Bursting in tears

In the final chapter, The Train to Tibet, Paul Theroux writes: 

An early European explorer to Tibet burst into tears when he saw one lovely mountain covered with snow. When I saw the landscape of Tibet that did not seem to be an odd reaction. The setting is more than touching—it is a bewitchment: the light, the air, the emptiness, the plains and peaks . . . It is a safe and reassuring remoteness, with the prettiest meadows and moors buttressed by mountains. It was, somehow, a mountain landscape with a few valleys—a blue and white plateau of tinkling yak bells, and bright glaciers and tiny wild flowers. Who wouldn't burst into tears?

This is one of the best books I've read, and I will likely get back to this piece of art and history soon enough. 

It goes without saying that this chapter, too, resonates deeply with me. My hometown, a piece of paradise inhabited by proud, happy, and smiling people, may disappear soon. A huge mining project in a nearby town has been approved. That will bring money and prosperity to people, sure, but those will mostly go to politicians and people in power. But the land will be destroyed. And the rivers, too. Supporters of this project say this mining project will be sustainable—but who are they kidding? 

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The rain began to leak into my soul

As I return to Paul Theroux's Riding the Iron Rooster on this cool Saturday morning, the feeling of calm-after-the-storm descends upon me. After a tiring week of my kind and gracious grandmother's passing away, I can go about my day without anything urgent floating in the air. I want to tell you more about Lola Ugól, of course. I can start with the story of why nobody—not even her children—knows why she was called Ugól when her real name was Trinidad Zamora Garcenila. But not today. Of course, there are patients to see and faculty work to be done, but those can wait until 10 am. 

For now, I want to savor this moment: the possibilities of a weekend. A quiet morning in the porch, the vanilla-smell of old book pages, the exquisite gray strokes of my Blackwing Palomino, the minimalistic design and engineering of my MacBook Air. These small things and habits allow me to both dwell on and forget about grief. The running joke in the family is that May is a particularly harrowing time of the year: it is when deaths and birthdays happen. 

Escape is not quite the word for what I want to do today. Perhaps, adventure might be appropriate. For the vicarious opportunity to travel distant lands, I am grateful for books, such as the one I'm holding.  In this memorable paragraph which appears in the chapter, The Shandong Express to Shanghai (p. 400), Paul Theroux writes about the pleasures of anonymity in a foreign land. 

I stayed in Shanghai a while longer. I bought an old goldfish bowl at the antique shop. I saw a truly terrible Chinese film: it was violent and thoroughly philistine. It rained. People talked about the power struggle in the inner party. They were not cynical or indifferent to such big changes—the expulsions and resignations—but since they could do nothing about them they had to accept them. The rain began to leak into my soul. I walked through the rat's maze of back-lanes near the cathedral, and got glimpses of ancient China in the drizzle. I was happiest those nights, trudging alone in the rain, glancing into windows, seeing people ironing and making noodles and pasting up the red banners for the Chinese New Year, watching people roistering in cheap steamy restaurants and strangling chickens. It was wonderful to be anonymous those dark nights in Shanghai, when no one could see my face, and I heard a mother scolding a child with 'Where have you been?'

More than sight-seeing, I like snooping around best in places where nobody recognizes me. Fulfilling this curiosity with a heightened sense of observation and note-taking amplifies the joy of travel; it also helps one forget, but also, eventually, remember. 

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Paul makes a wise choice

It's too bad that, as a canine, he is perpetually disenfranchised from participating in democratic exercises.

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A day in contrast

Driving at 6 AM along the Gensan-Polomolok border, I see a tricycle on the outer line. It is jam-packed with five people, excluding the driver. As I inch closer, I notice that a motorcycle, propped up vertically on one wheel, is strapped on the tricycle's metal sidecar. Yellow ropes keep the motorcycle from falling off the road. The men reinforce the motorcycle to the tricycle with their arms. In their late twenties, wearing shirts and denims, they grin, smile, and laugh. Are they bringing home this brand new vehicle at home? If that's the plan, why don't they ride on it? Perhaps I'll never know. In the meantime, an olive-green Vios, which I'm presently trailing, slows down. A window opens. A teenager, her hair tossed by the wind, emerges with a camera phone. Realizing they are being recorded, the men wave in the light, intermittent rain. They are having a great time.

As soon as I arrive at home, in time for the Sunday service, I receive a text message that M has died. He was around my age. He had an aggressive kind of lung cancer. He has left behind a wife and two children.

Ours is a bittersweet existence.

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Glory in the ordinary

My high school classmate and friend S dropped by my clinic to have her blood pressure checked. Told her she was a newly diagnosed hypertensive. It runs in her blood. These past months, she could only count the nights when she's had a good night's sleep. How could she if, at any given moment, one of her daughters would cry? Her maternal instinct does not allow indifference; her reflex reaction is to land on her two feet to be with her children. Mothers are amazing.

I thought of S when I read this passage from Glory in the Ordinary by Myra Dempsey:

Even in life’s mundane tasks, God is shaping us into a people who beautifully reflect his glory to the world. Left to our own devices, we will never naturally drift toward holiness. We rely totally and completely on God to rewire us and re-mold us, making us more like his son, thereby making us more and more holy. Because he loves us so perfectly and immensely, there isn’t a moment of our existence that he won’t use to accomplish just that. Those late-night work hours, those early morning feedings, those middle-of-the-day grocery store runs, they are all clay cutters in the hands of our perfect potter, wielded with precision to trim away all that does not drive us deeper into him. He knows that we are only alive in him, that all of the joy and purpose we crave is found in him alone. Nothing is wasted, dear friend, and you are not in a green room waiting for that call up to the main stage.

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"Life is surely muted and compromised...": on the pandemic life

From a blog I've just subscribed to, La Vie Graphite: an eloquent meditation on pandemic life:

Enduring these months is a learning experience of what to eliminate or change. There are shortages and there are pinched resources. Less money, in the face of inflation and reduced pay, but less to buy. Three full tanks of gas in my car, in six months. Having less causes a discipline of needing less. As the workplace began requiring a weekly on-site workday, I’ve simply treated my department like a quarantine: A straight-out eight-hour day, with granola bars and thermos of coffee. There are no places to go for lunch, anyway. Then it’s become two days on-site. More granola bars for the perpetual motion. I just want to get the work accomplished, plain and simple. Perhaps it’s an imposed austerity, but the workplace is the place to get work done; there is no more socializing, and it’s hard to tell how much longer the situation will last. I’ve noticed myself working faster and more strategically, as I cram all I can into those hours. Working from home is no less industrious, but it’s much safer. Most of us are under pressure to make the best of a bad situation. I’m grateful, at least, to be working. Life is surely muted and compromised, but I’m always brought to step back and consider this context when I see the clusters of those encamped in the city park with no place to call home. The pandemic forces us to learn to not take tomorrow for granted.

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A surprise visit

A teacher from high school dropped by the clinic yesterday, just as I was about to close shop. She was surprised that turned out to be a medical oncologist. 

"I thought you took up neurology," she said. "But why 'Bottled Brain' then?"

Ma'am T said she visited my blog daily until her phone was stolen. She couldn't access it anymore. 

I'll help her bookmark this page the next time she visits. 

The Hiligaynon word for the day is ma'éstra. It means "teacher or instructor."

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Sun-kissed in Camotes Island

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Sane and wonderfully tender

I often get asked how I deal with patients who cry in the clinic. There are no easy answers. But I assume that most of my patients and their families know more than what they'd be given credit for. They might not know the nitty-gritty details of treatment and prognosis, but they carry with them a vague, often accurate, idea that what they have is "not good." When they enter the consultation room, I don't immediately get into the details. I warm them up with questions of where they're from and what they do. I establish a connection. Where I practice, that involves asking if they know a common person. It helps that I speak the vernacular for a more nuanced, intimate back-and-forth. They hardly get surprised when I break the news: that they have cancer. But my speaking to them confirms the fact of their disease. They cry, usually quietly, grappling for a handkerchief or tissue paper. I have a stack of napkins on my desk that I offer to them in a few minutes of silence. I assure them it's okay to let it all out.

There's a common belief that it is detrimental to the body and soul if one keeps the pain inside. Grief must be expressed and let out. I'm sure there are psychological and theological reasons for this. In my experience, encouraging outpourings of grief is cathartic and ultimately beneficial. 

This is a bit of a stretch, but this daily reality of my private practice seems to find resonance in Dr. Edward Donnell's The Christian Life, a chapter in the book, "John Calvin: For a New Reformation" (ed. Derek W.H. Thomas and John W. Tweeddale, Crossway, 2019). I love John Calvin. Each time I read him or about him, I learn something new—as a Christian or, in this case, as a cancer specialist. I must note that cheerfulness is not defined here as being happy-go-lucky. It is, in my reading of this text, a deep-rooted joy. 

Yet Calvin's humanity and pastoral wisdom shine out when he explains that cheerfulness can coexist with anguish. The point of a cross is that it hurts terrible, and this is is the paradox and glory of Christian suffering. He has no time for what he calls the "iron philosophy" of Stoicism. The Lord himself shed tears over his own trials and over the misfortunes of his disciples . . .  As Calvin describes, "If all fear is branded as unbelief, how shall we account for that dread with which, we read, he was heavily stricken [Matt. 26:37; Mark 14:33]? If all sadness displeases us, how will it please us that he confesses his soul 'sorrowful even to death' [Matt. 26:38]?"

Dr. Donnell concludes, 

This is sane and wonderfully tender pastoring. 

In practice terms, this translates to me saying, "It's okay to cry." I end with a word of encouragement, ask their permission if I can pray for them. As they leave, I take care not to give false promises of cure, but I don't withhold from them sufficient hope to carry them through the days before they see me again on their next consult.

An aside: napkin versus tissue paper

The main difference between napkin and tissue paper is that the napkin is a soft piece of fabric material, used to wipe the face before and after eating. On the other hand, Tissue Paper is a soft easily absorbent paper used for cleaning purposes. Both are available in different colors.

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On blogging

I stumbled upon Alan Jacobs’s blog. I’d been there before, but I hadn’t read it with sufficient curiosity to keep me going. Until now. An author, university professor, and blogger, he writes about cultivating his blog as a kind of a garden. He uses his blog to “generate and try out new ideas, get feedback from readers, develop the ideas a little further…” He writes about blogging as someone who seeks to understand this medium. Reading him is inspiring and instructive.

Part of me wishes I’d thought blogging through. When I published my first post in 2004, I didn’t think Bottled Brain would live long—at least, long enough to be older than high school students. Had I been a wiser 16-year old in that internet café in the row of houses near the UP Shopping Center, I should’ve planned out what content to put out. I could’ve chosen to write about a niche topic rather than post flotsam and jetsam about books, pens, faith, family, travels, and medicine. I could’ve planned to turn my posts into book chapters, which I’d subsequently publish. 

But I didn’t. Today the blog looks more like an online diary than a well thought out website. Perhaps that is why I find it so charming. Because it is my space—my own dot com domain—I can write anything. My friends and family are my audience. There’s no pressure to please or impress. There’s a sense in which I write for myself; my delight in the writing overflows to delight others, too. That is my hope.

What I can learn from Alan Jacobs is to make sense of my logorrhea. One of these sunny days I’ll find the time to organize my posts. Surely, several themes will emerge: my experiences in medicine, my thoughts about Christianity, my fountain pen collection, and so on. Maybe I can do something about them.

Moving forward, I envision more posts more about medicine, medical education, medical humanities, biochemistry, and technology in this space. I should also post more quotes from books I'm curently reading. Who knows? I might just develop new material from these! 

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A Blackwing Pencil (Palomino)!

Snapshot of a page from my journal, currently a Midori Traveler's Notebook (Passport):



I turned 35 last April 22. I went on a short trip to visit my godmother. My aunt and Nanay were with me. I could tell you many stories, but the short of it is: we had a blessed time. During the tour, I found my grail pencil, something I've been meaning to buy but I never had the chance to—until this trip!

It's a Blackwing pencil (Palomino). This is the favorite writing instrument of Mary Norris, the New Yorker copy editor, and Austin Kleon, the book author and blogger. 

I adore the writing experience! Praise God for this blessing—and for 35 years of His goodness and faithfulness.

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Christ is risen!

Woke up to a rainy Sunday morning. Drove Nanay to Rizal Park to buy flowers she subsequently arranges for the pulpit. She couldn't bear the sight of a flowerless pulpit, especially on Easter, the most joyous of all Christian celebrations.

Christ is risen! What a glorious, marvelous, and comforting truth! 

Meditating on the centrality of the resurrection to the Christian life, Dr. Albert Mohler writes:

As Paul well understood, Christianity stands or falls with the empty grave. If Christ is not raised, we are to be pitied, for our faith is in vain. Those who would preach a resurrectionless Christianity have substituted the truth of the gospel for a lie. But, asserted Paul, Christ is risen from the dead. Our faith is not in vain, but is in the risen Lord. He willingly faced death on a cross and defeated death from the grave. The Resurrection is the ultimate sign of God's vindication of His Son.

He quotes Dr. John A. Broadus:

It was the signed manual of the Deity, it was the seal of the Sovereign of the Universe affixed to His claim, it declared Him to be all that He had ever professed to be, and so it establishes the truth of all His teachings and the truth of the whole Christian society. The great fact that Jesus Christ rose from the dead is the central fact of the evidence of Christianity. 

Have a meaningful and Christ-centered Easter Sunday, dear friends!

*  *  *

Photo above was taken yesterday when the sun was up and the April shower plant was showing off its blooms.

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Moderating a class forum from Lola's garden

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The coming-home ritual

Coming home from work, where two lovely patients had just died, I am welcomed by Paul in the garage, his nose toward me, his body crouched near the ground, just as I open the car door. I give him a belly rub, which leads him to roll over, enjoying the sensation of human contact. "How are you, my boy?" I ask. He responds by choking on his saliva, his tongue wagging. After two minutes of this welcome, he follows me as I enter the house. Distracted by the clanging sounds in the kitchen, he leaves me and bothers whoever happens to be there. Paul's love language is bothering humanity.

Dogs are God's gift to us. Despite the nightly destruction of Nanay's cherished plants and cacti and the tearing away of shoe laces and chewing of electric cords, Paul brings to our home a youthful joie de vivre, a reminder to not take things too seriously. 

Now—where is he?!

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How to manage chemotherapy side effects: a guide to general internists

Yesterday I talked to some 1,200 internists from the Philippines on how to manage cancer-related treatment side effects during the Bootcamp of the Philippine College of Physicians. In that talk, I argued that, in an era where cancer is set to become the leading cause of mortality and morbidity in the world, general internists—and non-medical oncology specialists—can take part in the care of patients with cancer. One of those opportunities is the management of treatment-related side effects. I wish I had more time to speak about immunotherapy-related adverse drug reactions, but, with my 20 minutes, I focused mainly on chemo- and targeted-treatment-related side effects—hypersensitivity reactions, nausea/vomiting, diarrhea, mucositis, and many others. Dr. Julie Gabat-Tan—or Madame Julie, as I call her, because she was my first ever senior resident during my internal medicine residency—moderated the Q and A. It felt like being on rounds again at Wards 1 and 3. I'm sharing my slide set here. Feel free to share or use this, and it would be great if you can link to this site. 

Image credit: Dr. Jeriko Aguirre, who took a screenshot.

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Do not make premature judgments

I love this line from the concluding pages of the chapter, The Fast Train to Canton, which appears halfway through the book, Riding the Iron Rooster, by Paul Theroux.

It made me think that you never really know anyone until you have traveled 10,000 miles in a train with them. I had sized them up in London, but they were all better and worse than they had seemed then, and now they were beyond criticism because they had proved themselves to be human.  

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Notebooks and first chemo sessions

It's appropriate that my first entry in my new notebook is about my remarkable patient, a woman around my age, who gave it (and a few others) to me today. I love composition notebooks. In fact, I love notebooks in general. I use a Traveler's Notebook (passport size) for my personal journals. I use composition notebooks for my consultancy and faculty work. The wide lines are great for jotting down first drafts of my stories, many of which will never see the light of day. The pages are fountain pen friendly. See my writing sample below. I used a Pilot Custom 823 (Amber) with the classic blue Pilot ink owned by my brother Sean.

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Innovative ways of disseminating research: an argument for blogs and podcasts in cancer research

I talked to Filipino medical oncologists about innovative ways of disseminating cancer-related research information last Saturday. I argued that, as part of knowledge translation/mobilization, it is important that researchers, clinicians, and people involved in knowledge generation and dissemination must creatively, proactively, and intentionally think about how to share their knowledge more effectively to their colleagues and the public at large. I talked about blogging—academic blogging—as a tool to accomplish that. I also spoke about podcasting—using recorded audio to tell stories—and conducted a workshop on how to record and edit audio files using Audacity. I've never done anything like this before—much less through an online interactive platform. Many thanks to Merck and to Dr. Mary Manalo, my boss in the research committee of the Philippine Society of Medical Oncology, for the opportunity to talk about a topic so very close to my heart. I love reading blogs and listening to podcasts. My presentation was an overflow of my fascination. 

Here's a copy of my slide set. 

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Summer fruit

The mango tree bears much fruit this summertime. Nanay snapped this on Sunday morning, 30 minutes before the start of the worship service, when the church parking lot was not yet packed. (It has been a long time since I had last shared Nanay's photos in this site. You see, years ago, I synced her phone to auto-upload photos in my Flickr account, an arrangement that gives me access to the goings-on in her life, which mostly revolves around family, friends, and church.) I love mango trees, not just because of their fruit but because anywhere they are planted, they offer a comforting shade and coolness, a respite from the tropical Mindanao heat. I look forward to see this mango tree grow up and flourish.

The Hiligaynon word for the day is búnga, which means "fruit."

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Grace

Since my brother Sean got serious in his coffee hobby, I haven't been to the coffee shops as often as I used to. I could get the same, even better, kind of coffee at no cost at home. Sean knows coffee growers from Kulaman, Sultan Kudarat and helps these farmers by reselling the beans. (If you're interested, drop me a message; I'll relay it to Sean.) He likes the process of grinding the beans, measuring them by the gram, and experimenting with various methods of coffee-making. 

If I have lunch in malls, I drop by the café chains to stave off sleepiness. I visited Coffee Bean at SM Gensan recently. I got a swirl card so I could access the wifi. The password was Ephesians 2:8. "This is one of my favorite verses," I told the lady behind the counter. 

For it is by grace you have been saved, through faith—and this is not from yourselves, it is the gift of God—

The Hiligaynon word for the day is grásya, which means grace or blessing.

Postscript: I dropped by Coffee Bean at Veranza, the other mall. The wifi password was Romans 8:28.

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