MoMilli – Mixing up the Medicine
What does it mean to master a discipline? I guess I think about this question a lot now that all my friends are in graduate school. Are all my friends in graduate school? Maybe I’m extrapolating that conclusion from how much everyone I know seems to complain about graduate school of late. If we believe in anything after all the schools we’ve spent so much time learning about, it is that all of them are stupid and petty. We usually take it all back when we realize we’re mostly griping because we feel stupid and petty having invested all this time into working on half-wit PowerPoint slides. That’s the process of mastery, developing the ability to assess what you do not know. Suffice it to say that becoming an expert in something requires a lot of buffoonery on our parts, and we do hate to goof.
I am still a little uncomfortable with being wrong all the time. Wrong used to be in the classroom. Now wrong presents in clinic as well. At least I am starting to get a better feel for wrong’s cadence. When your attending physician says “What is the most common cause of urinary tract infections?” you say E. coli. UTI? E. coli. Et cetera. Call and response. The first time a pediatrician asked me that I think I said staph, which is why what I just said, E. coli, the better answer, has stuck. The right answer is right there in the epidemiological data, and I didn’t know the data. She was nice about it. I was not so kind to myself after, but I’ll never forget the diagnostic pattern now.
Thus one begins to derive a perverse pride from participation in rounding, maybe the central ritual of medical training. She doctor, you student. Call and response. In my limited experience as a student, the best way to manage in clinic is to embrace your student role full throttle. Earnestness helps, as does appending “as a student” to each of your statement so as not to rock the boat. That way you survive. Feel me? For me, then, the few times when the doctor isn’t right brings us both closer to the profession’s crisis of faith.
Sometimes it isn’t clear if the student or the resident or the department’s research rainmaker has the most up-to-date information on evidence-based clinical practice. To reach consensus we will all check uptodate.com, and often one of us will be put in the uncomfortable position of telling the others that the most recent review on there is not recent enough. A pager call will interrupt the flow of conversation, the daily hour for I.R.L. itself an insistent nod to the tradition of academic rounds, and somebody will take the break to look up the answer to a “clinical question” on a smartphone. I know a few doctors who keep photo albums of interesting pathology specimens on their phones. They are careful with them, too: Otherwise they might put data on an open server or information cloud in an inadvertent patient privacy violation under HIPAA, the Health Insurance Portability and Accountability Act of 1996.
HIPAA Hooray! Would that be a good hashtag, with its nod to Naughty by Nature, its cutesy, ungainly acronym? Medical school call and response, which can obscure meaning in impenetrable inside references and jargon, has a lot in common with “hashtag rap,” Kanye West’s dismissive term for a style tic that has become ubiquitous in hip-hop lyric writing within the last two years. A hashtag rap substitutes a hashtag, or pound sign (#), for “like” or “as” in a simile, as if the rapper is posting the thought association on Twitter, where the conditional nature of the relationship between the terms is implied. Consider the following instant classic hashtag flow in “Forever” by crossover heartthrob Drake:
Swimming in the money, come and find me: Nemo —
If I was at the club you know I balled, chemo.
Well, I’ll admit I enjoyed that. The writer Rivka Galchen, who got an M.D. from Mount Sinai School of Medicine before finishing her Columbia M.F.A., has said that medical jargon helped restore her aesthetic pleasure in language. At their best hashtag rap and call and response are okay with me.
Hashtag rap may be the logical extension of rappers’ frequent invocation of an acronym popularized by the Wu-Tang Clan, “C.R.E.A.M.,” which is now so widely used that spelling out “cash rules everything around me” after every usage seems besides the point. However valid that comparison, hashtag rap definitely strikes me as the equivalent to someone “pimping” you on the etiology of anion gap metabolic acidosis and you shooting back “MUDPILES”:
Diabetic (alcoholic, starvation) ketoacidosis
Propylene glycol, and formerly paraldehydes and phenformin
Iron and isoniazid
Ethanol, ethylene glycol
For a hashtag rap to work, the association must be so automatic that further exposition is superfluous. In such cases context has become intuitive. Why not shout out what you know and leave the reasoning out? This is how one becomes a doctor, by internalizing cognitive patterns and packaging them into a differential diagnosis “bucket” off the books. In time, we hear, a presumptive diagnosis will come easily to us off the cuff.
By trade I am both a physician-in-training and a “rap genius,” which is to say a founding editor of Rap Genius, the foremost hip-hop lyrics exegesis website on the Internet. Sometime around the start of medical school a college friend looking to scale back his hours at a New York hedge fund asked me if I would help him develop the editorial voice for his new programming side project. Not that I qualified: Back in high school my brother had a pan-ethnic hip-hop collective, the Kevin Gnapoor Experience (KGE), named for the oversexed math nerd in Mean Girls. Its biggest hit’s hook was “What class we in? Duh-na-na-na!” (“Duh-na-na-na” refers to DNA Science I, an advanced biology elective.) Not that it mattered: My participation seemed like a good idea, if not a foregone conclusion to my friend, the Web expert, at the launch time.
So I have continued to write and edit Rap Genius on and off since my first day of medical school. Like Jay-Z’s new book Decoded, or the Yale Anthology of Rap, Rap Genius conceives of hip-hop as a corpus. We have defined ours with the help of the Internet hivemind, sort of like what Facebook has done for circles of friends, or Google for information proper, except they got there first. When we want to know what a rapper means by a name he just dropped or a new slang word she wooed out of the ether, we transcribe the lyric, post it on the site with a mixtape mp3 for cross-reference, and wait for the genius of crowds to strike. Within 24 hours we will probably receive two or three competing interpretations that our editors will monitor, address, and then collate into a humorous footnote. The constant feedback has made me a more meticulous and diligent student than I ever imagined I could be. Their piece said, then brushed off the shoulder like so much dirt, has helped Rap Genius build a kind of rapid response system for users, really just copious admissions of our own inartfulness and inexpertise. Whatever our own failings as exegetes, our work has built the site’s audience up to about 250,000 unique visitors a day.
Sometimes I try to imagine what it might be like to encounter a Rap Genius user as a future patient. Google Analytics data mining suggests that he most likely found RapGenius.com after a friend shared one of our footnotes to a rap lyric on Facebook or Twitter. He is likely a he from America. Maybe he has a connection to Australia or South Africa. And he is sure that his life has granted him a certain authority about the rap canon, that or a need to seek out authority on the subject that his own situation cannot confer. More germane to my website work, I am certain he is a genius. His genius is not necessarily ’hood genius or street smarts. He has critical authority as a participant in the writing of the website specifically because his perspective differs from mine. It is separate from the experiences I have of America as a medical student who also writes a rap website on the side and who is consequently accustomed to life without a lot of free “life” time.
Embracing the accumulated wisdom of a community necessitates denying some of the intellectual authority of any one genius of the field. It is a little foreign to me, having not only grappled with “dead white men” in my college syllabi, but the ones we saw in the flesh on the table like Vesalius before us, and Galen before him. Certainly experience is the best teacher. See one, do one, teach one, is that what they say? It is sure strange to be training to become a kind of authority figure at a time when an entire body of world knowledge is available to anyone in one place.
As an Internet wiki, Rap Genius tends to throw around the word meme a lot. One would think I’d hear it more at medical school, as Richard Dawkins coined it in The Selfish Gene, but the virality I know best at this point is that on the Web. There is, however, a meme going around medical students, as ever, that the crawl of biomedical science research has outpaced the ability of one person to memorize its more salient points in four years of top-notch 21st century education. The notion of even trying is enough to exhaust even the most eager preclinical student. It is disheartening the first time you learn that your candle might have only one end to burn.
I take solace in the fact that a similar realization once hit Cam’ron, the founder of The Diplomats. A consensus has developed among American music critics that the creative forces around Dipset single-handedly “saved” New York hip-hop. This swagger so got to their frontman, Cam’ron (Cameron Giles) that in his debilitating anxiety to duplicate the success of his dizzying 2004 solo album Purple Haze, he developed irritable bowel syndrome. In response to his chronic medical trouble he recorded “I.B.S.,” a polemic against the whole notion of hip-hop saviors, in 2006:
Ay yo, god body, I’m hard-bodied — word, mami — vanishin’
Had to go low, the Mayo Clinic, Minnesota
I couldn’t get cake, a rock in a hard place
For me that’s a odd place, I’m only here by God’s grace
Like a lab rat, them tests dishonor Cam
Ultrasound, MIR, CAT scan, sonogram
Laryngoscopy, endoscopy, I be stressed (I be stressed)
The prognosis, diagnosed, I.B.S.
Cam’s use of “cake” here may be synonymous with bupkes, but is also slang for heroin. His wordplay here is characteristically tortuous: As Rap Genius managing editor Mahbod Moghadam wrote in liner notes to this track on our site, “this song is an example of an ‘extended metaphysical conceit.’ Cam raps the symptoms of irritable bowel syndrome (I.B.S.) as a way of saying ‘he shits on y’all’ (i.e., he’s the best). Then there’s the ‘I BS’ (I’m full of BS) pun (get it? Get it?).” In Understanding Media Marshall McLuhan speculated that the television medical drama would succeed because it “creates an obsession with bodily warfare.” Even McLuhan probably could not have conceived of the hip-hop medical drama of “I.B.S.,” but it is an example of an expert creating dramas as a kind of palliative against his own anxieties about the limits of his own genius where the only omnipresent thing is scientific expertise.
Self-medicating is of course a common theme in rap, as it is in any other popular music genre. Cam’ron’s protégé Juelz Santana recently released “Mixing Up the Medicine,” built around a sample of Bob Dylan’s “Subterranean Homesick Blues.” Santana introduces his verse as “rap penicillin,” a magic bullet to reinvigorate the game. Though Santana’s swagger is winning, it is not without precedent: “Mixing Up the Medicine” came out almost a year and a half after “Dr. Carter,” a Lil Wayne (né Dwayne Carter) fantasy of himself as a physician on call to resuscitate hip-hop:
Good afternoon, Dr. Carter.
I don’t know about this one.
His confidence is down, vocab and metaphors needs work
And he lack respect for the game
Uh, let me see…
You think you can save him?
It is perhaps not surprising that these songs have been chopped ’n’ screwed on YouTube, chopped ’n’ screwed being a style of beat slowdown that originated out of Houston in the early Nineties to mimic the feeling of being on cough syrup, promethazine and codeine.
Both Lil Wayne and Juelz Santana play on a hip-hop trope older than Biggie and 2Pac — the former prophetically Ready to Die, the latter still releasing deep cuts via hologram over 10 years after his death — hip-hop as salvation. They are writing specifically to the most recent “death of hip-hop” meme, crystallized in an October 2009 article by New Yorker music critic Sasha Frere-Jones, which argued that commercial success and radio omnipresence killed New York hip-hop artistry. That idea is nothing new, as Frere-Jones was certainly aware, and may date back as far as the late 70s when Afrika Bambataa was chanting “Planet Rock” to add Kraftwerk’s edge to party music from the South Bronx. Hip-hop constantly knocks itself down and declares its own death — its own unfitness for the times, or its inability to generate new ideas — then builds itself back up better equipped to address a “new generation” of artists informed for the better by the artistic failures that came before.
Yes, raps are rhythmic speech over a beat — Gucci Mane’s signature introduction “It’s Gucci!” is as good a facsimile for the cadence of the S3 “Kentucky” gallop I can find — and usually, though not always, the lyrics rhyme. Using the architecture of a single rap song as a stand-in for the entire genre would be about as silly as trying to recreate “normal” human anatomy from the insides of a single cadaver. What makes hip-hop interesting is its intertextual nature, the way one track does the same thing and wears the structure differently. Compare it, maybe, to hip-hop éminences grise who playfully diss, or “ether,” as Nas to Jay-Z, younger or less accomplished artists. They knock them down for a while to ensure they have been learning and listening. When they get over the beef, they are rebuilt into better professionals. When I was studying English in college, we used to call this notion of writers “in conversation” in this way “the anxiety of influence.” Well, Harold Bloom did, anyway, and I never took any of his literature classes. As Kanye West said last year, though not of Bloom specifically, “No one man should have all that power.”
So I see what Rap Genius does as something akin to ethnography, an archive of a series of experiences and associations for a thoughtful student of hip-hop that the listener can have at the ready later on when a lyric triggers a new association. When an expert points out how little we know of what we write, we listen, learn, and immediately update the text. They call us on it, and we respond as soon and as best we can. The medical anthropologist Paul Farmer has said that he feels like it’s become harder for him to do his life’s work in ethnography because he can’t learn all the right languages in due time. Not that I would know: I have skimmed his books Pathologies of Power and Infections and Inequalities. Once I read that the average preclinical medical student learns 10,000 new words in her two years of basic science study. Learning hip-hop, which is more than a dialect to “translate,” has taught me as much if not more terminology, and I believe it made me a better taker of medical histories.
When they are not making too many mistakes, the energetic efforts of upstarts to learn the language on time are undeniably appealing. Two recent graduates of Wesleyan University did just that after responding to Sasha Frere-Jones’ “death of hip-hop” essay, and in so doing are resurrecting weird strains in New York hip-hop. Victor Vazquez and Himanshu Suri of Das Racist sublimated their enthusiasm for Cam’ron into a series of self-produced mixtapes, with lyrics discussing everything from their food preferences to their voracious college readings in critical race theory. They are willing to be silly and amateurish: In one memorable bit from their early live shows, they yell “When I say ‘call’, you say, ‘response’! Vazquez, posting as YouTube user bisonbisonagain, even annotated his own performance of “Call and Response” at the 2009 Montreal POP Festival:
Jitty Rap Authenticity Theorists Das Racist engaging in the musical/poetic tradition of Call and Response to a Caucasian audience at the POP Montreal Festival in Montreal, Canada, affectionately known by the locals as “The Maple Leaf State.” Call and response patterns between two musicians are common in Indian Classical Music, particularly in the style of Jugalbandi. Call and response is likewise widely present in parts of the Americas touched by the trans-Atlantic slave trade. It is extensively used in Cuban music, both in the secular rumba and in the African religious ceremonies (Santeria).
The whole joke here is that this dense academic banter informs without enlightening: The writer, riffing on the voice of East Coast ethnomusicology professors — think Anthony Braxton at Wesleyan, Wayne Marshall at MIT, or Robert Farris Thompson at Yale — dismisses a major Canadian city as if it were a stopover on a scenic tour of New England. Everybody hates a tourist, no?
The last paragraph maybe sounds authoritative. That was my secret hope. Actually I just named the first three ethnomusicologists I could think of off the top of my head, then confirmed on the Web that I got their home institutions right. Given any medical professionals reading this piece, I am sure that any one of those readers could fake or sincere as much in response to any single article published in the New England Journal. The reason they continue to converse with one another about their work is that their training has taught them that the humbling is a valuable way to develop more nuanced knowledge for the collective whole. Either that, or they just like free-associating from a firm knowledge base, coasting on their ability to hashtag rap with the best of the teenage hip-hop talents handpicked by Lil Wayne to be in Young Money.
For my part, I am still working on not making so many free associations and assumptions before I can back them up with automatic knowledge drops. This past winter we learned the mental status exam. Four students and I met weekly with an inpatient under the supervision of an attending psychiatrist on the Bellevue substance abuse ward. Usually I got to the interview site earlier than my classmates The activity room where we saw our patient was homey enough — multimedia compositions, yoga mats, plastic form-fitting chairs — but I was mainly afraid that if I showed up for our sessions late that I would get locked out. While the midday atmosphere of the rooms was characteristically sedate — we met our patients on Wednesdays after lunchtime — the sound system was not. Usually the speakers had on “Throwback at Noon,” Mister Cee’s long-running show on New York’s Hot 97. One time I walked into the activity room to Nas (“The World Is Yours”). Hits from Cam’ron, Busta Rhymes, and Ma$e followed. With their music surrounding you, it is hard not to get a little overwhelmed: Their cockiness tries its way into your body as if by force. Osmosis. When my classmates arrived 15 minutes later, the attending psychiatrist turned off the activity speakers.
“No, I was enjoying it,” I insisted. “It’s funny: I help run a rap website. Hot 97 is kind of our bread and butter.” On Rap Genius no one has to know that your primary exposure to “the game” comes from life experiences like supervised visits to the Bellevue psychiatric ward. Would such a disclosure undermine Rap Genius’s credibility or reinforce it? Now that I get to thinking about it, I have not felt so self-conscious since confronting those fifth graders in the classroom all those three years ago, or since my last patient encounter, or upon meeting every single person with whom I come into contact in clinical practice. Like most graduate students-come-latelies, I love rap, but do not consider myself anything even approaching an expert in “the game.”
“Oh,” my attending said. “The volume.”
Wrong again? Probably. All in the game.
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