Notes From The Depths

After a particularly dark day as a medical student, I decided to document my innermost feelings of despair and sadness, censoring as little as possible, so that others could experience the easy spiraling descent a student can be lost to if coping mechanisms fail or are absent. Even now, removed from the threat of that day and having passed the test I was sure I had failed, I am shocked at my words, yet I write them here to show solidarity with those who think they're the only ones:

I took a major career-defining test all day yesterday. I studied for weeks for it. It was supposed to be a comeback whereby an old guy comes off the bench and knocks out the heavyweight champion. As I was taking the exam, it didn't feel like that. At the end of the 9-hour bout, I stared stunned at the computer screen telling me the test was over. As I left the testing center, I was consumed with the thought, "What if I just failed that thing?" A passing score on the United States Medical Licensing Exam Step 2 CK is one of a number of requirements for all MDs to be allowed to practice medicine in the United States. You get 352 questions in eight 44-question chunks wherein you get an hour for each chunk. It's all on a computer screen. Some questions are long and difficult to read, requiring lengthy blood lab value interpretation or complicated math formula computation. Some have more than one answer that could be right but you only get credit if you pick the "best answer".

If you take a minute to read the question, you get about 20 seconds to make your decision. If you don't pass, you don't practice. In some states, it's one-strike-and-you're-out. In others, it's three-strikes.

I left the exam not knowing if I had used a strike. I couldn't see straight. I could hear my breathing and I could feel my head throbbing. I drove around as the gravity of the possibility of failing settled in. I felt alone. I wanted a close friend but I also wanted to be alone. I let myself into a church and as I sat on the floor praying, I fell asleep, only to wake up prostrate to the reality that the possibility of a shambled professional life was still there.

A hundred thousand dollars plus in debt and a family I had drug into yet another career-seeking fiasco - "Boys, dad couldn't pass his test and can't get a job ... oh and sorry about spending your college tuition." I wondered if it would have been better had I never been born and if it would have been better if my wife had never met me. Had I infused the boys with some kind of "failure genes" that would predispose them to fail just as their dad had failed in medicine, education, video, filmmaking, engineering [not true but it felt like it at the time], and I was going to get to live with that knowledge that I couldn't teach them how to succeed.

And my wife ... I married a woman who'd follow me to hell, I just didn't plan on leading her there. The problem with marrying "up" - and I married a Saint with a capital S - is the unworthiness - the knowing that the most beautiful thing was disintegrating due to my clumsiness, like an intricate snowflake on my warm hand. To be clear, I never wished I were dead, mostly because it would make things vastly more difficult for a woman who deserved the best, and while I couldn't give her the best [or at least that's what it felt like], it was clear that widowhood would be the worst. Boys needed a great father who was successful, but what they got was me, and at least that was better than nothing.

I wish I were anonymous. That way, no one would care when I failed. They wouldn't shake their heads and avoid eye contact with me when they saw me at some other job.

I did pass that test. I got nice interview offers all over the country.  I got a wonderful residency offer. The injustice of the experience however: for as miserable as I made myself feel during that dark time, I did not relish in the thrill of having survived and thrived (yet!). My only failure in retrospect was my focus.

Loving The Ones You're With

I wrote the following after an experience I had in 2008:

For the first time, I saw a patient with dementia and it shook me to my core.

Its victim and her husband, both in their late-eighties, creaked through a hospital corridor, he escorting her. She, confused most of the time, would have momentary flashes of realization and we all knew she was rediscovering for a fleeting instant who and where she was - then cloudy puzzlement again. When they asked her name, she turned to her husband and asked him what it was. When asked to sign a document, she didn't know what to write and looked to her husband for clues as to the answer. And he, very patiently, answered her every question and corrected her every foolish remark.

Such a pretty lady did not match with the picture I had in my mind of a demented elderly lady. She was polite, gracious, and jovial with everyone. I thought this must be what it is like to see a person's soul -- when our brains, as part of our bodies, die, maybe what's left is the spirit, and hers was certainly peaceful and kind. The hospital staff seemed to know how vulnerable she was and was so careful with her. Her frail husband was quite the faithful sentinel. In all her world, her husband was the only steadily familiar presence, and she trusted him completely. For her sake, I was grateful he was alive, and I shuddered to think what would happen to her if he were to die first.

So what shook me? It wasn't her condition. It was the idea that it could happen to me, or worse to someone I love. What if that happened to my wife, the Lord forbid? Who would be there for her. Instantly, I wanted to take extra care of my body so that if that were to be her fate, she would have one face she could turn to in all her confusion and feel okay. I pushed the idea away about what they would do to her if I weren't around. I remember a friend telling me that when you're told a close loved one has a fatal disease, your ideas shift, and even food doesn't taste the same anymore.

Bad in the Best, Good in the Worst

So much good in the worst of us,

So much bad in the best of us,

It is hardly fitting for any of us,

To talk about the rest of us.

bad in the best of us,

good in the worst,

if anybody talks about the rest of us.

we only magnify our curse,

Saab story

In 2005, I did something I never thought I'd do. I got on the internet to look for what was my "dream car" - a classic Saab 900. I ended up purchasing a 1994 Saab 900 Turbo Convertible Commemorative Edition - one of only 500 made of the very last year model for the car, and a collector's item to boot, though you wouldn't know it looking at the less-than-mint-condition fixer-upper.

I flew to Rhode Island and drove it cross-country back to Texas. I had an interesting drive home. I drove through New York City and drove it to see the Statue of Liberty. I stopped in St. Louis to see the big arch. I stopped in Kansas City to see my sister Miranda and go to church with her there. And I drove almost the whole way with the top down.

Then, on 9/11/2005, Sunday evening, I was going through Oklahoma City and I thought it might be nice to see the memorial honoring victims of the federal building tragedy. I followed signs in downtown directing me to the memorial, but for some reason, I got lost. And then something broke on the car -- the catalytic converter started dragging on the pavement -- not a big deal; simple inexpensive $30 repair but I needed to figure out a way to wire it to the exhaust pipe until I got to Lubbock. I was in a plain white t-shirt and jeans, rigging something on the bottom of the car. Not 5 minutes later, who do you suppose pulls up? Two police cars.

They asked me for identification. They frisked me for weapons or illegal items. They locked me in the back of their squad car. They ran all kinds of background checks on me. They checked the VIN number of the car and get a history of it. They pulled me out of the squad car, HANDCUFFed me, and asked me to sit on the side of the road. They repeated strange questions like, "You say you are from Lubbock, but why do you need to go to Rhode Island again?" They asked me about all the suitcases filled with clothes that relatives in Ohio gave me to donate to the church to give to poor people in third-world Egypt. "Why would your church need clothes from Ohio?" They opened the suitcases, the trunk, the glove compartment. 

It was then that I remembered what my dad had told me years prior. "You're not white enough to dress badly. You have to dress nicely." It was clear to me that I was being detained because of the way I looked. I am ashamed to admit that at one point, I remember trying to show them photos of my white wife, as if to say, "See? Although I'm not white, my wife is." I wanted to wash the dark off of my skin so they wouldn't think I was a terrorist.

I remember that towards the end of the ordeal, the female officer told me they weren't able to access all the computer records from Rhode Island since it was Sunday. She said they would hold me in jail overnight but that I needn't worry since they weren't going to book me and nothing would be on my record unless something came up and that I since I had probably been in jail before, I knew that it wasn't a big deal and my car would be fine in the impound lot. She was surprised when I told her I had never been handcuffed before and had never been in jail before.

My wife was pregnant with our second son and there was no way I was going to call her from jail to tell her not to worry. I explained, rather firmly, that if they didn't have any reason to hold me, I needed to get back to her so she wouldn't worry and perhaps harm the baby in her distress.

Finally after around an hour and 15 minutes, they uncuffed me. They couldn't tell me how to get to the memorial. I said, "please just show me how to get back onto I-40," and I got out of that city as fast as I could. On the one hand it was very humiliating to feel helpless in the face of racial stereotyping and it made me sad that we live in times that perhaps the officers have to be like that. It could have been much worse and they were as civil as they could be. On the other hand, it makes a funny story once a little time and distance have been sprinkled on it.

Well, I got home. Except for some anticipated repair, the car is just fine. When I told the story to friends and colleagues, and while many were shocked and saddened and even angered, I was surprised to hear some laugh and say, "well what did you expect?" as though dark-skinned people ought to know not to travel in Oklahoma on September 11th.

It is an experience I am grateful for. Everyone should know what it feels like to wish you could take off your skin and your race when threatened with loss of freedom or danger to your family.

ON THE OTHER SIDE
by Joseph Bishara

Well she / does her chores

and she / prays for him
on those /distant shores

where the / news is grim
'cause we / send our boys

and we / lose our men
in those / freedom wars

that we / have to win.

Well we / pick up sticks

and we / march in time
and we / follow rules
and we / hold the line
and we / lick our wounds
and we / lose our minds
to find a better world on the other side

We lost our way as we stepped on those mines.
and we'll dearly pay but we'll get it right this time.

We'll pick the flag up
and we'll / dust if off
and we'll / string it up
it'll / fly aloft
and we'll / cover hearts
and salute the cloth's ideals
and know how freedom feels
as we build a better world
on the other side.

We'll / armor up
and we'll / hunker down
and we'll / hold on tight
to a / higher ground
and we'll / reach beyond
and we'll / reach within
and break / every bond
and we'll / be a friend to what's right
as we build a better world on the other side.

I lost my way as I chased down those dimes
But I'll spend my pay and I'll get it right this time.

Well now / I've got you
and now / you've got me
and we / have our hopes
and this / family
and we'll / make it through
every / tragedy
and we'll / find a place
you just / wait and see
where we'll / build our dreams
and make a better world on the other side.

copyright Joseph Bishara

Wish I had Wings

(a song by Joseph Bishara)

You know those birds that go up in the air
carrying their prey to somewhere way up there?
From dizzying heights they just let it go
Right in mid-flight over rocks down below.

I know how that feels now... I know how it feels.
Feels like flight. Your heart pounds and sings.
But when she lets go, you wish you had wings.

Wish I had wings.

You know that feeling when you jump into thin air
Right out of a plane, somewhere way up there?
And nothing comes out when you pull the ripcord
And you know it'll end as you hurtle toward...

The earth feels hard... I know how it feels.
Feels like flight. Your heart pounds and sings.
But when she's not there, you wish you had wings.

Wish I had wings.

It was a terrible accident that Roland died in.
My closest buddy, my very best friend.
At the funeral I saw his brother cry.
The family still misses him. So do I.

I know how they feel... I know how it feels.
The pain still bites and my heart still stings.
When I think of him in heaven, I wish I had wings.

Wish I had wings.

The Body Analogy For Society

Often I have looked to the human body to evaluate my theories about the universe's construction. Nature is infinitely concentric, like a Russian wooden doll which holds when opened a smaller version of itself. The patterns of the universe can be seen repeated on smaller or greater scales: the rings around Saturn look like a miniature version of what our solar system might have looked like as the planets were condensing in their orbits or of what the little whirlpool in the bottom of your sink when you open the drain. The flow of electricity from one end of a storm to another looks like a neuron conducting a thought from one part of the brain to another or a fracture spreading across a sidewalk. Our universe is ordered, not random, despite our inability to predict it. Fractal mathematics has demonstrated an order in the nature of structure infinitely nested and repeating within itself.

One implication is surprising. One can glimpse the entire universe by studying any aspect of it. If the largest Russian doll is too big to see, no matter - just study the tiny one in your hand and know that the big one looks like the tiny one and envelops it. Like an architect looking to a scale model of a building to anticipate challenges with the completed structure, one ought not be surprised.

The infinite concentricities go beyond physical structure. Motion, expansion, contraction, decay, and relational dynamics also have their macroscopic and microscopic versions. The poets were right to draw from observations in nature to parallel an experience or emotion - the metaphor is the recognition of a non-mechanical pattern in some other aspect of the experience of life. Maybe unwittingly, the poet bears witness to a unity that binds all existence.

Why, then, should the organization of life be any different? I was taught in 7th grade biology class that the smallest unit of life is a cell and the organization of those cells also constitute life. The an organized group of living cells is a single living tissue. An organized group of living tissues is a single living organ. A group of living organs participate in a single organ system. A group of organ systems which work together form a single organism. Is a liver cell alive? yes. can a liver be alive? yes. Is a person a collection of individual living things? philosophically debatable, but yes. And yet, a person is also a single living being. The relationship of one cell in an organism to another within the same organism is a useful miniature model for how one person in a society relates to another. Like organic tissue, communities have both their individual lives and their collective life as part of the societal organism.

The model's application, like the nested Russan dolls, proves to be more accurate than one might assume. Do you know a person who consumes enough energy, or attention, or resources enough for three or four other people? If that person started to convince other people to consume in a similar way there still wouldn't be a problem so long as there were enough for that cadre and the other masses. What if that cadre started to grow to such an extent as to cause other communities in distant lands to adopt the same way of thinking and the same expectation of life? What if success was measured in terms of how much one could consume, or how many resources one could redirect to themselves? What if success then became measured not by quantity of resources brought in, but by growth of the consumption of resources? "Never mind how much you made this year, is it at least 10% greater than last year?" What if that cadre measured success by how much attention it could attract? Or what if small businesses all sought to be purchased by large corporations and the trend went away from small business? There still shouldn't be a problem, because prosperity is infinite like an ocean, right? If everyone in the world took as much water as they wanted out of the ocean, the ocean would not go down, right? Capitalism is the best economic policy humanity has come up with and because it is based on consumption, there's nothing wrong with finding ways to consume more and more, right?

To examine those questions, I like to use the body as model. If that person were a cell, or if that cadre of people were a tissue, what would medicine call it? A tissue that not only commands more resources than it ought, but also recruits the rest of the body to create more blood supply to it and ceases to function like it did before - a tissue that not only grows in size but also in demand - a cell-line that now travels to other parts of the body, not only growing in those distant sites, but crowding out the other tissues, transforming those other tissues into similar resource sinks, and hurting the functions of other tissues - what would you guess the medical community would call that? Cancer is a scary word if it is mentioned in any context having to do with you or your loved ones. However, examine the condition in an intellectual petri dish, away from anything near and dear, and malignancy seems fairly basic and straight forward - too much growth, too much demand, too much recruitment, spread to other sites, not enough turnover, no cell death.

And the question of infinite prosperity? I'm sure, compared to a cell, the entire body must be infinite like our planet must seem to an individual. I think it is becoming abundantly clear our planet is not infinite. It seems a new word has entered our vocabulary over the last 30 years. "Unsustainable".

The ramifications of "unsustainable" is threatening. Why? Because in a society of capitalism, the way to fix anything is to increase consumption. Problem with jobs? create more consumption. Problem with economy? find a way to make folks consume more. Sad? consume comfort food or go shopping, or consume this pill. Even in the national epidemic of obesity, the government or the First Lady or whatever is very careful to say, "exercise more," without saying, "consume less." They'll hand out jumpropes (consumption) and apples (consumption) all day long, but they don't dare challenge people to eat less processed foods. The problem with "unsustainable" is you can't consume your way out.

But if many people or much of the communities are already transformed to a fix-it-by-consuming-more, then what? Truthfully, if everyone started living within their means, if our obese selves ate less, if we produced our way out and reduced consumption, megacorporations would collapse, economies would crumble, disaster would ensue, layoffs, etc., right? Our society *needs* you to consume, and not just consume - consume *more*. In the wake of 9/11/2001 and the economic fall, the President encouraged us to go shopping to keep America strong economically - his logic, however lampooned, was flawless given the standard by which we measure economic prosperity - capitalism demands a consume-your-way-out mentality.

The solution? It has to cease to be just about the individual (cell, or tissue, or community). In the body, the heart needs the kidney to be sustained and vice versa. On some level, it is in the interest of each cell, each tissue, each organ, each person, each community, each country, to contribute to the well-being of other cells, tissues, organs, perople, communities, and countries.

I sit in a local coffee shop typing this. The shop is struggling. The cooler is broken and it has remained that way for a while because there's not enough right now to fix it. But I want the owner to succeed at this business. I need her to do well. I need her beautiful little coffee shop to continue to support the artists that play here every weekend and the artists who exhibit their paintings on its walls and the employees who are trying to make enough to go to school and the students who need a comfortable place to process ideas and study. I clean up after myself and the schmuck who sat here before me because I need this place to remain viable. I tell people about the shop. It'll never grow to the level of Starbucks but maybe it doesn't need to. Ain't nothing wrong with a small shop that never gets bigger than local but gets big enough.