I've also included the text here.

And then just a few more because I was curious: