INTERVIEW: Selina Mahmood, Author of A Pandemic in Residence: Essays from a Detroit Hospital

Interview by LaVonne Roberts

Selina Mahmood’s debut collection, A Pandemic In Residence: Essays from a Detroit Hospital, felt like a postcard moment for what it was like to be a resident thrown into a hospital system in a once-in-a-lifetime pandemic.

During the early months of the COVID-19 pandemic, Selina Mahmood ― in the middle of the first year of a neurology residency ― found scraps of time between grueling shifts to write. The resulting collection is her personal and meticulous chronicle of an unprecedented year in medicine. It’s also the debut of a young and uncommon talent.

In the tradition of Oliver Sacks and Paul Kalanithi, Dr. Mahmood takes the science of neurology and spins it into poetry, exploring theories of the mind, Pakistani-American identity, immigration, family, the history of medicine, and, of course, the challenges of becoming a physician in the midst of a global health crisis. Skipping nimbly across continents and drawing inspiration from an array of sources ranging from Thomas Edison to Yuval Harari to Beyoncé, she has crafted an elegant, incisive, and utterly original investigation. As Salon put it, this book is “A profound, moving and unfiltered account of not just a frontline worker’s experience at an unprecedented moment, but a story of family and identity, of pop songs and PPE.”

A must-read for anyone seeking insight into the front lines of the COVID-19 pandemic as well as a broader understanding of our universal search for meaning. (Description courtesy of Belt Publishing.)

Selina joined me for a Q&A about her book, healthcare in the U.S., the pandemic, identity, and the writing life.

LaVonne Roberts: There’s a lot of talk about how clinicians and health policy experts think the post-pandemic world will look like. I’m wondering how your experiences have affected you personally, especially since we spoke last. You were thrown into the fire, and as I’m sure you’re aware, so many clinicians are leaving medicine. What about you? Have your dreams or expectations changed? 

Selina Mahmood: I’m now in my third year of residency, and things are generally better during the latter part of residency. We have less calls and the hours are less intense. At this end though, I’ve realized how much the last two years have jaded me. It’s taking a conscious effort to realign myself with the purpose of medicine. The one thing that has helped me is that I didn’t enter residency completely idealistically. I love the brain for its theoretical aspect and its strangeness. Through everything, that wonder has remained intact and I guess what has kept me doing this.

Selina Mahmood

LVR: I wrote a lot about moral injury, and the trauma clinicians have endured—also suicide. Health care has changed more since COVID than any other period in modern US history. How do you find respite? Can you do so within your hospital with your co-workers, or does it feel as insular as when you wrote the book? Are mental health services more readily available

SM: Ironically, writing the book gave me less respite than one would imagine. People are sick about hearing about COVID, and anyone writing or talking about it gets an automatic eye roll. I think the problem is well beyond what mental health services can provide. I have yet to meet a resident who thinks wellness rounds or activities help. It’s almost sad that the idea of mental health is often almost as, if not more, stigmatized within the medical community as it is outside. I’m not sure if it’s possible to promote mental wellness without calling it that, maybe that would help. But I wonder if the issue is deeper than that, even though I’m not quite sure if I can put a finger on what it is.

I think you could do almost anything if you believed in its utility. There’s a huge problem when we start questioning the purpose of what we’re doing and why we’re doing it. When we start wondering if public health could not solve a lot of these issues. I go into a grocery store trying to look for something that has low carbohydrates — and nothing. In a nation that has astounding diabetic rates, you would think it would be easier. Diabetes is known as a silent killer. Why is still so little being done when it comes to the food crisis in this country? Why is a small fresh orange juice ten bucks, when I can get sugar-loaded candy bar for one? I’ve also realized that more doctors have to start going into administrative roles for things to start changing.

LVR: I sense that writing was restorative, and at the same time, I imagine it can connect your trauma in a way that doesn’t allow escape. Are you writing now?

SM: I’m still writing but not at the same pace. Lately I’ve been trying to find a self outside of words, thoughts and feelings. It feels luxuriously indolent to not write, which is probably a needed balance for when I do start writing furiously again. I think it’s important to balance out writing periods with non-writing periods. I think the importance of writing is in connecting you to a past that you sometimes didn’t even realize existed. Retrospective existence is its own kind of glorious madness.

LVR: Now that you’re a senior resident, teaching a junior resident, do you find that your experiences, or even writing your memoir, have put you in a position to better guide someone new to your day-to-day world? 

SM: It does, or can, get better. It’s hard to believe that when you’re in the thick of residency. It also doesn’t automatically get better. You have to start actively looking for meaning in what we do.

Writing my experiences down has given me a window to go back and actually remember how steep the initial learning curve was. Just that reminder does a lot, because otherwise human memory is so flawed, we honestly forget. It’s easy to be blindly critical about others. We change though, in personality, behavior and knowledge. I know I have over these past few years. It’s important to afford that flexibility and malleability to others as well.

LVR: Has your relationship with death changed? Do you work with your hospital’s chaplain to process death?

SM: My relationship with death started changing in medical school. I’m still not sure how we delude ourselves into thinking life is anything but tenuous. It may be one of the most important delusions though, because I also know that living with the acute knowledge of the tenuous nature of life paralyzes you. If the truth paralyzes you, then is that the truth? Or is truth whatever makes you feel and do better? These are questions I still struggle with.

Also, on a tangent, I love how you phrased that question, “relationship with death.” It’s been dawning on me lately how much of life has to do with relationships: relationship with emotions, relationship with thoughts, relationship with God, relationship with work, relationships with others etc., the interesting thing is that there’s a concept of an immutable “I” in all these relationships. Or, maybe I just want there to be a concept of an immutable “I” in the face of death.

LVR: Having experienced a hospital system in Pakistan, is there something/s you learned there that you wish America would adopt?

SM: Medicine has become so defensive, that clinical judgement often goes out the door. The fear of being sued drives so much clinical judgement that it still astounds me. I don’t know what the solution would be, because I also understand the importance of checks and balances. I saw the repercussions, often deadly repercussions, of a lack of checks and balances in Pakistan. Yet at the same time, every patient was not pan-imaged. The physicians in Pakistan had fine-tuned their clinical judgement, and to this day, some of the most brilliant physicians I know are from there.

We still read entire medical textbooks in Pakistan. You’re expected to and can’t get away without reading them. Most of my friends who went to medical school here tell me they mostly studied from slides and notes. I think there’s something irreplaceable in having studied from actual textbooks. Grey’s Anatomy, both the student and the original versions, is still alive and thriving there.

There’s also a lot to be said about the societal breakdown at large. I’ve spent too much time trying to locate a patient’s family members to get a clearer history than should be warranted. There are too many elderly people who get dropped at the ER from their nursing homes with no family or friends to care for them. It is awful to see the end of human life so isolated and miserable. In Pakistan, we had the opposite problem. There were generally so many friends and family with the patient that we would have to request people to leave.

LVR: Are you comfortable talking more specifically about what led you to study in Pakistan? Your existential crisis (as someone who’s had their own, I get it)?

SM: Belongingness is a strange concept. It’s something you don’t want to write about as a product of migration but something you’re inexorably warped into. I’m also sure as many people have endorsed that thought as the actual migration stories themselves. I knew people whose family pedigree had been in America as far back as they could see. I was sure that existence was distinct from mine. A state of mind and wholeness that I couldn’t attain by nature of my different existence. I wanted that. I suppose thus the existential crisis, though I’m not sure if I’ll ever be able to pinpoint why or how it occurred. It continued to bulldoze through medical school and I think it’s only being somewhat resolved now with writing.

During my senior year in undergrad I was taking a higher level English class and wrote a ten page paper on Daniel Deronda by George Eliot. She had this quote in there—some place of land we must call home. I was like that’s what I need in my life: a home. Here’s the paragraph in whole:

“A human life, I think, should be well rooted in some spot of a native land, where it may get the love of tender kinship for the face of the earth, for the labours men go forth to, for the sounds and accents that haunt it, for whatever will give that early home a familiar unmistakable difference amidst the future widening of knowledge: a spot where the definiteness of early memories may be inwrought with affection, and kindly acquaintance with all neighbors, even to the dogs and donkeys, may spread not by sentimental effort and reflection, but as a sweet habit of the blood. At five years old, mortals are not prepared to be citizens of the world, to be stimulated by abstract nouns, to soar above preference into impartiality; and that prejudice in favour of milk with which we blindly begin, is a type of the way body and soul must get nourished at least for a time. The best introduction to astronomy is to think of the nightly heavens as a little lot of stars belonging to one’s own homestead.”

I didn’t relate to the popular immigrant story. My parents did not come to this country with nothing to make something of themselves. They were not economic refugees. My “country back home” had electricity and water, albeit with load shedding. My grandparents were bureaucrats and doctors who had studied in the US. My parents came here for higher education and ended up having kids here. There’s no romance there or pulling yourself up from your buck-sleeves.

I didn’t relate completely to the Pakistani diaspora community in America either. It always felt like a shell of something else. The best adjective to describe it would be “sterile.” The facade of culture without the richness of culture. Then there’s a problem that migrant populations are often time capsules of the lands they leave. Immigrant homelands tend to progress, in often more liberal dimensions, while the people who leave are no longer representations of either their homelands and sometimes I think even of themselves in these new places.

I also think it’s interesting to gravitate towards people just because they’re from the same religion or race and form these isolated groups. People “back home” don’t do that, so why is that done outside of “home”? But I think that may be more a manifestation of American-ness and the way the “melting pot” works than of migrant populations chunking themselves off. I can understand the importance of chunking off, of holding onto certain family values, and the value of being raised by not only nuclear but extended families. But at the same time, it’s important to be able to foster rich connections with the people you’re physically surrounded by, one that breaks down the limitations of “us” and “them.” The burden comes to lay on migrant populations, they’re the ones making the move after all, and it can get exhausting.

When I decided to move to Lahore for medical school I hadn’t realized I was more “American” than I’d anticipated. Or maybe it’s just that I was kind of strange. Who knows. Either way in my head I was going to a Pakistan that I had known when I was younger. I have a large extended family and lots of childhood friends there. I hadn’t recognized the strict cut off of socioeconomic classes in the third world and that there are different worlds living within the same city. The elite of Lahore were businessmen, bureaucrats and politicians and my image of Lahore was solidly based with that society. It was more “westernized” and “liberal” than the American-Pakistani community in America.

The elite classes’ children came to the U.S. and Europe for college before heading back to Pakistan to run their parents’ businesses. They didn’t have an obsession with the West, they had a healthy relationship with it, and were comfortable in their existences. I was comfortable in that existence. I hadn’t realized that medicine in third world countries has basically come to be considered a working class profession in the past few decades

Socioeconomic classes in the third world aren’t only differentiated by lifestyle, but also in how conservative they are. By token of that, I found myself in a very conservative environment. Yet, there was a weird dichotomy of both striking conservatism and idealization of the West. I was surrounded by people who looked at America as a kind of promised land. I stuck out like a sore thumb and constantly felt uncomfortable in my own skin.

LVR: This (to me) is what’s interesting about you and your story. Can you explain to me what you mean? You’re studying neurology and can go anywhere from here. Was it that you felt trapped or that your studies stunted your progress? Was it that you felt like an outsider, that the training wouldn’t be as rigorous, or that everything you wished was familiar was foreign? Or something else?

SM: Well, not exactly everywhere. Once you get ticked off as an “IMG,” or an international medication graduate, in the medical community that’s an automatic stigma of its own. I didn’t realize that’s one of the reasons my parents didn’t want me to go to Pakistan for medical school in the first place. Yes, I’m ashamed to say I really was that stupid and had to go through my parents’ struggle to figure out what they meant. Getting into elite residency programs regardless of sky high STEP scores is near impossible—even if you’re a born American citizen.

It’s actually almost worse if you’re an American citizen, because the automatic assumption is that you couldn’t get into an American medical school and that’s why you decided to go to an international medical school. I didn’t even bother with explanations when I was asked during residency interviews why I went to Pakistan for medical school—I knew the idea of an existential crisis just wouldn’t pass.

I don’t know how far it can hold you back. I’m in the process of applying for Fellowships, so I guess we’ll see. But honestly, if anything I’ve learned it doesn’t even matter anymore. When universities become brand labels you know something has gone wrong. It should always have been about the love of knowledge and education for itself. When I say I stepped off the course of greatness, it was the course of gold-labeled academic institutions pathing my way and resume.

LVR: Thinking about the struggles you went through in Lahore, was there something (or things) you learned that enabled you to think about your time as a resident?

SM: If I’m going to be completely honest here, I hadn’t realized how much the stigma of being an IMG would hurt. Somehow, I’d become foreign in my birth land. I was falling into an ABCD (American Born Confused Desi) label that I had always considered myself to be above. Lesson to be learned: never think you’re above anything because it will come back to bite you in the rear. Something I’ve learned is that I’m so utterly grateful for where I am in life now. I think this may be the first time in my life I’ve been able to say that, and that’s truly liberating and freeing. I think it was the Iranian American artist, Shirin Neshat, who said that every migrant has their own story across a borderline. As much as I’m done with cliched immigrant stories, I guess I have my own now as well. I just hope that’s not what it’s reduced to.

LVR: Can you explain how Sonnet 105 shifted your vision and what that means to practicing medicine, relating to patients, or how you want to live your life?

SM: Oh, this is a beautiful question. I used to like sketching/painting growing up and was decent at it. I started sketching with words at one point and was like what would it be like to paint the world in words-how crazy would that be. There was this exhibition at the MOMA or MET, I don’t quite remember which one, and the artist had put together these gorgeous natural scenes with newspaper clippings. Anyway, poetry ended up being the crazy (and obvious) answer.

In Sonnet 105, Shakespeare plays with the reader. He’s saying one thing and doing something else. He makes you hold these paradoxes together. The shift came from my mind being blown that I had read this poem initially and taken it at face value, and suddenly I saw what he was saying was completely contrary to what he had written. It was a physical mental shift, if such a thing exists. And I think that’s one of the greatest achievements of the human imagination: holding paradoxes together and making them work. That facet of imagination is important for a lot of things including creativity and medicine.

LVR: Is there something you wish more people knew about you?

SM: I’m sitting outside on our deck as I’m writing this and the one thing that’s coming to my mind is that I love leaves. Is that allowed to count? All kinds of leaves. Rippling in the summer air or on fire in fall or buried under winter snow.

LVR: Where would you like to be in five years?

SM: Hopefully, I’d like to be a staff neurologist with an academic institution. I hope I’m still writing but I’m not sure whether I’ll be publishing again. I’m at a phase where I’m still trying to figure out if I’m any good at this or whether I should hang the towel and call it quits and only keep writing for myself. I don’t know how to gauge my own writing and I’m still waiting for that “aha, maybe you’re decent at this” moment.

LVR: Did studying the science of medicine or philosophy and literature cause you to question your belief system? Do you feel that science dispelled any of your spiritual beliefs or vice versa?

SM: I’m sure they’ve influenced each other in more ways than I’m cognizant of, but it’s never been a head-on-head collision for me. A part of it may be because I was born into a family of physicians and a practicing Muslim household.

Evolution was a fact and I wasn’t even aware it was at odds with different religions until I heard about it from others. I knew about my father’s brain stem research before I knew there were ethical concerns with stem cell research. A normal family conversation could include science, religion, and literature, without clear distinctions. I guess when you grow up with everything kind of together it stays together?

Philosophy and literature are definitely in conversation with my belief system, but it’s emotions that lead to questioning of my belief system. Doubt, and I’m not sure if faith can stand in isolation of doubt, stems from emotions. It makes more sense to hold doubt with emotion instead of arguing with a philosophical argument ultimately born of emotion. I tried that for a long time, with often disastrous results, and it just didn’t, doesn’t, work. At least, that’s how I see it.

LVR: Do you feel that most of the historically Black schools that were shut down led to fewer clinicians of color? 

SM: I would definitely assume so but need to research more into it myself. A lot of this information was honestly surprising to me as well. It’s something that I only started looking into while putting together this essay collection. It’s just another example of how racism in that age entrenched almost every institution to a fundamental level. As for the divergence from public health, there’s an article by Dr Thomas Duffy in the Yale Journal of Biology and Medicine^.. Duffy says it’s the hyper-rationalization of the German inspired model that caused an imbalance in the art and science of medicine.

LVR: You write so eloquently about literature. Did you study writing?

SM: I saw that you recently graduated from the New School and read your article in CNN—congratulations, that’s so very inspiring. I was unsure of whether to major in English or History in undergrad. It was hard to decide which one to major in, because the University of Michigan has such amazing faculty in both departments. I took a medieval English literature course with Dr Theresa Tinkle. We talked about Sonnet 105 during her office hours and it was a bright shift in my vision. The history professors were as amazing. I ended up studying and majoring in history but that also required a significant number of English classes, so it panned out well in the end. I tried to take classes that overlapped both.

LVR: You dedicated your book to Dr. Zia Ullah, who I see died from Covid-19 (so sorry). Could you tell me what he meant to you? 

There were a few people in medical school in Lahore who didn’t make me feel like an outsider. Dr Zia Ullah was one of them. He was Head of the Medicine Department and had faith in me. He’d trained in England and moved back to Lahore in the hopes of bettering a home. I ended up graduating at the top five percent in my class and it was in part due to the passion in medicine he inspired in us. I was living in my new resident apartment in Detroit when one of my medical school friends messaged to let me know that Dr Zia was on the vent. I didn’t have a dedication to my collection at that time, and added it after he passed away. He deserved so very much, and for the hope of nostalgia and goodness, I hope he got a fraction of it.

A Pandemic In Residence is out now with Belt Publishing. Selina Mahmood was born in Detroit and serves as a second-year neurology resident there. She has also lived in Lahore, NYC, and Ann Arbor. She graduated with a major in history from the University of Michigan in a previous life before pursuing medicine. Her work has appeared in The Manhattanville Review, Squawk Back, Blood and Thunder—Musings on the Art of Medicine, The Conglomerate, and others. She has also blogged book reviews on HuffPost and worked as a reader for Boulevard, Bellevue Literary Review, and Frontier Poetry. When she isn’t busy diving into the brain, she’s trying to swallow her way out of it.