Red Velvet

Jason M. Nagata, MD, MSc

Fam Med. 2018;50(5):392-393.

DOI: 10.22454/FamMed.2018.906890

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A thick swirl of cream cheese frosting and a speckling of maroon sprinkles coat the red velvet cupcakes our clinic coordinator has brought to celebrate her birthday. I avoid this dessert by heading over to see my first patient a few minutes early. “Ashley” is a 24-year-old female with anorexia nervosa who I have followed for the past year. I know how she would react to the situation. The cupcake: 250 calories. The frosting: 100 calories. The sprinkles: 5 calories. Ashley would fear the corpulence caused by these cupcakes and refrain from consuming them at all costs, unless, in a moment of unrestraint, she splurged and then purged.

I flash back to the first time I met Ashley at the beginning of my adolescent and young adult medicine fellowship. She sports a teal track jacket, tight spandex leggings, and a black athletic headband controlling her wavy brown hair. She paces at the far end of the room as though warming up for a marathon.

“I ate three meals every day this week,” she announces. She hands me her smartphone report where she has dutifully recorded every morsel of food she consumed in the past 7 days, including her lunch today: four almonds and three edamame soybeans at 12:24 pm.

“Am I allowed to swim now? If you let me, I can even make it to the pool after this appointment.”

I review her vital signs. Despite her best intentions, she has lost two pounds in the past week, and her resting heart rate has dropped to 43 beats per minute.

“I’m sorry,” I say, “your heart rate is dangerously low today.”

Ashley’s smile fades. Her eyes fall to the floor.

We sit in silence.

“I think it would be safest if you were monitored in the hospital.”

She gasps for air. Her eyes pierce mine in search of an escape.

“Michael Phelps’ resting heart rate is in the 30s,” she snaps. “I don’t need to be in the hospital if he doesn’t!”

I hear my own ferocity in her voice and am stricken by the uncanny parallels in our life stories. We both competed in the 100-yard breast stroke with our high school and college swim teams. Ashley’s athletic success as a state champion, nationally-ranked swimmer, however, had become intertwined with a need to control her food intake and exercise, ultimately leading to the development of her eating disorder. She restricted her food intake to 400 kilocalories per day and some days consumed nothing but water.

“Plus, I have midterms for my biology class this week. I have to maintain my A!”

We also share the same career aspirations, as she is enrolled in prerequisite classes for medical school. Although I had been encouraged to pursue medicine at an early age by my Asian tiger parents,1 once I committed to becoming a doctor, my identity was consumed with a rigid work ethic in pursuit of academic success. During medical school, I compulsively studied in the library all day, skipping breakfast and lunch and then binging late at night at the campus taqueria. By the end of medical school, my life revolved solely around success in the residency match.

However, at the culmination of the residency selection process, my life spiraled out of control. The internal medicine clerkship director called my cell phone on the evening before my first residency interview, while I was at a recruitment dinner, to inform me that I had failed my subinternship rotation. Knowing I was not matching into internal medicine, I had fallen short, focusing instead on my residency applications. How could I have made such a critical error? Now my graduation and eligibility to match were jeopardized.

I also faced the monumental task of coming out to my family2,3 during the winter holidays, given that my boyfriend and I were planning to move in together after the match. My voice faltered and sweat drenched my face each time I revealed the news to a new family member. A week before my final residency interviews, I developed a massive stress ulcer leading to a gastrointestinal bleed.4 After missing my remaining interviews, being unable to eat any solids by mouth, and losing 25 pounds during my month-long hospitalization, I hit rock bottom.

Sitting with Ashley and reflecting on my own tumultuous hospitalization, I think about what approach would most resonate with this smart, logical, goal-oriented young woman. I methodically review her past medical records until I find her resting heart rates before the onset of her eating disorder, which were significantly higher than today. As compassionately as possible, I share this information and explain why she needs to be hospitalized.

“Nobody ever told me that before,” she says, and starts to sob. A reluctant nod indicates that she agrees to the hospitalization.

From my first encounter with Ashley, I learned that the physician’s and the patient’s stories are often intertwined. Finding the common ground and valuing these connections can lead to a stronger doctor-patient relationship and shared decision-making.

My stress ulcer was a wakeup call to prioritize myself and my health, not my work and accomplishments. Faced with my own mortality, being with loved ones was suddenly all that mattered. With the help of family and friends, I slowly recovered, made up my subinternship rotation, and matched at a residency program that encouraged life balance.

A year has passed since Ashley’s hospitalization. Today, her vital signs are stable and her weight has been restored to her previous growth trajectory. We discuss the gradual reintroduction of physical activity, and she chooses to participate in yoga for 30 minutes this week. By the end of clinic, after seeing 10 back-to-back patients, I feel hungry. I eat the last cupcake, thank our clinic coordinator for the special treat, and head off to swim team practice.


Special thanks to Jacqueline Genovese and Peter Lessler for feedback on this work and to the Medicine and the Muse Program in Medical Humanities at Stanford University.

Funding support: Dr Nagata is a fellow in the Pediatric Scientist Development Program (K12HD00085033), with funding from the American Academy of Pediatrics and the American Pediatric Society.


  1. Nagata JM. The battle hymn of the tiger child. JAMA Pediatr. 2015;169(12):1087.
  2. Nagata JM. Until death do us part. J Palliat Med. 2017;20(1):97-98.
  3. Nagata JM. Challenges, health implications, and advocacy opportunities for lesbian, gay, bisexual, and transgender global health providers. Glob Health Promot. 2017:1757975916677504.
  4. Nagata JM. The patient rotation. JAMA Pediatr. 2014;168(8):697.

Lead Author

Jason M. Nagata, MD, MSc

Affiliations: Division of Adolescent and Young Adult Medicine, University of California, San Francisco.

Corresponding Author

Jason M. Nagata, MD, MSc

Correspondence: Division of Adolescent and Young Adult Medicine, University of California, San Francisco, 3333 California St, Suite 245, Box 0503, San Francisco, CA 94118. 626- 551-1932.


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