The unspoken language

Amazing patients in my brief encounters taught me their view and philosophy in life.

One such patient lost almost half of her face due to head and neck cancer. She came to the FNA clinic because of a tumor regrowth in her scar site. She was severely disfigured and shocking to see. She wore a hat and wrapped half her face with a scarf. She lived in fear that people would look at her with disbelief and disgust. She was in pain and shame. The extent people prefer to stay living by paying such a costly price is astonishing. Life is indeed priceless. She hesitated to show the lump or allow me to procure samples. As she began unwrapping her face and revealing her scar, she was crying. It was difficult to disguise the horror in my body language. I held her hand. She knew that I had my own sets of physical limitations and knew I had gone through emotional and mental pain not too dissimilar to hers. (I have polio on my right leg). There was unspoken language of understanding and compassion with each other. We had a special bond at that moment and there was a mutual understanding of enormous burdens we each carried in our daily lives. This kind of human understanding needs no words and felt between people who go through certain amounts of pain. After the procedure, I hugged her without a word. This patient helped me realize why I must suffer from my own physical limitations. From my new book, “Who says you have cancer?” available on Amazon.

Images of cancer patients courtesy of pixels-shvets-production

Unnatural action: Forgive

Forgiveness and a metaphor from Italian medical history

Pacinian Corpuscle is a major tactile sensory mechanism in mammalian skin, discovered by Italian anatomist Filippo Pacini. It detects pressure changes and vibrations in the skin. When the external pressure such as touch is applied to the skin, it senses the vibration by deforming layers of lines until the nerve ending in the center processes the touch. The Pacinian corpuscle can be described as oval-cylindrical-shaped, 1 mm in length and consists of 20 to 60 concentric lamellae (like onion rings) connected by nerve endings at the center.

This microscopic image depicts the inner struggles we as humans experience via external stimuli, especially when it is negative. Natural reaction when the core of the structure is sensed as unfavorable is to recoil, retreat, shrink, flee, and finally fight if necessary.

Act of forgiveness, whether it is given or received, requires unnatural process of action. The power of the unnatural process of forgiveness is perhaps not possible by natural selection of human ability. God needs to intervene, so that humans can live peacefully with others and our own selves.

Photo of Florence by #Josh Hild

How I measure up.

My male colleague once said, “Medicine used to be all men.”

Even now, certain specialties such as orthopedics and neurosurgery are pretty much exclusively men, secretly and sometimes outspokenly against women joining their exclusiveness. White older males perpetually dominate key positions in medicine, and their defense is, “Bring us the qualified women!” with no intention to hire a woman. How can women enter a leadership position when men are not providing opportunity into their exclusive club? 

Women are “the other sex,” the “second sex,” the “sex to be further explained.” My anatomy training in medical school featured a male body. It is the model and norm. The study of entire organ systems modeled a male body in 90% of our anatomy studies and a woman’s body introduced as the “different reproduction system,” as if a woman’s breast, ovaries, fallopian tubes, uterus, cervix, vagina, and vulva are aberrant and complicated organs. 

Researchers, usually males, further identify women with an ever-so-growing phenomenon of syndromes with mostly problematic connotations attached such as premenopausal (PMS), menopausal, superwomen, imposter, and battered women syndromes. The implication is that women are deficient and should measure up to what is considered “normal.”

This concept extends further by saying since women are hormonally dependent on their mood with a monthly cycling “problem.” Ironically, these speculations are tested to not be true that hormonal imbalance will lead to irrational behaviors. It places the burden of adjustment on women. Countless books and conferences have existed to “fix women” of their inferiorities while mostly men published lists of their problems. If women did not fit, it was their own fault.

A woman often faces a “double bind,” frowned upon for being too aggressive but weak if she is too sensitive or cries in public. What is wrong in showing emotion? Just because most white male leaders are stoic does not mean female leaders must act and dress like them and meet the same expectations in social behaviors.

Men are still the standard against which women are judged. A woman leader who acclimates well to the male norm of being outspoken, decisive, assertive, self-confident, independent, and courageous is often described as a “bitch” who lacks feminine qualities of kindness, consideration, warmth, pliability and her gaudy display of female emotions. No wonder many women struggle to find balance in the workplace as a leader. They have a double standard. The values of females become “deviant” when the measurement definition starts from males. No wonder why females often fail to measure up. 

I define good leadership as:

  1. excellent communication
  2. sound decision-making
  3. integrating connection
  4. empathy
  5. emotional cue-taking
  6. consensus-building and 
  7. mutuality

However, these leadership values become misconstrued as a “less-than or weaker” leadership style which clashes with the dominant male culture of charismatic leadership, top-down authoritative style of leadership. This is reflective of our social and family culture; he respects his father’s authoritative voice, and he runs to his mother for consolation. 

If the society’s value system were to flip and emphasize what is wrong with males, the problem lists might include an inflated or overly confident identity, unrealistic self-esteem, rigid and selfish, offensive sense of humor, insensitive, aloof, autonomous, uncooperative, angry, linear in thinking and a pathologic inhibition to express their emotion, suppression of pain, guilt, shame, remorse and fear of losing control. 

Currently, women outnumber men in college and medical schools—they account for about 55%. Women tend to have higher grades and drop out less frequently than men. Yet according to a study sponsored by the Rockefeller Foundation, women hold only 4% of leadership positions in Fortune 500 companies.

I became a leader physician believing that the mission is to serve patients by offering excellent care, to transform health care by innovative research, and to teach the next generation with knowledge, transparency, and compassion. The mission is clear which both genders are equally capable to achieve. But I came to realize throughout the centuries, women are seldom seen as chairman of the department, chef, conductor, pilot, president, CEO, dean, astronaut, ship captain, sports coach or any other visible leadership position. Women do not need affirmative action requiring women in leadership positions to fulfill an institution’s public image, and to meet a diversity quota. We do not want the job as a leader for the social sympathy and endure suspicion that we are in the “inclusive program project.” We want to be a leader based on merit and talent. As Ruth Bader Ginsburg said, “I ask no favor for my sex. All I ask of our brethren is that they take their feet off our necks.”

Women doctors share inspirational and heroic stories to successfully navigate sexism or discrimination in medicine, overcome impostor syndrome, or powerfully stand up for equity.

All of these stories are empowering and inspirational. But this too is measuring up to someone else’s standard; a mere illusion of being the winner. In truth, there are no winners or losers. No tombstones ever mention how much one worked and stood up for inequality. The writing merely says BELOVED WIFE, or MOTHER.

In the end, it is about who you loved and who loved you when you lived in this place called earth.

Being truthful to oneself and living comfortable in one’s skin in honesty may be the most heroic and meaningful story.

Read more about women in medicine in my new book, FORGIVE TO LIVE.

Now in paperback: A female perspective on Covid-19, life, medicine and God

https://www.amazon.com/dp/B08P7486XX
The Unseen Doctor

Ms. Apple is a practicing pathologist…she brings a perspective to the effect of the pandemic that unfortunately is seldom seen, and millions would be enriched and informed by her unique vision…The story begins with a woman intern pathologist arriving on Hart Island to an unimaginable scene of mass burials. The web of relationships and events expands to an international scope. This is a medical but personal story, not a political one. I hope everyone can read and share this book, whose proceeds are going to charity.

—Book reviews on Amazon
https://www.amazon.com/dp/B08P7486XX

Let’s first live and then talk about injustice!

Blog #8: June 7, 2020

Year of the Rat, 2020! It is indeed an amazing and extraordinarily difficult year thus far. The traumatic effects of the COVID-19 pandemic with a death toll of 118,000 as of today (but who is counting anymore?), unemployment rate hitting 20% (a record high surpassing the great depression in 1932), and now the national riots.

Recent murders of George Floyd, Breonna Taylor, and Ahmaud Arbery in our country have laid bare the realities of institutional racism. America is built on the principle of all people are equal, and deserve to be treated fairly and respectfully. The commitment to equality, diversity and inclusion in order to positively impact human rights and to reduce disparities are shared by most of us. We must reject injustice, violence and racism and strive to heal the division. It is powerful to see the protestors in all US major cities, calling out for justice and chanting, “Black lives matter!” And I would join the voice, “Hear, hear!”

I saw the image of a pool party in Missouri’s Lake of the Ozarks over Memorial Day weekend and cringed in disgust with people not respecting social distancing and potency of the coronavirus.  Now, news has reported that some who attended the pool party have the coronavirus despite having temperature checked before getting admitted to the party.

Similar images of crowds are seen in all major cities in the US day after day, but now, the images are protesters marching, not the pleasure seekers, with or without facial masks, disrespecting social distancing. But are we not in the midst of a pandemic? Gathering without social distancing and not wearing facial masks are a real concern. It will have a negative impact on our fight against COVID-19. Resurgence due to mass gatherings of protestors are guaranteed to bring a second peak of COVID-19, and it will probably have even a worst peak with a death toll of another 118,000 people dead, all too soon.  All the good works we have done for the last two months by lockdowns caused a huge unemployment and economic depression, and these sacrifices will have no fruit in return.  This requires health care workers to sacrifice even more. We have not complained much thus far because of our commitment to take care of the sick.  

Both scenarios have people gathering without social distancing, but this time I see myself cringe for a different reason. I see the protestors take their chances and risking their own lives to come out to speak, for them it is a life and death situation. It’s either coronavirus or police brutality to lose one’s own life. And when I see the people coming together regardless of their own colors of skin, it is very powerful and moving. 

Then, I think about the what ifs. What if I was down on the street with my neck pushed down by a Caucasian policeman for almost 9 minutes when I am pleading for my dear life to breathe? What if I died instead of George Floyd? Will the nation become outraged for me? Martin Luther King Jr. said, “The ultimate tragedy is not the oppression and cruelty by the bad people but the silence over that by the good people.” The situation becomes another story. I would like the people to come out and say something to the world protesting, in spite of the pandemic. It makes the whole thing more personal. The voice of collective people saying, “This is not right, enough is enough” is comforting. 

But then there are the opportunists. The looting; why do these come together? It is absolutely wrong, no matter how one explains it.  

What about the negative impact on the protestors? Killing and injuring both sides; lives of police, firefighters, and the protestors. Both are unwelcomed downstream effects.  Is the anger the appropriate emotion to use at this time?

Emotions put aside, can we come together first in fighting a pandemic? Many people do not realize the actual effect of the virus, a silent and deadly killer of COVID-19, because they do not see the killer first hand. Some believe that the media and the government made it up. But I saw the impact on our morgue with piled-up bodies in a hospital.  The media cannot come and show what I have seen because they cannot come inside to reveal what’s really happening in the hospitals with COVID-19. 

The question really boils down to, “Is the first amendment more important than a pandemic now?”  My personal answer is both are equally important. But there should be a sequence. First, pandemic and then, the first amendment. Let’s first live and then talk about injustice!

Let’s not give the virus the upper hand to control the fate of our humanity. Let’s try to have the rest of 2020 without losing additional hundreds of thousands of lives by the virus.  

The injustice I see in this country is as familiar as a dear friend, and this does not occur only in racism, but also in gender discrimination. Crying out for justice among all races has a powerful effect, but when it comes to gender issues, more than half of the population suddenly becomes shy and quiet. As a female physician in this country, this deeply rooted gender discrimination is very evident. Yet, everyone hesitates to stand up and fight for they will soon belittle the women who spoke up for the equality in pay and opportunity, for instance. The unwelcome inequality and ignorant complacency seem to be with us, some consciously and some unconsciously. 

But whatever our differences are, can we first fight against a pandemic together? Anger leading to violence and looting is dangerous and deadly at this time. Even COVID-19 is showing injustice in racism, killing African Americans and Latinos disproportionately more than other races. There are understandably predominant populations of African Americans protesting. Spreading the virus during the protesting will have a negative impact on the African Americans who are already dying disproportionately.  Then, these people visit their elderly parents, unintentionally killing their own. 

God hates these things; violent people, haughtiness, lying, murdering, scheming, eagerness to do wrong, a false witness, stirring up discord, and proud people. (Proverbs 6:16-19)

Where is God in all these? I think God is crying now. God is saying, “What have you done? Listen! Your brother’s blood is crying out to me from the ground!” (Genesis 4)

How coronavirus changed the world

The coronavirus pandemic entered quietly into our spaces without any warnings as many other natural disasters. And it forever changed our reality and normalcy. Actually, there were some warnings, but we underestimated its potency and downplayed it by saying “it’s just another flu, thousands of people die with flu every year.” This silent and deadly enemy cannot be seen; we cannot shoot a virus by enlisting military forces to honor our heroes amongst the army, navy and air force. In fact, this formidable enemy crosses all boundaries of countries, red and blue states, all races, religions, genders, ages, education, and economic status, a true definition of An Equal Opportunity. In fact, this coronavirus hijacked our lives without our consent. We are consumed with news regarding the coronavirus attacks locally, regionally, nationally and internationally. No other news was emphasized from March of 2020 till now, almost 3 months straight by this brainless and incompetent packet of DNA and RNA strands which has changed and captured the human enterprise.

As of today, there have been more than 5.1 million infections with the virus and a death toll of more than 335,000 globally. Just within the US, confirmed deaths caused by the coronavirus surpassed 95,000. The negative impact caused by the virus is not just the death rate but the accompanying collateral economic damage with 23 million unemployed Americans as of mid-April which translates to an unemployment rate of 14.7%, and growing every week, approaching the highest level since the Great Depression in 1929, 10 years after the influenza pandemic.
In 1918 during the worst influenza pandemic, the final global death toll ranges from 17 million to 100 million, depending on the way victims are counted. Almost 700,000 people are thought to have died in the U.S., equivalent to more than 2 million people today as a proportion of the population. The predominant population who died were young males, soldiers. 
In 2020, the coronavirus pandemic largely, but not entirely, spares the young, and targets the older population, testing how much contemporary U.S. society values the elderly.

This virus changed every aspect of our culture, society, politics, business, economy, and life attitudes. In fact, it permeated through so many levels, we cannot even fathom. 
The culture is changed in fundamental ways, for example, by the way we greet each other; we recoil from handshaking, even elbow bumps to keep the distance of 6 feet away from each other.  The greetings have now altogether become a no-go, not even smiles hidden under the mask.

Politics have changed; no campaign events with a large crowd, travels to every state by candidates, and voting may change entirely to mail. The blaming games for faulting others in delayed response to the pandemic has not changed, however. The Americans also became better at several things; cooking, being more homebodies and accustomed to be more introvert due to limitations going out to restaurants and bars.

Education has changed. Most classes are by website or zooming.  Students without computers will be left out in the dark which creates lack of access and opportunities in learning for the poor. “Tele schooling” is now becoming more of a norm affecting at least 55.1 million students impacted nationwide.

Traveling, entertaining, vacationing, and hotel businesses have been halted by the virus. Instead, on-line ordering from Amazon, Walmart, Costco and groceries has been doing well, some with price gouging to follow the fundamental economic rule, “as consumer demand increases, the price increases.” Delivery truck drivers’ job security has been increased since they are now the lifeline to many.

Our hygiene requirements and habits have been changed; we wash our hands more frequently, something we should learn from obsessive-compulsive patients who have perfected this art. Americans also became hoarders of hand sanitizer, disinfectant, toiletry and tissue products. In lieu of high fashion clothing, more colorful designs of facial masks are selling better. The definition of personal hygiene has shifted. Both men and women’s hair length are increasing, including some of the governors who are showing up every day on the television monitors. The people with sign language also stepped up and are more visible than before.

What about the attitude? American people naturally tend to focus on two desires, safety and freedom. Hyper-individualism shouting, “keep me safe and leave me alone.” But we now know that these two desires are inter-related and even conversely related. One cannot be safe unless you do your part in the four pillars of our strategy—hygiene, distancing, screening, and masks. Who would have thought someone (index patient zero) from Wuhan China can affect the entire global world like today? Can one person change the world? Absolutely. Freedom? Yes, we want that too, but not when it affects other people in such a detrimental way. What we do today is intertwined with how we affect others tomorrow more than we can possibly imagine. 

We lost our innocence in the trust of being together socially. Hugging, handshaking, talking and singing together, touching and holding hands to comfort others, and even breathing the air in an enclosed space has become risky. Every causal contact has become a calculated risk as if it is a sexual encounter. The question of who and where have you been with recently crosses our mind before welcoming someone into our boundaries. The comfort of being in the presence of others has been replaced by the comfort of being alone. All the things extroverts flourish in have become a thing of the past. 

Nobody can predict when is the end and the full consequences of the coronavirus pandemic. History repeats itself and we can learn a great deal of knowledge by studying past experiences. Key points from observing the epidemiology of past influenza pandemics in 1918 may provide insight into the COVID-19; the length of pandemic will likely be 18 to 24 months, as herd immunity gradually develops in the human population. Given the high transmissibility of coronavirus, in order to halt the pandemic, an estimate of 60% to 70% of the population may need to be immune to reach a critical threshold. One thing we can predict with confidence is that it will take time to get back to the normalcy we once used to know. We will soon forget what the pandemic was like—our memory is short-lived and amnesia is guaranteed, but the history will repeat itself again by having another pandemic. The way the pandemic with COVID-19 will end is most likely by our exhausted energy and fading memory in dealing with it before the actual virus pandemic will be over.  

The only sure things in life are death, paying taxes and perpetual mutation in viruses. Currently, the pandemic is far from over. Despite a still rising coronavirus infection rate worldwide, America will open the businesses and resume the usual domestic air travel starting 5/25, the special train to transport migrant workers on 6/1, and 200 general passenger trains across the country. Slowly and surely all the businesses, essentials and non-essentials will open, tip-toing the balance of sacrifices from the health care workers who actually take care of the residual contagious and sick population.  There will be spikes of COVID-19 back into emergency rooms and intensive care units. The government will calculate how many bed capacities are available, rather than how many doctors, nurses, EMT, janitors and other allied health care workers are risking their own lives and their loved ones in their family. Most health care workers did not sign up to be enlisted as military personnel, understanding one’s own life may be endangered by the duties, but they simply want to help others who are sick. They did not sign up to risk their lives every day as if we are going to the battlefield on the frontline. As the pandemic prolongs, the glory and honor of the jobs being heroes, albeit involuntary, will be soon forgotten and diminish. The price of paying one’s own sacrifice needs to be thought through, weighing the benefits and risks, as we now see many early retirements from health care workers. The younger generation will pick up the tune of, “for the whom the bell tolls,” and we may face severe shortages of health care workers in the future. 

At the peak, we are witnessing COVID-19 crisis overwhelm the hospitals, and we are in dire need of physicians and health care allies on the frontline. However, in the midst of all of this, hospitals had to furlough thousands of employees, cutting their pay, requesting volunteer staff, and yet failing to provide adequate PPE while demanding that staff risk their lives. Some nurses and doctors are speaking out on the reality of lacking adequate PPE and over-working their shifts to 15 hours, but some hospital administrators are punishing those that spoke up against the system. Some other hospitals are laying their employee off. Even worse is that these same CEO’s, administrators, and executives were being compensated with million-dollar salaries or more.  It is very perplexing how health care workers could be fired, furloughed, or asked to take pay cuts as they put on PPE to care for critically ill patients at great personal risk.  

Life goes on as death goes on. More recently, news media rarely covers how many deaths occur daily by regions any longer, as if 50 dead are not important as 800 dead. As media coverage dissipates, so will be our reality in COVID-19. The tail end of the mess, perpetual chaotic reality that virus left will be cleaned up by the unsung heroes just like the Vietnam veterans with amputated extremities, still with mental and physical scars.