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

Who says you have cancer?

Only your pathologist determines the “final diagnosis” for a patient’s illness. This is the first medical book of its kind that describes pathology, the unseen doctors and workers who who are behind the scenes working for patients in every hospital. Dr. Apple donates all her book sale profits for those in need of a wheelchair through Joni and Friends, and those who lack access to food through the Valley Food Bank.

Available at Amazon

“Pathology is one of the most misunderstood fields of medicine. In Doctor Apple’s book, she makes it clear what pathologist do, the joys and rewards of practicing pathology, and why she choose to enter the field. This is a must-read for any medical student contemplating their choice of specialty, any physician trying to better understand their pathology colleagues, and any patient who may incur the services of a pathology laboratory.”Michael H. Kanter, MD, CPPS, Professor and Chair, Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine

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.

Mutation of virus is as sure as we pay taxes.

Viruses are efficient creatures that borrow human cells to reproduce themselves without our consent.

From the perspective of the virus, its function and purpose are to replicate and infect the host as much as they can and fast as they can.

Image of Coronavirus from CDC/Dr. Fred Murphy

Mutations in the virus’s genome are normal and guaranteed as it is copied over and over. The GISAID database identified thousands of changes along the genome. Viruses are clever and naturally select mutations that can result in a strain to be more transmissible or impervious to proposed vaccines. University College of London Genetics Institute researcher Lucy van Dorp is a co-author of a study that identified more than 12,700 mutations in the SARS-CoV-2 virus.

The naming of these variants is done by WHO, in collaboration with partners, expert networks, national authorities, institutions and researchers in the established nomenclature systems for naming and tracking SARS-CoV-2 genetic lineages by GISAID, Nexstrain and Pango. The letters of the Greek Alphabet, i.e., Alpha, Beta, Gamma, Delta is chosen to be more practical for discussion by non-scientific audiences.

The working definition of Variant of Concern (VOC)

VOC of SARS-CoV-2 are Alpha, Beta, Gamma and Delta variants which meets the definition of a Variant of Interest (VOI) and one or more of the following changes:

  1. Increase in transmissibility or detrimental change in COVID-19 epidemiology,
  2. Increase in virulence or change in clinical disease presentation,
  3. Decrease in effectiveness of public health and social measures or available diagnostics, vaccines, therapeutics.

The working definition of Variants of Interest (VOI)

VOI of SARS-CoV-2 variants have genetic changes that are predicted or known to affect virus characteristics such as transmissibility, disease severity, immune escape, diagnostic or therapeutic escape and to cause significant community transmission or multiple COVID-19 clusters to suggest emerging risk to global public health. VOI includes Eta (B1.525), Iota (B1.526), Kappa (B.617.1), and Lambda (C37) from various countries. Recently the Lambda variant has met the definition of VOC. 

So far seven VOC have surfaced throughout the globe:

B.1.1.7, (Alpha) first detected in the U.K. is known to be 50% more transmissible and found in Florida, Michigan and Colorado. 

P.1, (Gamma), first detected in Brazil and Japan, and the U.S. has reported 323 cases of this variant.  

B.1.351, (Beta) first detected in South Africa, again 50% more transmissible and the U.S. has reported 224 cases of this variant. 

B.1.427, first detected in California, 20% more transmissible, and 

B.1.429, another variant first detected in California, 20% more transmissible. 

All these variants do not have clear information whether the various vaccines are capable of protectinginfection or have significant effect on neutralization by antibodies. 

The trend appears that the states which had successful vaccine delivery seem to have decrease in death rate by COVID. 

B.1.617 (Delta variant), originated from India.

C.37 (Lambda variant), originated from South America, particularly Peru.

The coronavirus is composed of five different components: envelope small membrane protein (E), membrane protein (N), spike glycoprotein (S), nucleoprotein (N) and genomic RNA. 

The virus’ genomic RNA is a complete set of genetic instructions that is written in 30,000 “letters” of code composed of A, T, G and C.

Within the genome are various parts: see the diagram below.

Below is the process of how the virus enters into the host cell, which in this case is humans.
Schematic of the SARS-CoV-2 S protein and the mechanisms how virus enters into human cells to replicate themselves using human engines.  
a. The schematic structure of the S protein. 
b. The S protein binds to the receptor ACE2. 
c. The binding and virus–cell fusion process mediated by the S protein. 
d. The life cycle of SARS-CoV-2 in host cells. By Y. Huang et al Acta Pharmacologica Sinica (2020) 41:1141–1149; https://doi.org/10.1038/s41401-020-0485-4

Pfizer and Moderna vaccines are made from mRNA in the different spike protein area, a new type of vaccine to protect against infectious diseases by triggering an immune response unlike many vaccines which is made from weakened or inactivated viruses. Vaccines trigger immune response, which produces antibodies, which protects us from getting infected if the real virus enters our bodies. Before releasing these vaccines, both companies conducted rigorous studies and the vaccine effectiveness is proven to be 95% from the original coronavirus before mutations when tested among 30,000 people ages older than 18. This means 5% or less still can have a chance to get COVID-19 infection. While the vaccine is not effective in 100%, it is still excellent in preventing infection and at least subsiding its significant symptoms and deaths. 

Will the virus escape vaccines?

If the virus changes by mutation substantially, particularly the spike proteins, then it might escape a vaccine. The race against the virus mutations is on. As the entire population gets vaccinated, we seek herd immunity; likely ~70% of population vaccinated. The goal is to slow transmission globally and slow the clock. If people do not get vaccinations, the COVID-19 pandemic prolongs. We do not have to see any more additional deaths beyond 609,000 people. When the virus mutates increasingly, more vaccinated people will be susceptible to infection because the vaccines were not made from the variants. Time is of the essence to race against virus mutations by vaccinating most people. This is the only way to win over the war against the coronavirus.


God was with the science and scientists who developed these effective and great vaccines in the US. Both mRNA vaccines are superior to any other vaccines known from other countries including China and Russia. We can celebrate superior vaccine science in America and be thankful to live in such a great country.

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Read Dr. Apple’s fictional novel based on real events at:

https://www.amazon.com/dp/B08P7486XX

  • 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. – Amazon book review

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)