Showing posts with label Tempeh. Show all posts
Showing posts with label Tempeh. Show all posts

Thursday, April 16, 2009


So you probably all know the old saying about what happens when you assume, but just in case anyone is coming late to the game, I'll remind you: when you assume, you make an ass out of u and me. Nowhere is this truer than in medicine.

My 5 year-old son has a life-threatening allergy to eggs and peanuts. His allergist told us ominously a few years ago, "Kids with known peanut allergies have a life-threatening event every 4 years on average." Ever since then, we have been holding our breath, thinking that we are past due. We have been extraordinarily cautious since learning about his food allergies when he was only 4 months old. We have no peanut-containing products in our house ever, period, and have eggs at home, but keep them far from my son and cook with them only under very controlled situations (since his egg allergy is less severe). He attends a "peanut-free preschool." We have Benadryl and Epipens in every bag and car and never leave home without them, even to go for a walk down the street. We have stopped flying airlines that serve peanuts. Everyone in his life, from family members to friends to our nanny to his preschool teachers, knows that we have to read the labels on every food every time. Most of them are far more conscientious about this issue than I would likely ever have been before it touched my own life, and many have gone to great lengths to learn where to buy or how to prepare foods for him safely.

My son's preschool teacher is one of the most endearingly over-cautious individuals of the bunch. She will often dash outside on mornings when I am dropping him off to make sure that the candy they will be using for the buttons on a snowman is safe for him, even though the ingredients are literally "sugar and Blue #4". Our nanny is also meticulous about keeping him safe, having chased after me more than once when I left his Epipen behind as I headed out to the car with him, and having noticed that the same cookies we have been buying every week for 2 years, which have always been safe, now say "May contain peanuts". I really don't worry about his safety when he is in their care, and they are pretty much the only two adults I ever leave him alone with for any length of time as a result.

Yesterday was the 4th birthday of one of my son's preschool classmates, Anna. Unbeknownst to me, Anna's mother had asked their teacher weeks ago if she could bring cupcakes. The teacher told her no, not unless they were made without eggs. Apparently she also inquired about bringing in a variety pack of mini candy bars, which his teacher also rejected not only because of his allergy, but the fact that the preschool is officially peanut-free and many of those would surely contain peanuts. Anna's mother, determined not to give up, went to Costco and bought a big container of gourmet jellybeans, which she divided into little snack sacks for each of the kids and sent to preschool in Anna's backpack. Their teacher helped Anna to pass them out to each of the children, including my son, at the end of class.

I am in clinic on Wednesdays, so our nanny picks up my son. When she got there, he had his head down on the table and said he didn't feel well. She noticed that his bag of jellybeans was mostly full, unusual for my son who is a sweet fanatic. He had eaten only a couple of them, he told her, since he felt kind of sick to his stomach. But then he asked to be able to stay and play with his friends in the adjacent play area, so she forgot about it. After playing for awhile, he came back to his goodie bag and ate a few more jellybeans. Within 5 minutes, he was complaining of nausea and saying he needed to put his head down. Noting that his "nausea" coincidentally occurred as they were being asked to clean up, she didn't make much of it. By the time they got back to our house, less than 2 miles away, he was coughing and wheezing, complaining that his throat was tight, and dry-heaving. She promptly gave him Benadryl and called my cell phone, Epipen in hand. By the time I answered 3 rings later, his face was noticeably swollen. She knew he was having an allergic reaction, but to what, she said, she had no idea. He hadn't eaten anything that should have peanuts or eggs.

When I talked to my son about what had happened later that day and asked him what he thought had made him sick, he said without so much as a pause: "those speckled jellybeans I ate at Anna's party". When I asked him how he knew, he said, "the package didn't have any words on it, which means there could always be peanuts," a rule I have repeated over and over to him for the last 5 years of his life. At least he has been listening.

Ultimately with treatment, my son was fine, but how on earth did this happen? My son is extraordinarily aware of the seriousness of his allergies and routinely surprises me with his own cautiousness about foods that didn't come from our home. He was in the care of multiple people who know him, love him, and are frankly paranoid of messing this up. I called his preschool teacher later that day, quite distraught, to tell her what had happened and to let her know that he was fine, in case she had already heard through the grapevine. She had and had immediately called Anna's mother, who checked the label of the jellybean container and confirmed what I already knew: peanuts, plainly listed among the ingredients. In fact, one of the gourmet jellybean flavors was PB&J.

It turns out that Anna's mother JUST ASSUMED that jellybeans would be safe, so she never actually thought to read the label or bring the original container to preschool. Understandable. Who would suspect jellybeans might have peanuts in them? I wouldn't. His preschool teacher JUST ASSUMED that Anna's mother must have checked the label since she had asked so many questions about which foods were safe to bring to school for Anna's birthday, so she never actually asked her whether the jellybeans were definitely peanut- and egg-free. Understandable. Anna has been in preschool with my son for months, and his allergies were widely known in the class. My son JUST ASSUMED the jellybeans were safe since Anna had brought them, and his teacher had handed them to him, so he never actually asked. Understandable since he is just beginning to read and has learned he must rely on a few trusted adults, one of whom is his teacher, to tell him if a food is safe for him to eat. Our nanny JUST ASSUMED that the jellybeans must be okay for him since a friend's parent had brought them and his teacher had let him start eating them, so she never actually asked to see a list of ingredients. And our nanny JUST ASSUMED that, because he had already eaten some and was apparently okay that, when he began demonstrating the earliest signs and symptoms of anaphylaxis, which she knows very well, it could not have been the jellybeans.

This could all have been prevented had anyone NOT JUST ASSUMED. This is why two OR nurses count sponges at the end of a case, to make sure none get left inside a patient. This is why two oncology nurses independently verify the chemotherapy dose the medical oncologist has written before giving it. This is why the blood bank requires that the nurse check the hospital bracelet of the patient she has been caring for all week and match it to the name on the bag of red cells before starting the infusion. These policies realize explicitly that when you assume, it is only a matter of time before you make an ass out of u and me. And if you're a health care worker, you might kill someone in the process, too.

As I tried to think of medical examples for this post, I was struck by one thing. All of the ones that quickly came to mind involved nurses. The reality is that, on this issue, they are light years ahead of doctors, who may have historically been too proud to acknowledge their potential for error...and who in many cases remain so. The attention recently given to the alarming prevalence of medical errors has led to some positive changes in physician behavior, such as surgeons initialing the correct side of surgery while a patient is still awake before a planned amputation or joint replacement, for example. But we still have a long, long way to go before these double-checks are built into every important medical decision. And finally, let us remember that all of these practices arose from the terrible tragedies of patients, most victims of health care workers JUST ASSUMING.

If you are a medical student or a nurse or a physician in training, there is a lot of unspoken pressure to just assume that someone "superior" knows what he or she is doing and not to question that person. If you are that someone "superior," there can be a lot of unspoken pressure to appear to know what you are doing and not stop to question yourself. Please, for everyone's sake, don't assume anything. Stop to question. I can promise you that it is only a matter of time before your questioning will save someone's life.

Wednesday, April 1, 2009

Finding my net

My husband deployed 3 weeks ago today. Before he left, I said a silent prayer that the following 3 things would not happen while he was gone:

1. Sudden demise of a major, cannot-live-without-it household appliance
2. Vomiting illness
3. An ER visit for me or my kids

In those 3 weeks, we have had 2 distinct vomiting illnesses tear through the entire household. One of them, in my 3 yr old, was severe enough that we wound up in the hospital with a very scary clinical situation: dehydration, distended tender belly, anion gap metabolic acidosis, elevated LFTs, and alarming lethargy. Fortunately, after lots of fluids and antibiotics, she is now back to normal. Oh, and did I mention that our washing machine began a slow, spiral of death within 12 hrs of my hubby's departure and ultimately took its last breath in the midst of wave two of vom-a-rama, leaving me to wash about 2 dozen loads of vomit-soaked bedding and clothes in total in our tub, wring them in the washer (which would still spin until close to the end), and then dry them...ALL NIGHT LONG on more than one occasion.

Deployment is really not going so well for us. Or so I thought.

But today, I had a fantastic day. Why? I bought a new washing machine over the weekend, and I did four loads of laundry today. Ordinarily, that would not be cause for celebration, but today I felt like whistling a little tune as I watched our clothes gyrating around. Even they looked happy in there. I could have sworn my sweater was flirting with my jeans. And no one vomited. In fact, no one has vomited for 4 days now. And, although I was in a hospital today and my clinic ran hours late, I was on the right side of the stethoscope. Amazing how a little badness can make a whole lot of ordinary look pretty fantastic.

But the real reason that I am feeling on top of the world is that I have found my safety net when I was beginning to think I was flying without one. In the midst of illness and household crises,not to mention general deployment sadness, we were invited to dinner by other Navy families (thanks, KC!) and preschool families we didn't know especially well before. I had acquaintances who heard about what was going on show up unannounced at our door, asking to take our vomit-soaked laundry to their house to wash and dry and return it to our home (!). I watched in awe as our clearly exhausted nanny stepped up with a smile and came to the ER after working a full day with vomiting kids to take my non-sick kids home for dinner and bed so that I could focus on taking care of my desperately sick one without guilt or distraction. And I had busy family members volunteer to drop everything and get in the car or on a plane to come to us as fast as modern transportation would allow if I said the word. Suddenly, I feel strangely lucky that my husband is deployed. Surely these kindhearted, generous friends and acquaintances and relatives were out there all along, and I could have seen them if I had looked hard and long enough, but it took deployment and all the minor crises that ensued to bring them into focus for me. It has dawned on me how much a little nugget of goodness can resonate with someone who is in a crisis, however defined.

Today in clinic, I saw an elderly woman with newly-diagnosed metastatic breast cancer. Through a series of unfortunate self-fulfilling medical prophecies, including misreading of a CT scan and erroneous interpretation of pathology slides, she had been told that her cancer was widely metastatic, required urgent, very aggressive chemotherapy, and that she would almost certainly die within 6 months regardless. I had the distinct pleasure of telling her that while she does have metastatic cancer, it involves only a few spots on her bones, appears biologically quite indolent, and should be easily treated with one pill a day that won't cause nausea or hair loss or any of the things she fears terribly. As she teared up for the first time, about 30 minutes into our visit, I took her hands and said, "Listen to me. It is far more likely that you will die WITH this cancer than OF it. You are going to live for many years to come." It was one of those moments that every cancer patient coming to a large medical institution for a second opinion (and every oncologist seeing such a patient) silently dreams and prays will come to pass, but which very seldom does. Today, she and I shared a moment of joy that was like nothing I have ever experienced in my life except at a birth. In a way, it was a kind of birth. It was her life, unwittingly stolen by a devastating comedy of medical errors, being dusted off and handed back to her. At the end of our visit, she said to me, "I have had people coming out of the woodwork since this diagnosis making such offers of help to me and my wouldn't even believe it, if I told you some of stories. And now, I feel on top of the world even though you confirmed I have metastatic cancer. Who would have thought such bad news could sound so great? Weird. I know that probably doesn't make sense to you at all."

Actually, today, it makes perfect sense.

Monday, March 9, 2009

Let me know if you need anything...ok, how about right now?

So, it's almost here. We've known it was coming for more than 6 months, but in less than 48 hours, my husband will be deploying for 5 months, leaving me to manage the madness of 3 kids under age 5, two part-time physician jobs, and a home (can someone remind me why we thought a half-acre of grass was a good idea?).

We recently had a few families over to dinner. They are dear friends--originally the parents of our kids' friends from preschool, now our close friends in their own right. They live 5 minutes away. As they were leaving after dinner, a few weeks before my husband was to deploy, one of the women said to my husband, "Well, if we don't see you, stay safe" and to me, "Let us know if you need anything." My heart sank, and my husband immediately saw it on my face.

Now, I'm not complaining...well, not that much anyway. Believe me, I know it could be waaaaay worse. He's only going for 5 months, not the 12 or 15 month deployments that Army families cope with all the time. It's pretty safe, as deployments go. We'll even be able to talk on the phone for about 20 minutes once a week. And, most of all, I fully expect him to come home to us. At some point, he won't be in the Navy anymore, and all of this will be behind us.

But the fact of the matter is that I will definitely need things. When people say, "Let me know if you need anything," the implication is that you probably won't, but just in case, you know how to find us (and we won't be finding you). The fact is that needing things is not the exception; rather it is the rule during deployment. I need things right now, and he hasn't even left yet. Like someone to babysit my kids for a few hours so that I can have a date with my husband where we finish sentences (or do our taxes), someone to help me cook and freeze a bunch of meals to decrease the evening madness, someone to invite us to dinner on the sad evening of d#1 of deployment, and most of all, someone to reassure me that I can do this, we can do this, and we will all get through it.

I have been giving "Let me know if you need anything" a LOT of thought since then. As far as I can tell, we only say it when it is clear that help will be needed...and a lot of it. Someone's husband dies: Let me know if you need anything. Someone's baby is born prematurely and is in the NICU: Let me know if you need anything. Someone loses his job: Let me know if you need anything. And, most relevant to us, when we are the bearer of catastrophic medical news: Let me know if you need anything.

If these words make it to the antechamber before your lips, STOP THEM RIGHT THERE! This is probably a situation where the person in front of you needs not just anything, but everything. I have decided to banish the phrase from my vocabulary and instead make a concrete offer. She can say no or barter for something different, but at least she knows I expect she will need help--it's not a sign of weakness and not an exception. If she wants to refuse it, she is free, but I won't make it easy. From here on out, I'll be saying "I'd like to bring dinner tomorrow night for you and the kids. Is 5 o'clock okay?"

Friday, February 6, 2009

Could I get a little Zen here?

My kids have a book I love. It's called Zen Shorts, and it's just that: a series of short stories, each with a Zen message. (Note: we are not particularly religious in general and completely non-Buddhist, in case that matters to anyone.) One of these short stories includes a well-known parable from Zen Buddhism. It goes like this. A young monk and an elderly monk are walking along. They encounter a high-class woman stuck at one side of a big mud pit fretting about how she will get across. The elder monk picks her up, carries her across, and gently puts her down on the other side. She is quite unpleasant to both of them, complaining all the while, and never says a word of thanks. The elder monk walks on silently as he did before. The younger monk ruminates on what happened for the remainder of the afternoon as the two monks continue their journey, marveling at how the woman could be so rude and disrespectful and asking why the elder monk didn't just put her down. Finally the elder monk says, "I put her down hours ago. Why are you still carrying her?"

My kids love the book, so we read the story often, and I have a Eureka! moment every time. THAT is how I want to be, like the elder monk. I have to cultivate this Zen thing. No, wait, I know, even better: maybe I'll even BECOME A BUDDHIST!!!

But the sad reality is that I am SOOOO not Zen. I am the young monk. No...worse. I am the anti-Buddha.

I have an extraordinarily hard time letting anything and anyone go. I have a lifelong tendency to accumulate clutter in my house and office--not DSM-qualified hoarding or anything, but real clutter--and in my mind. The sad fact of life as an oncologist is that yes, there are many people we save, and yes, we've come a long way, especially in breast cancer which is my specialty, compared to 10 or 20 years ago, but we still lose a lot of people. I remember the name of every single patient who has ever died in my care--all of them, even my patients in the ICU as an intern--and, in most cases, the names of their spouse and kids and various random facts about them, too. I don't know if this is because I doubt myself and wonder whether I could or should have done something differently that might have saved them. Or if I actually have too much empathy for patients and families. Or if that's even possible. All I know is that I take every death very much to heart. And, as an oncologist, if you're still carrying patients long after you should have put them down, you are in for real trouble.

Although I suspect that most of the readers of this blog are in fields other than oncology where death is fortunately not a regular occurrence, I wonder if and how you put patients down once you have done your job of carrying them across. When you have made mistakes, do you let them go? If you have lost patients, can you put it behind you? And if so, how do you do it? I know we don't have a doctor-patient relationship, but, please, can someone prescribe me a little Zen?

Tuesday, January 13, 2009

Healing at home

My kids' preschool teacher, Miss Amelia, is the kind of mom dreams are made of. She has 4 kids ranging in age from 2 to 10, all of whom are being homeschooled and come with her when she teaches two mornings a week. She lives 2 hrs away in the country but somehow manages to get herself and 4 kids ready and make the drive to school to receive her class of 8 preschoolers at 9:30am on the dot. She is never late. Her 4 kids always have creative, healthy, homemade lunches. They are intelligent, respectful, cooperative, helpful...miraculous. Her 10 year old daughter oozes patience and sweetness and wisdom beyond her years. One morning, my 4 yr old son got out of the car and immediately started wailing because he had forgotten to bring anything for show and tell. My systolic pressure shot up by about 20 points as I tried to figure out how I could end this scene without driving all 3 kids back home to retrieve a dinosaur from our living room. Meanwhile, the 10 year old sweetly said, "I'm sure we have something in our class treasure box you could use for show and tell. Would you like to look in the treasure box? Ok, it will be our secret, but only if you stop crying..." As he wiped his eyes and wandered off with her, walking on a cloud, I stared in amazement. She is her mother's daughter.

A few days later, I decided to take stock of how I was doing as a mom by sitting back and observing my own kids' behavior. Unfortunately, in the span of an afternoon, I heard my 5 yr old son telling my 3 yr old daughter, "I am closing my eyes and counting to 10. If ALL of those toys I just cleaned up aren't back in the toy box again when I open my eyes, we are not going to California next month..." or worse, my 3 yr old telling her teddy bear, "No, I can't play right now. The house is a mess, and I am busy!" with a familiar tone of irritation. Yikes! I think this reap what you sow business is the real deal.

This past weekend, I came down with a terrible cold. My kids had a friends' birthday party to attend. They had been looking forward to it all week. As I sat there coughing and feverish on the couch, I had to tell them I couldn't take them to the party because I didn't want to get all of the party guests sick. I braced myself and prepared for the fallout--here come the tantrums, I thought. They looked at each other, then walked out of the room silently. Two minutes later, they reappeared. My 5 yr old son was lugging a huge flannel quilt and a cup of water, and my 3 yr old daughter came bearing her favorite stuffed animal and her blankie. Together they worked, their tiny faces concerned but reassuring, their body language unhurried, gentle, and kind, to wrap me in the king-size quilt. My daughter put her bear and her blankie under my chin, and my son pulled the coffee table a little closer so that I could reach the cup of water without having to get up. Then before going off to play quietly with her brother, my daughter kissed my hot forehead and said, "Shhhh, I love you. You'll feel better soon."

And she was right. I did feel better. For all my shortcomings as a mother, and there are many, I am teaching my kids by example to be healers, at work and at home. For that, I am grateful.

Wednesday, December 24, 2008

Getting in the sterile field

This is an old story, very unexpectedly resurrected by a near-stranger. A few years ago, as an oncology fellow, I was on an outpatient "float" rotation over the Christmas holiday week. What I thought this meant was short hours, no call, and no eternal rounding on the inpatient service. Hooray! What it actually meant was that all of the attendings were on vacation, so I was double-booked or triple-booked with procedures on their patients to be done--tapping malignant effusions from this space and that one and instilling chemotherapy in some of them--and that I wouldn't eat lunch or usually even get to the bathroom during my workday for the entire week.

One of the patients I met that week was a woman I'll call Sara, a nonsmoker in her 40s with lung cancer and carcinomatous meningitis. She was getting intrathecal chemotherapy instilled into the Ommaya reservoir in her brain three times a week...and this week, while her attending was skiing in Colorado, it was my turn to do it.

As you can imagine, putting chemo into someone's brain is a tad unnerving. The sterile field is no joke. Enough said.

Sara was a delightful young woman but very scared of needles. Sara's husband was an extraordinarily hairy, extraordinarily affectionate guy. Though I had never met them before, it was obvious they were MADLY in love. They had been married for 7 years, as they told me in a giddy voice at some point, but they looked like honeymooners--nuzzling noses, rubbing each other's shoulders. It bordered on inappropriate for a clinic waiting area, but I figured: hey, she's got metastatic cancer; they can do whatever they want. I certainly wasn't going to say anything about all the physicality....

except that it was almost impossible to administer her intrathecal chemotherapy. Over and over, I would sit her up and prep and drape her upper half. At the moment of truth, dose measured, name and history number of the sticker double-checked against her hospital bracelet, syringe full of chemotherapy approaching, his big hairy hands would grip her cheeks through the drape, and he would plant a big kiss on her forehead and say, "It's just one more small needle, hon, and it'll be over in a few seconds" or "I love you so much. You are the strongest woman I know." On more than one occasion, he actually lifted the drape with those big furry hands and said, "Baby, how do you manage to look so beautiful without a single hair on your head?" He looked lovestruck every single time I saw him, as though he would die if she had to be draped and therefore out of his sight for another minute. Over and over, I explained that this was the brain we were dealing with. Over and over, I explained the sterile field and how you really couldn't get in it, seriously. Over and over, he couldn't resist--or, more precisely, couldn't resist her. Every single time I saw her that week--three visits in all--it took at least 3 tries to seal the deal and instill the chemotherapy into her brain. Though I will admit that it drove me crazy at the time, particularly on the busiest days, I always walked away from those visits kind of smiling to myself.

I learned 2 or 3 weeks later from Sara's attending that she had passed away. She was sitting on the toilet one morning and just fell over dead. Her husband was so grief-stricken by the realization that she was gone that he just held her on the bathroom floor until she was cold and it was dark outside, and then called 911. By the time the ambulance came, she was clearly long-deceased, and they did nothing more than give her (and the back, lying on the stretcher with her) a ride to the hospital. Apparently it violated their policies, but apparently they couldn't say no to him. Huh.

Though I didn't know either Sara or her husband well, I was absolutely overwhelmed by their love. I have cared for a lot of cancer patients and their families at the end of life and witnessed love under the magnifying glass of impending death more times than I can remember. But Sara and her husband were different somehow. Their love was truly unconditional, timeless...raw and unstoppable.

I'm not sure why, since I really didn't know him, but I decided to write him a quick condolence card. It was a completely nondescript card from a box of generic condolence cards--a sad reality of life as a medical oncologist that we buy the bulk condolence cards in packs of 10 or 25 the way others buy their generic thank you cards--but it's the thought that counts, right? As I wrote and reflected on why I had been driven to write to this near-stranger, the words just kept coming. It ended up having 2 or 3 extra pages (all on basic white paper from a Staples 500 pack) added, folded up inside the card. Unleashed, the letter morphed out of my control--as I recall, there was talk of great loves and young life inexplicably cut short and spirituality. I never got any reply. I hadn't really expected to, but I nonetheless wondered if I had overwhelmed him (did he even remember who I was?). Eventually I let it go and kind of forgot about the letter and Sara and him in the deluge of loss we face in oncology.

Years passed. On a random busy December day, I was in clinic and one of the front office staff came to get me, saying I had a visitor. It was Sara's husband. I didn't recognize him at all at first. He had cut his previously longish hair very short and shaved off his full mustache and beard since I last saw him. He looked tired and old for his apparently middle-aged age. As I approached him, I searched his face for clues of who he might be, not wanting to deal with the awkwardness of confessing I had no idea who he was. Then he stuck out his hand--the hairiest hand I have ever felt--and it all came rushing back. "You're Sara's husband. How are you doing? I hope you're not here as a patient..." (it is a Cancer Center after all).

He proceeded to ramble, standing right there in the lobby, how much he had loved Sara, how much he treasured that letter, how much it had quieted his mind that a stranger could see how much he loved Sara, reasoning that if a stranger could be so moved by his love for her, then surely Sara must have known how much he loved her, and how that was all he could ever ask for on earth. Then he said, "We always had a bunch of photographs and knick-knacks on our hearth. After Sara died, I cleared them all off. The only thing up there now is the urn with her ashes...and your letter. Anyway, I just came to tell you that." Then he turned and walked right out the front door.

I was too dumbfounded to say anything or walk after him, but in mind, I said to him: You just got in the sterile field all over again.

Tuesday, November 18, 2008

How to get a part-time job in medicine

I got married near the end of my last year of residency. When I started medical school, in fact when I started residency, I hadn't yet even met my husband, and I didn't have any of the 3 kids I now have. That's probably a good thing because I would surely have talked myself out of the specialty I really loved into something more "family-friendly". There's nothing wrong with family-friendly, mind you. I always read the classified ads in the New England Journal just out of curiosity, wondering whether there are more part-time jobs cropping up as women, who more often work part-time than men in general, represent a greater share of young doctors. So far, I don't think much has changed in the job advertising sphere.

When I happen to have a bad day at work, which is fortunately rare, I permit myself to back up and take a different fork in the road. In my alternate life, maybe I became a dermatologist, where "full-time" seems to be 4 days a week...but who works full-time anyway? Or infectious diseases, where every other ad seems to start "Full-time or part-time". Ah, travel clinic...seeing some healthy people and getting them ready to travel to exotic locales. Lest fear of boredom be a factor, keep in mind that the occasional traveler will come home with a fever of 40.8--is it malaria? Dengue fever? Ebola? See, that would spice things up. And clinic finishes at 3p.

But snap out of it. I became a medical oncologist, had my first baby midway through my second year of fellowship, another baby at the end of my third year, and a third baby about a year and a half into my first "real job". At some point in late second year when other fellows were beginning to do their job talks and interviews, it dawned on me that I didn't want to be away from my son and his future sibs for 60 hours a week. I didn't want to miss first steps or first words or first anythings. It didn't feel right to me that someone other than me--indeed, someone I hadn't even met yet--would be there for more of my kids' waking hours than I would, and that's exactly what working full-time meant.

I starting looking through journals, online, anywhere for part-time medical oncologist jobs. Zip. Zero. Nada. I even tried, and all I got for combining "part-time" and "oncologist" is: Busy oncologist seeks part-time front office staff. Bummer. Oh, and did I mention that I had kind of subspecialized to one particular type of cancer. And can't move out of the area because my husband is in the military, unless they tell us to move, in which case I have to pick up and leave instantly. When I told people that I wanted to work part-time, and no I didn't want to just take a hospitalist job, and no I didn't want to work in an urgent care, and no I didn't want to review charts for utilization management or do life insurance physicals for a living, and yes, I did plan to work as a doctor, and yes, I did plan to work as an oncologist, and yes, it had to be in this area, they just looked at me with some blend of pity, empathy, disbelief, disdain, and said, "Well...good luck."

Six months later, I was agonizing over my choices: one job working 3 days per week as an academic oncologist, one job in private practice oncology working 2-3 days per week, and one job in oncology public health/health policy working anywhere from 2-4 days per week. All of them were within 30 mins of my house. All of them were in the particular subspecialty of medical oncology that was my interest. None of them was advertised. None of them existed when I interviewed. So, what's the deal?

If you happen to fall in love with a specialty of medicine that doesn't bear the family-friendly label, here are your career choices at the end of your training, assuming you aren't willing to compromise on the family side:

1. Let this specialty be the one that got away and pick something that's more family-friendly.
2. Train in your specialty, but work in a more general field with your specialty as your area of expertise (e.g. take a part-time internist job with an interest in pulmonary disease--a big group private or academic practice may be glad to have one internist who likes to see all of the asthma and COPD folks, there are plenty of them, and is comfortable with critical care if patients get admitted to an ICU).
3. Move beyond the standard black or white career paths--academic or private practice--and look at jobs in the government (FDA, NIH, CDC, etc), public health, the pharmaceutical industry, hospices, and so on, many of which are more amenable to part-time employees.
4. Interview for your dream job, whether academic or private practice or whatever, and give them enough time to decide you are their dream candidate. When they start trying to recruit, play your part-time card. Most will use salary or benefits to try to sweeten the deal. What you want is flexibility or fewer hours or whatever it is that you want. Take a deep breath, picture your kids clinging to your leg as you try to leave for work in the morning, and then speak up without apology. You will surely benefit from a part-time job if that's where your heart is, but there are also benefits to the employer, and you should point them out: cost savings (part-time employees generally accomplish more on a per hour basis than full-time employees and generally cost their employers less in benefits because fewer benefits are provided), greater loyalty (from grateful doctor-moms such as yourself who are committed to making part-time work work) and therefore less employee turnover, improved staff morale, and fewer absences from work (you can schedule the kids' well-child visits and your tooth cleaning on your days off, and , if you're lucky, some of their colds and vomiting illnesses might even occur on your days off). You will likely be pleasantly surprised. I interviewed for all of the jobs I mentioned above, and they were all full-time. After I made my priorities for recruitment known, all agreed to work with me to tailor a part-time arrangement. In the end, I actually created a hybrid of 2 of the part-time jobs I had negotiated, working a total of 3 days per week, and it has been wonderful.

Bottom line: If you assume it will be impossible to find a part-time doctor job in your specialty, it will be. If you assume it will be possible, then it will be.

Wednesday, November 5, 2008

Burying the message

We recently had an ant problem at home. After getting through the hot months without any real indoor ants, which are usually a summer problem in this area, we began noticing during a couple ants on the floor in late September, a little trail marching by the patio door, a few appearing under the sink...then full-on ant explosion. They were everywhere. Major ant problem. We made a valiant effort with the Trojan horse model, the little environmentally-sound childproof baits that are supposed to result in poison being carried home to the grand matriarch, then watched as our ants consistently walked a wide circle around them to get to the food remnants my 10 month old is eternally throwing on the floor. After a week or two, we gave in and called an exterminator.

A nice fellow came out, looked around, sprayed some stuff inside and out, then rang the doorbell again to give me the receipt. I thought the transaction was over, but it was just beginning. He also had a very long verbal list of suggestions of things to do to keep the ants from returning. It included removing all of the flowers from the beds adjacent to our home and sidewalk and replacing them with stone (or nothing), taking out all of our bushes whose roots might contact the home, removing the vines and other random vegetation touching our foundation, cleaning out the dishwasher filter twice a day and promptly cleaning crumbs, drips of juice, etc up when spilled, recaulking our kitchen counters and every other little gap in the kitchen, installing quarter-round moulding in several areas of the kitchen, emptying out our sandbox on the deck and powerwashing the desk, and "ideally" redoing our relatively new deck floor so that the gaps between the boards would not be so small as to provide a place for the ants to set up shop and build their nests. I'm sure I've forgotten some of them, but those were the biggies. When he started talking and told me that just spraying wouldn't be enough, we would also need to do a little work around our house, I thought, "Sure, of course, that's reasonable. He's going to tell me to try to mop the kitchen every day--I can do that, in fact, I'd like to anyway." Then the list started and went on and on and on. At some point in the list, I was amused, then kind of annoyed, and eventually came to a complete and final stop at hopeless. There was nothing to be done. We would have ants forever. So be it.

The next day in clinic, I heard myself giving a patient the list. It was a woman with cancer and a number of other medical problems, many of which were caused or exacerbated by lifestyle choices. I sensed that we had a strong connection, she was really listening for the first time ever, she seemed motivated and invested, and I had my in. This was my chance to really change her behavior. So I went for broke. I said she had to stop smoking, period. Her chemo wouldn't work as well if she continued smoking. Her breast reconstruction was more likely to be unsuccessful, from a vascular standpoint, if she continued smoking. If she survived the cancer she had, she'd be far more likely to develop another unrelated cancer if she continued smoking. She needed to eat less fat and lose some weight because we know that obesity is associated with a worse outcome, and a low-fat diet has been shown to reduce the risk of recurrence in a large randomized trial. And she should stop taking phytoestrogens--there were lots of them among her lengthy list of supplements. If she could manage to do an hour per day of exercise, that would be helpful too, and ideally, the program would include a half hour per day of the most vigorous exercise. Oh, and the other thing is...on and on and on. I saw her eyes glaze over the way mine did with the exterminator. I had her for a minute, then she looked vaguely amused, then she got a little irritated, and then she just got the zombie eyes and nodded in completely non-genuine assent. She had no intention of doing anything I asked. The requests were too numerous, too overwhelming, too unrealistic. The message--that she had the power to change her lifestyle and really impact her health in a positive way for the first time in her life--had been buried. In my enthusiasm, I had slammed shut the window of opportunity.

I saw another patient later that day who admits to smoking 3 packs a day, which probably means 4, and has for over 40 years. She also has a long list of medical issues related to lifestyle choices. At the end of the visit, I said, "I'd like to see you try to smoke less. Do you think there's any way you could cut your smoking back by one cigarette per day each week?" She said, "One less per day? That's it? Sure, I could probably cut out 2 or 3 without even missing 'em. You really think that matters, a couple cigarettes less per day, when I smoke 3 packs a day? Yeah, I can definitely do that. You watch, doc, I'll be down to 2 packs a day when I come back to see you in a couple months."

Sounds like a plan.

Saturday, November 1, 2008

"The health of the mother"

Considering that most of us probably have an opinion about a certain upcoming national event taking place on Tuesday, let me applaud us for having shown surprising restraint when it comes to talking politics on this site. A usual TV non-viewer, I know that I am dashing down from bedtime books with the kids to the couch every night now, eating up CNN with a spoon. I am off in la la land as I sit in boring meetings, wondering what the latest polls show.

But as a doctor-mom of 3, I am hopelessly behind. I frequently gush over movies I have seen over the weekend only to have people say quizzically, "You mean 'Walk the Line' that came out like 3 or 4 years ago?" Yeah, that's the one. I have made my peace with the fact that I will never catch up.

Anyway, I am ashamed to admit that I did not see the last Presidential debate (which took place over 2 weeks ago for those of you who are also 3 weeks behind on dictations and looking at 6 loads of laundry next time you can bring yourself to go to your laundry room) in real time. I recorded it to watch the next day--ha, ha, right! Anyway, I finally watched it tonight, before the election at least, and holy mackerel!

There is a moment in there where Obama and McCain are discussing abortion. Obama says, "I am completely supportive of a ban on late-term abortions, partial birth or otherwise, as long as there's an exception for the mother's health and life." McCain proceeds to offer his rebuttal and says IN AIR QUOTES "health of the mother", not once but twice. Here's a link to one video on youtube that shows just this brief exchange, rather than having to sit through the whole debate for those of you who were together enough to watch it in real time:

Whether you are Republican or Democrat or Independent, pro-choice or pro-life with or without conditions/exceptions, can any woman, particularly a woman in medicine, watch a potential future leader of this country put the "health of the mother" in air quotes during a mainstream media event watched by tens of millions of people without falling off the couch? I managed not to hit the floor, but just barely. And I'm posting at 1:30am because I cannot sleep for wondering the implications of such an attitude for the women of our nation.

Thursday, October 23, 2008

Generation M--what would Abraham Lincoln say?

So I was driving to work the other day, listening to NPR while checking voice mail on my handheld cell phone and eating a banana with a glass of OJ balanced on my thigh (and driving, remember) when I heard a story about Generation M. The M in this case was for multitasking. The story was about teenagers who do online research for their homework while listening to music on their iPods, surfing around on Facebook, and instant messaging up in the corner of the screen with a couple of friends. I pictured the kids in this story like those computer-game-addicted adolescents I see everywhere these days and thought to myself: "I am not going to let my kids do that." And then I looked down, noticed the steering wheel, the banana, the OJ, the cell phone, the radio, and the patient chart I was about to open on the passenger seat so that I could return a phone call from a referring physician during my drive...oh no, I am ONE OF THEM! My fruit and juice and cell phone are the low-tech, old-fashioned version of Generation M, Generation M for the not-quite-middle-aged.

I have to say that I love multitasking. On the one hand, I resent being so busy that I have to do 4 things at once to have any chance of getting a solid night's sleep. Kind of. The truth is, though, that I love that feeling of productivity, knocking 5 items off my To Do List simultaneously during my commute, getting a day's worth of errands done in one big sweeping geographic circle with no backtracking and no dead time. I might even be addicted to it. I suspect that many physicians share this perverse enjoyment of multitasking, and if it wasn't in their blood when they started med school, it certainly has been beaten into them by the time they finish their internship. Add to that parenting as a physician (or maybe parenting period), and it's easy to see how multitasking gets reinforced in all of us. We multitask, we get rewarded, we multitask more, we get rewarded more.

So, I'm not the only one addicted to multitasking and thinking about it. NPR apparently can't get enough of it, either. They have had 3 stories about it in the month of October. And they are alarming. One segment reported that multitasking on a cell phone while driving reduced reaction time and driver attention to a degree similar to driving while intoxicated. Another talked about the results of functional brain imaging showing that we really don't multitask even if we think we do. We just switch quickly from one task or thought to another and back. But, in so doing, we really cause a kind of "brown out" in our brains. The electricity doesn't go out entirely, but it dims noticeably, enough to be an irritation to those in the environment. In one experiment, a highly accomplished professional musician was noted to make several mistakes while playing familiar pieces of music if asked to perform simple mathematical calculations in his head simultaneously. There were several other experiments, all with similar results.

Once I began paying attention, I realized that it was true; I really wasn't keeping all the balls in the air, as I thought. I was remembering to gather up the overdue library books and a shirt to return to the mall as I dashed out the door to my physical therapy appointment, which is on the same road as the library and the mall, but I was leaving the house without my car keys, then my wallet, then the library books, then the receipt, rushing back to the front door over and over. I was dealing breakfast dishes onto the table like cards in Vegas and unloading the dishwasher and throwing the laundry into the dryer and packing up my breast pump and absentmindedly putting a halt to the sibling bickering at the table, but I wasn't really listening to the kids or even noticing anything around me. I was missing a golden 10 minutes of making a real connection with my kids in the morning, hearing them say something goofy or precocious that would bring me joy repeatedly over the course of a long workday, or (God forbid!) eating breakfast while not in a vehicle. I had come up with creative questions for patients whose answers would provide multiple essential bits of history and also serve as ice-breakers or social chit-chat, but I wasn't really engaged in the process. I was missing the body language and the pauses. I was always one step ahead, trying to pick up a few minutes here or there because I was so overcommitted. I was being a mechanic, diagnosing and fixing a problem, instead of a doctor.

So, what's the message here, and where is Abe Lincoln going to come into the picture since this post is nearing its end? I haven't stopped multitasking. Sometimes I have to do it. Sometimes we all do. But I have stopped multitasking without thinking about it, and I've realized that we really don't have to do it all of the time to get by. In order to stop multitasking 24/7, I have also had to stop saying yes to everything and everyone, including myself. I just acknowledged that I couldn't do it all anymore--it's too much with 3 kids and 2 physicians in our family of 5--took a deep breath and felt relieved. And so, as Abe said: You can please all of the people some of the time, and you can please some of the people all of the time, but you can't please all of the people all of the time. Amen!

Thursday, October 2, 2008

My Grass Has Always Been Green

How do you keep going with a juggling act after losing one hand? I am a doctor married to a doctor. I am fortunate to possess the holy grail of mothers in medicine: a part-time job that is (mostly) really part-time. Somehow though, much like getting a raise and then finding yourself saving no more money than you used to a few months down the road, I have the same issue with time. The extra TWO FULL WEEKDAYS OFF per week I reveled in two years ago have somehow become the new norm, and we are again wishing for more hours in the day, more days in the week. Somehow my daydream that the busy work of our three small kids--the doctor’s appointments, grocery shopping, haircuts, laundry, trips to return library books, etc--would be accomplished in those two days with hours of quality time to spare, leaving evenings and weekends for nonstop family fun, was popped in a matter of months. We are in no better shape than we were before. We feel like we are just barely keeping our heads above water again.

So, picture the scene. It’s Wednesday, my late day in clinic. I get home at 7:15pm. Bedtime is officially at 7:30pm. The kitchen looks like a still shot from Storm Stories. No one is in the tub yet. A quick survey of the kids’ bedrooms alone foretells at least an hour of “pre-cleaning” for our once-a-week housekeeper visit. I breastfeed “Fig,” our 7 month old, on my lap while attempting to eat a petrified bagel that I actually toasted YESTERDAY morning and never managed to get out of the toaster because at least, it’s ready to eat, lunging simultaneously for 4 year old “Munch” who is begging to be tickled over and over in the next seat, all while nodding and listening to precocious not-yet-3 “Iggy” describing random events of her day in what has to be the world’s longest run-on sentence ever, except this one. Everyone eventually gets washed, combed, toothbrushed, pajamed, read to, and tucked in. The house is returned to some semblance of order. Finally, after 2 ½ hours of the parental version of running uphill on a treadmill backwards, it’s 9:45pm and we collapse in bed to say hello to each other for the first time. Then my hubby drops the bomb. “The Comfort is leaving on Sunday.” The Comfort is the Navy’s hospital ship. I am too tired to wonder why this would be the first thing out of his mouth when we haven’t seen each other all day. “Oh really?” I say. “This Sunday,” he adds hesitantly. “Wow, where are they going?” “Georgia…ex-Soviet Georgia.” “That’s really short notice,” I note with vague disinterest. At this point, he obviously can’t take my dementia of exhaustion another minute and says, “I’m on it.” “WHAT?!?!?!”

And, in that moment, the juggler lost her left hand in mid-act. Suddenly I had 72 hours to figure out how to swing being both the “drop-off” and the “pick-up” parent, who was going to get my son to his weekly PT appointments which were right in the middle of my late afternoon clinic, how I could even register our kids for the preschool they have been so excited to restart which required being in line outside the school by 5:30 am the day after he was leaving, what I would do if we had a childcare crisis since I had just used up every iota of my vacation and sick leave and then some from taking 4 months of maternity leave, and on and on. My mind raced. The list grew. The punctuation vanished.

Ok, I told myself, you can do this. You have done this before. He had been deployed for 19 weeks while I was pregnant with our third child, just gotten back only 10 months prior in fact. We already knew he would be deployed again in April 2009. But for those, we had time to prepare ourselves and the kids, time to make arrangements, time to exhale and come to terms with it. This time, it came out of nowhere. Well, it wasn’t entirely out of nowhere. There was a moment, I think, during my commute two days prior when I heard on NPR that Russia had just bombed Georgia, a fleeting moment when I thought to myself: “Uh-oh”. But I put it out of my head, reasoning that we couldn’t be in Iraq AND Afghanistan AND Georgia. Our military was stretched too thin as it was. And there was an election in a matter of months. No, nothing to worry about.

The next week after that Wednesday night bombshell went by in a blur as I attempted to cancel and reschedule our lives, make contingency plans, prepare the kids emotionally when I wasn’t even prepared myself. The miraculous news that the entire US deployment to Georgia would be canceled came several days later, not from the US Navy, but rather from a Baltimore Sun reporter and new personal hero named David Wood. That is a saga in and of itself for those who are interested: But this is one long preamble for the real topic of this blog.

The next woman I saw in clinic was a new patient, 34 years old, a mother of 4 kids ranging in age from 1-7, widely metastatic breast cancer, a recent move from out of state for her husband’s high-travel job, no immediate family on either side, and no friends to speak of yet for 800 miles in any direction. She reported in a perfectly matter-of-fact way when I asked about her meds that she takes an extra dose or two of Oxycodone to control her bony pain enough to be able to make the kids dinner and do their baths. I was paralyzed by awe, by shame, and by the perfect storm of awe and shame: humility. As I sat wringing my hands over my husband’s unexpected, uncertain, and slightly risky deployment of probably a few months—maybe six at most—here sat this woman in constant pain, facing her own certain mortality, juggling despite having lost both arms, knowing that if she even blinked or faltered ever so briefly, it was over. Permanently. And her husband. What would he do? When she was gone, he would be on his own until the last baby was grown. And he worked full-time. Traveled several days a week. Seventeen years. It was an eternity. It was incomprehensible to me. How would he ever manage? How did he even lift his head off the pillow every morning? Here sat this young couple in front of me, and I was supposed to be the wise one? The doctor? And, in that moment, I became a medical student again. Suddenly I was the same young woman who years ago stared wide-eyed as patients gave their spouses a last kiss before being wheeled in for their liver transplants, wondering if they would make it, wondering how they managed to smile, wondering how they could be so strong, wondering whether I could ever be so strong, hearing that disquieting voice that told me I knew the answer and it was no.

It’s been over 6 weeks since this all happened, but I am think I am permanently that medical student again, if a bit more wrinkled these days. I realize now that every patient I see is living some variation of this story. She is trying to get her chemo and get home after dropping off her son at preschool and before her daughter gets off the bus and hoping her nausea medicines will work well enough that evening for her to cook dinner without the smells making her sick. She is terminally ill and desperately wants more time at home but cannot quit her full-time job because, without it, she will lose her health benefits and therefore, the treatment that may give her another month or two with her children. These people are all juggling more than I could ever comprehend and with so much more at stake.

I finally got it. After so many years focusing on whether the grass was greener on the other side, I finally realized that my grass has always been green. I just never sat still before long enough to notice.