Homoscedasticity

via Instagram

Written with a Platinum 3776 and a limited edition Pilot Iroshizuku while I was reviewing for an exam in biostatistics.

What to do when the patient starts to cry

This is my every day: breaking the bad news, reminding people of their mortality, and reassuring them I'd do my best to care for them. Dr. Bishal Gyawali's essay reminds us to connect with our patients' humanity. And nothing confronts a person with his humanity as when he is faced with the reality of death and dying.

Dr. Gyawali offers a peculiar insight on the beautiful intricacies of cultural differences in how patients and physicians from Canada, Nepal, and Japan approach bad news.

In my brief medical career, I have worked in quite a few different countries. I went to medical school in Nepal, where I was born and raised. I then went to Japan in 2012 to train in medical oncology. Five years later, in 2017, I returned to Nepal to work as a medical oncologist before moving to Boston, Massachusetts, for a research fellowship in cancer policy in 2018. I now live and work in Kingston, Ontario, Canada, having moved here from Boston in early 2019.

He continues:

Although training does help, the most crucial elements of delivering bad news to patients—having empathy and being sensitive—cannot be trained. Knowledge can be obtained anywhere, but listening to and genuinely caring for a patient has to be built into an individual's character with inspiration from experienced mentors. Protocols and guidelines help, but the richness and diversity of the patients we serve are reminders that we need to be flexible, listen to our patients, and respect their values and the culture that created those values.

Thanks, Alfie Chua, for the heads up on this article.

Rainy afternoons and quiet cafés

A near-perfect combination. I now read with a pencil at hand.

Footwear

When the going gets tough, I wear sneakers to work. I bought this pair almost at a whim after a long day of walking in Seoul. My feet hurt. I saw a nearby store that sold cheap shoes. They worked wonders.

Lord, have mercy

From Paradox Uganda, one of my favorite blogs, a continual source of encouragement for me:

In Bundibugyo, the Paeds ward is a centrifuge that applies a centripetal force upon all the misery of the world and distills it down into the bodies of dozens and dozens of small people.

This beautiful place, like all others on our planet, has a hidden brokenness. As we round the mountain curves to return home, I see the smooth amazing pavement which has replaced one of the most difficult roads in the world. I see the outlines of palms and the vibrant green of banana trees, testaments to rainfall and abundance. I see songbirds and sunsets, hear laughter, creativity, resilience, commitment.

But spin the globe a few times, and then enter the ward to see what settles out. Malaria, malaria, malaria, and the nurse tells me they lost one last night because the quick-acting and effective artesunate is out of stock. My first patient is a newly admitted 4-year-old, gathered on the floor on a mattress with her mother and little sister. I can see her skin is tortured with scabies (a mite) and her face puffy with marginal protein in her diet. Her baby sister's clothes, her mother's thin-ness . . . I am nearly certain that if we tell them to buy artesunate in a clinic, they won't be able to. We have a national medical store that supplies the district, but our population is large and growing, our malaria progress has stalled, the rain this year never stopped, and the vials of medicine run out too fast. We try giving her an oral dose which she immediately and dramatically vomits out. So I end up driving into the market and finding a private pharmacy where I can purchase 8 vials. 8 lives. $1.67 per life.

Dr. Myhre concludes thus:

Lord have mercy.
Give us wisdom and stamina.
Amen.

Let's pray for their work and ministry.

Fictional and technical

Reading fiction facilitates my technical writing—or so I like to delude myself. In this sense, I like to alternate between the two categories of material. I remember that the same method is employed by George Saunders, a fine short story writer who happens to be a geophysical engineer, too! After finishing more than half of the Elena Ferrante novel, I spend my Sunday evening writing the manuscript for a technical paper. It's not an easy process, but it's made easier by my remembrance of Elena and Lina.


Marginalia using broad nib, Pilot Custom 74, Diamine Chrome ink.

Weekend reading

The last time I stayed this long in bed—say, five to six hours, give or take—after waking up was, to be honest, a long time ago. So distant was the memory that I couldn't even remember. Yesterday, however, with the gloom and drizzle outside, and with the recent conclusion of the medical students' oncology module which I helped coordinate, I started my morning at 6 am with a fresh cup of brewed coffee, and, still in my pajamas, grabbed two books from my shameful but proud tsundoku pile. The first was The Science Fiction Hall of Fame Volume I (Avon Publishers, 1971), edited by Robert Silverberg, lent to me one of my mentors, Dr. Ding Fernando, a few months ago. The second was Those Who Leave and Those Who Stay by Elena Ferrante, book three of the Neapolitan novels, which I also bought many months ago. It was perhaps the closest I've ever gotten to an actual shopping spree—I bought all the Ferrantes at National Bookstore, fearing I may not see them in stock again.

As with most short story collections, I did not read the stories as they were arranged, but picked, without a predetermined plan, the stories at the spontaneous moment of actual reading. I treated myself to these tales after a handful of reading materials in medical oncology which, too, offered an excitement of a more technical kind. Helen O'Loy by Lester del Rey was about men who fell in love with robots. It was tragic but romantic in a way that left me uneasy. Theodore Sturgeon's Microcosmic God was about a scientist who shut himself away from the world and settled in an island, working on experiments made easy by highly adaptable and intelligent organisms he had invented. Isaac Asimov's Nightfall was about the coming eclipse that caused insanity to the entire humanity. Lewis Padgett's Mimsy Were the Borogroves was about toys from another dimension and the children who disappeared after they had played with them. The Nine Billion Names of God by Arthur C. Clarke was about monks who believed that the world would end after the nine billion names of God had been written down. The monks commissioned computer scientists to speed up this task. 

Those Who Leave and Those Who Stay was set in 2005, where Elena Greco was a writer and Lina Cerullo was a worker in a sausage company, already with a child of her own. Their friendship was complicated: they adored each other with a certain jealousy and contempt and fondness. Years have passed since I read the last Ferrante novel, but how this anonymous author weaves the stories, creates the characters' emotions, with interjections of humor, frustration, and anguish is beyond me: she is a master in her craft. To my mind, she is at par with Marilynne Robinson and Alice Munro—among my favorite contemporary authors. To understand Ferrante, and to see the city through my eyes, is the main reason why I want to visit Naples someday: so I can set an actual physical picture that will serve as a backdrop of my imagination when I return to her pages. In this sense, travel and reading are, in fact, complementary.



I interrupted this solitary reading confinement with quick walks to a restaurant that served Italian food, both for brunch and dinner. With all the Italian in my head and stomach, I may as well have gone to Napoli.

On my way home, I was almost hit by a tricycle as I crossed the street. It was a dark corner, and the lamppost was about to give up. It dawned on me then: I was, and still am, in Metro Manila.

Eating alone and together

I like eating alone. I also like looking at other people eating together. I make up imagined stories of what they may be talking about. This was taken at Muji Café, Plaza Singapura, Singapore.

On my Twitter accounts

I'm presenting a paper at the ASCO Breakthrough in Bangkok next month. I was asked for my Twitter handle during registration—how cool was that? It will be printed on my badge. This goes to show that social media is here to stay, and it is best that clinicians and researchers make use of this platform. (In case you're interested in all things oncologic, you can follow me at @lanceoncology.)



I maintain two Twitter accounts—@bottledbrain, which is more personal and private, and @lanceoncology, which is technical, academic, and public. I use the first account to follow the news, engage with friends, and write miscellaneous realizations. In my younger days, I may have inserted a few rants. (Forgive the ignorance of my youth.) I use the latter to monitor the current developments in medical oncology, tweet key points of the the conferences I'm attending (it also helps keep sleepiness at bay), and follow researchers from all over the world whom I've met and admired. Establishing this dichotomy has redeemed the personal value of Twitter for me.

I'm glad I listened to Dr. Iris Isip-Tan who has written and spoken extensively about the use of social media to generate one's academic portfolio, to create one's personal learning network, and so much more. Her blog, The Endocrine Witch, is a thing of beauty. How she manages to update it, on top of the gazillion things that she has to do, is admirable! I suggest that you subscribe to it.

Favorite group portrait

via Instagram

As I count the months towards the end of clinical fellowship, allow me to share a favorite group portrait during our foray in Seoul where we shared our research findings at the Korean Cancer Association meeting. I’ve been blessed beyond measure to have worked with these men. @k.momdragon, our leading lady, wellspring of compassion, mother of the sweetest girl in Manila, our source of estrogen and testosterone, deserves a separate citation.

Every day carry.

via Instagram

Isaiah 46:4. #diamineoxblood #parkerduofoldslim

via Instagram

Weathering

While watching Weathering With You (天気の子) in cinema, yet another film by Makoto Shinkai—whose masterpiece, Your Name (君の名は), I had just watched this weekend—it was raining outside. I once wrote that I used to love the rain until I lived in Metro Manila, where it translates to massive traffic jams and deadly cases of leptospirosis, but, when I think about it now, I still love the rainy weather. It reminds me of childhood when, trapped inside the house, I would play with my brothers and read the story book, "Who Made the Angels Cry?"—which was about a rabbit who stole a cookie from a jar.

Weathering With You is beautiful. I want to watch it again.