Showing posts with label m. Show all posts
Showing posts with label m. Show all posts

Monday, May 23, 2016

Learning to Talk Back to the Voice in My Head

I am, by all accounts, a person who should be doing ok in the self-esteem department. My parents were bleeding-heart, 60s-style, brown-rice-eating leftists, which is to say I was never, as far as I can remember, punished. Not once. I am part of that much-beloved generation, the Millennials (just kidding, we are widely reviled and lamented), so everyone got a trophy for effort at my sporting events growing up. We as a generation are not shy about seeking out and giving positive feedback. I have drunk deep the milk of feminism so I'm ok with my body just the way it is, at least conceptually. I have successfully graduated college and medical school, completed residency, and am employed as a physician. I have a sweet little family that brings me much delight. Basically, there should be a lot of positive self-talk going on in this little head of mine.

Instead, here is a selected list of thoughts I had during just one hour last week, when I was doing some last minute preparation for an important work meeting:

1. I am a failure.
2. All the things I am doing are never going to amount to anything.
3. Other people would be more prepared than I am.
4. If only I had _________ (fill in the blank with more than 25 different alternate universe scenarios ranging from having gotten up earlier to having chosen a different profession)
5. I'm so disorganized.
6. I will never make enough money.
7. Some people have five children and are full-time physicians. I only have one child. Why can't I get my shit together?
8. I am a terrible mother.

Now let me be clear: on a meta-level, I don't believe these things. Rationally, I know they are distortions. If I step out of the den of snakes that is my mind, I can objectively see that I am doing ok, certainly not without my flaws (or as my rabbi says: "growing edges" -- see #5 above), but also certainly a person of value. I know that I contribute important things at work, at home, and in my community. But then there is THIS VOICE UP THERE -- let's call her Harriet -- that just keeps going at me. Harriet has been going at me for (at least) 25 of the last 35 years and I wasn't even aware of it until last week! How could I have not noticed it, all this time? I think I just heard it as the truth.

It's tempting to lay blame for the existence of Harriet on a long list of factors: the endless disempowering and judgmental messages that girls absorb from an early age about their bodies, their successes, their worth; the harsh social conditioning of medical training; the unreasonable demands modern society makes on parents and/or doctors and/or the middle class; the wildly increased expectations for connectedness and task completion potentiated by technology; and on and on and on. On the other hand, maybe Harriet is just a function of my own tendency toward anxiety and perfectionism. Certainly, Harriet is at her worst when I am exhausted, stressed, or overworked. But something tells me I'm not the only one with a Harriet in their head, which is why I'm writing this. Because it is time for Harriet to go. I deserve better. We deserve better. We deserve the kind of whole-hearted love we give our children and our patients and our friends.

Since last week, I've been noticing these thoughts and have been consciously challenging them as much as possible. You are a bad mother, Harriet says, as I leave my daughter at daycare after a rushed morning. Bad mother, eh? I counter. I show a lot of tenderness and care for my child and prioritize her well-being and our time together as much as I can. You never accomplish anything, Harriet says. Really? I say. What about Thing X or Thing Y or Thing Z? Those things went pretty well. It doesn't feel natural to say nice things about myself to myself -- in fact, I don't even believe these things as I am saying them. But I think you can grow into the truth of your own ok-ness.

So for all of you out there who may be wrestling with your own negative voices, I'll leave you with a beautiful poem by Derek Wolcott that is resonating with me as I try to exorcise my own. May the voice in your head be that of a great lover and friend!

Love After Love

The time will come
when, with elation,
you will greet yourself arriving
at your own door, in your own mirror,
and each will smile at the other’s welcome,
and say, sit here. Eat.
You will love again the stranger who was your self.
Give wine. Give bread. Give back your heart
to itself, to the stranger who has loved you

all your life, whom you ignored
for another, who knows you by heart.
Take down the love letters from the bookshelf,

the photographs, the desperate notes,
peel your own image from the mirror.
Sit. Feast on your life.

Sunday, November 22, 2015

It Takes a Village

It’s a good day to be thinking about gratitude. I just got the results of my Pediatrics boards and, mercifully, I passed. Like many things in the life of a working mommy, the whole boards process felt fragmented, stuffed into the crevices of an already packed schedule. I studied in stolen hours, early in the morning, late at night, during E’s naps, during quiet moments on call. There existed the dream of reading the textbooks cover-to-cover, mastering the seemingly random landscape of dysmorphisms and eponymous genetic syndromes, committing to memory, not for the first time, the detailed physiology of the nephron. Instead, I did as many practice questions as I could and read all the explanations and made a stack of index cards that I only had time to review once before the test. Studying certainly helped, but what carried me through the process were my patients, the hundreds of people whose stories constitute my fund of knowledge. The symptoms they had, the way their bodies looked and felt under my hands, the labs and images I reviewed in an attempt to understand them, the medicines we prescribed, the way things turned out. All the babies whose birth weight I guessed just before putting them on the scale. All the toddlers who scribbled, babbled, stooped, and recovered during their well-child visits. How do I remember Hurler’s syndrome? I remember A, from my first year as a clinical student, and his mother who carried him everywhere in her arms even at the age of seven, because she could not afford a wheelchair. In the boards review study book, they used phrases like “coarse features” and “macroglossia,” but I just remember his face, whose beauty became more apparent to me over time, and all the grief and tenderness in his mother’s voice as she sang to him, more effective than any medication at calming his agitation. I can only hope that what I have given is somehow proportional to what I have received.

The medical path – and especially the parent-in-medical-training path – has been much harder than I expected and when I reflect on this path I chose, gratitude isn’t always right there on the surface. But when I opened the Boards score report, it was right there. I looked up from the computer and the first thing I saw was my spouse. I thought to myself, “How can a person be so steadfast in the support of another?” I am in awe of it. I was the one who first brought up the idea of having a baby in my last year of medical school, before starting residency. I spelled it out to her over the Formica table in our then-kitchen – how we would have an infant while I was taking 24 hour calls and working long days, how it would be an insane juggle. She said, “That seems like it’s going to be really hard.” But it felt like the right time. We gambled and got a jewel, our daughter E, who is infinite light and delight. But it has been harder than hard. Over the last three years my spouse has done breakfast, drop-off, and pickup almost every day, dinner and bedtime too many days, whole weekends, whole weeks, whole months, sick days, unexpected call-in days, holidays. She gives our daughter what I wish I could be giving her when I’m not there, and so much more. She gracefully bolsters me in my mommy role even though I spend less time with E, when I can imagine a different person laying claim to the “parent-who-knows-more” position. She keeps us well-fed, keeps our household functioning, and through her eyes, I feel beautiful and powerful every day. She does all this while navigating her own full career as an artist and teacher. She has sacrificed some of her own creative and career advancement over the past three years so that I could forge ahead. I know it is painful for her at times – not what she signed up for, even though she did (good love isn’t as simple as they say) – but her loyalty and support just keeps shining and it lights my way and keeps our family warm.

So there are many layers to the gratitude I am feeling on this, the first day of the rest of my professional life. Gratitude to my patients, who are my teachers, who have accepted my inexperience and given me the gift of their trust and allowed me to participate in their lives in a profound way. Gratitude to my spouse, for EVERYTHING. Gratitude to my parents, which is a whole essay in its own right, the YEARS of patient attention and thoughtful decision-making, late night high school research paper crisis management and SOS babysitting saves, self-sacrifice and deep concern for my well-being. Gratitude to my friends, who have stuck with me through long silences. Gratitude to my colleagues and attendings, for saving my ass and helping me find my voice and for caring so much and taking great care of patients and teaching me by example. The African proverb “It takes a village to raise a child” has become so cliché at this point as to have almost lost meaning, but I’m thinking today about the village that raised me, and no words of gratitude are adequate. I will have to thank them by trying every day, with the best of myself, to be of service to the world.

Thursday, December 18, 2014

Group think: What is the solution to the overwhelm?

It's 5:51am and I have 9 minutes to write this post. Well, I just spent a minute thinking about what I want to say and so now I have 8 minutes.

Lately, it's been feeling like I just can't do all the things I want to do, let alone all the things I've already committed to do, let alone all the things I have to do. This last year of residency has been a great one and I've become involved in many different projects that I feel passionate about: research, education, resident wellness. I feel an increasing sense of clinical mastery, which basically means I know what I know and also how much I don't know but it doesn't scare me as much. I've been active in my synagogue and at my daughter's school. I feel like all the pieces of the puzzle are, if not falling into place, at least face up on the table and waiting to find their place. But it seems like there is at least 100% if not 200% more to be done in every day and week and month than I can do.

Every email I write starts with the phrase "Sorry for the long delay in my response." Balloons that were up for my daughter's birthday party two weeks ago are still up and the stack of Thank You cards for her gifts still sits blank on the cluttered ledge between our living room and dining room, along with unopened mail and other flotsam from our stitched together life. I've been getting up one hour earlier than I have to for the last month to try and get on top of some of the research and scholarly work that I want so much to get done, and this has been helpful, but I'm so exhausted by the nighttime that I feel like I am not the kind of parent I want to be to my daughter in the few hours we have together during the work week -- I'm easily frustrated, less playful, and distracted, just waiting for the moment when I can lower myself into bed. I fall asleep in literally 5 seconds. The cost of starting a couple of new projects -- all of which I am excited by -- is that I'm spread thin on all of them, taking weeks longer than I promise to get things done, always twenty or thirty items deep on the to-do list. If I feel like I'm a leg up on the work side of life, I'm one step behind on the parenting side of the equation, with friendships and marriage and housecleaning and family always tap-tap-taping at my chamber door. And did I mention the emails? Oh, the emails. How and when will I master the emails?!

Sometimes I wonder to myself: Are we busier than people used to be? Am I uniquely incapable of multitasking? But wait, all I do is multitask. And is the overwhelm an external reality or is it a reflection of something about me? Would I be overcommitted and frazzled even if I were shipwrecked on an island with nothing but palm trees? Should I be doing fewer things? Or maybe this model of living is a successful one -- after all, in the end I do manage to do a lot and much of it at the "good enough" or even "good" level. But I long for a little peace.

I'm already over time by 9 minutes and 9 minutes and late for the shower that leads to throwing some kind of lunch in my bag that leads to hitting the road, so I'll pose my question and see what your thoughts are. Does anyone out there have creative strategies for getting on top of the overwhelm?

Thanks in advance for your thoughts!

Thursday, November 27, 2014

An extra cup at the Thanksgiving table

As a pediatrician-mama, I find that Thanksgiving is -- to use a timely cliche -- easy as pie. I don't have to search my mind for even the shortest moment to access my gratitude place: My child is alive and healthy (*gods, do not be tempted by this statement*). The ocean of gratitude I feel for this has no bottom. I am aware of it dozens of times in the course of my day taking care of sick children: How lucky my partner and I are. How tenuous and temporary and fragile our luck is. How we can claim no credit for this fortune. There are many, many other things I am grateful for, but even if all those other things evaporated, this one thing, this everything, would still fill me up on Thanksgiving day and every day.

Yesterday, as a pre-Thanksgiving treat, my partner came and picked me up from work so we could pick my daughter up together from school. It was a gray, cold day and little specks of icy rain were making it hard to keep my eyes open as I waited just outside the entrance of the hospital. I'm on Jeopardy call all weekend but if I'm not called in, I get to have four days with my family in front of our slightly creepy ventless gas fireplace. (Where does all that CO and CO2 go? Whatever -- pass the pumpkin pie!) So I closed my eyes and sent a surge of warmth towards each of my co-residents, wishing for their well-being and the well-being of their families. Sure, it started from a place of self interest and humor, but then it felt good and right to be sending them little non-denominational blessings in honor of the holiday. There is a special place in my heart forever for the people I am training with -- a certain affection and protective instinct and a huge folder of moments in which these people have awed and inspired me, sometimes unexpectedly.

Then my mind turned to all the families I have cared for who are without a child this Thanksgiving. The babies who never made it into the world, the babies who stayed for only a few hours or days, the babies who left this world after a long struggle in the NICU, the babies who arrived to our ED in the early hours of the morning already cold and pulseless, the children whose otherwise healthy lives were shortened by cancer or trauma, the children with chronic illness who were in and out of the hospital for months or years before a cold or stomach bug proved to be more than they or we could fight. Then I thought of all the children whose lives have been shortened by war or preventable or treatable disease or famine or -- this week especially -- by racism or homophobia or genocide or hate-motivated injustice of any kind. I thought of their parents and the huge, gaping unfairness of what they were given by luck, or the universe, or God, or just random chance, depending on what you believe. I wondered how they go on with things like Thanksgiving. Would I be able to? In Judaism, when someone dies, the thing you say to the people who love them is: zachur li'vracha. May their memory be a blessing. And so, my eyes closed against the rain, I sent this out to all the parents who have lost children: May the memory of your children be a blessing and may there still be things to be grateful for.

On the Jewish holiday of Passover, we leave a cup of wine out on the table for the prophet Elijah. The teaching is that Elijah will one day come as an unknown guest and you want to be ready to welcome him. This year at my Thanksgiving table, I'm going to leave out a cup for all the parents who have lost children, that they may know they and their children are not forgotten. That they should feel welcome back into the rhythm of ritual and community, whenever they are ready. Also, that we may never take our good fortune for granted. And that we may fight in whatever way we can to prevent parents from losing children needlessly.

Happy thanksgiving to you and yours today, from one mama to another! And a special shout out to all the mamas who are taking call today so that others can be with their families -- Thanksgiving is whenever you get home!

-Also posted at

Monday, July 14, 2014

Rediscovering quantity time

It's an old question: quality vs quantity time? When it comes to parenting, the people whose lives allow for quantity tend to argue in favor of quantity, while the people with less quantity argue for the importance of quality. Which is not to say of course, that you can't have quality while also having quantity. In any case, in the Mommy wars, its one of those false dichotomies likely to provoke a melee of defensiveness and self-righteousness.

I started my life as a parent with six months of quantity time. I took 8 weeks off, but then worked part-time, mostly from home. My daughter and I were together almost all 168 hours of the week. We marinated in each other. We stared into each other's eyes for long stretches. Most of the time, neither of us was fully clothed. I was engaged in elaborate procedures to increase my milk supply, so I was either nursing or pumping or nursing-then-pumping every 2-3 hours around the clock, and my daughter was never more than three feet away from me. There was no day or night, just a repeated cycle of hunger, contact, cooing and shushing, punctuated by the pchika-pchika-pchika of my loyal pump. I tried to work when I could. 

Then I started residency and parenting changed completely. Now the demands of my job were absolute, predictable down to the hour for an entire year in advance. I had to be fully available at work and so my partner took over the job of being fully available at home. My daughter started day care and began to adhere to a more consistent bedtime. Instead of working when I could, I had to parent when I could. Many days I had only half an hour or an hour with her before bedtime and I learned to make these minutes gleam with high octane focused attention. Then there were golden weekends, unexpected early days, vacations, and continued nighttime awakenings, which killed me but also kept me going. We cuddled as much as possible. When people lamented to me on behalf of my daughter about my demanding schedule and how little time I was able to spend with her (frequent occurrence), I gently told them how proud I was of the quality of our relationship despite these constraints. I didn't exercise, travel, or buy a new pair of shoes for two straight years but with what time I had, I parented with my whole heart. 

Now I'm a third-year and it's not feast or famine anymore. I can eat breakfast with my family, put in a solid work day, then eat dinner with my family. And weekends are back (sometimes). The timing of this detente is coinciding with a leap on the part of my now two-and-a-half year old towards more independence and awareness and conversational ability. To celebrate, I took her on a road trip to see her grandmother in Vermont. We were in the car for fourteen hours in total and I gained a new appreciation for the things that quantity time can give you that quality time cannot. There was a period of twenty minutes in which she screamed "Mommy, I want to poop in the potty!" at top volume and I thought I was going to lose my mind. Then I figured out a tickling game we could play while driving and the car was filled with both of our giggles. We slid from mutual frustration to laughter to boredom to song to negotiation then back to boredom then back to jokes. It's not that these transitions don't happen over shorter stretches but with 72 uninterrupted hours ahead of us, I didn't feel pressured to make every moment fun. I didn't feel pressured to entertain E. We were just inhabiting time together, without bedtime or daycare drop-off or a specific activity to get to. E asked lots of ontological questions like "Mommy, who is your Daddy?" and "Where are all these cars going?" When we stopped for lunch, she laid out her chicken nuggets and french fries in a perfect straight line and said in a matter-of-fact voice, "Nuggets and sauce is my favorite. What's your favorite?" It felt like we were on an epic date, complete with some long silences and surprising moments of synergy and a sense of time without limit.

Like most of the issues in the Mommy wars, there is no one right truth for anyone and on average the truth is somewhere in the middle. The truth also changes. Parenting with limited time taught me mindfulness and focus and priorities. It made me a better parent. Now I'm looking forward to spending longer stretches of less goal-oriented time with E. I'm hoping to build a life in which quality is the focus both at work and at home, with enough long weekends and road trips and lazy vacations in remote places to marinate in timeless time together.

Tuesday, February 11, 2014

Evidence of things not seen

I usually don't cross-post from my personal blog, but this recent piece seems to have really resonated with fellow residents and physicians in general. People have approached me in the hospital to talk about it, and as a result, I have had a lot of honest, wonderful conversations with my colleagues -- about their love for medicine and for their patients, about the traumas of training, and about the systemic problems that make their jobs less satisfying than they had hoped they would be. These conversations have reconnected me with my own deep motivation to serve patients and have inspired me to fight for a better system. I look forward to hearing from fellow MiMs about your experiences and hopes and ideas for how to better heal our patients and protect ourselves from burnout. 

*         *         *         *         *

I am on retreat with my residency class. We are in an otherwise empty hotel on the Jersey Shore whose just-an-average-hotel-ness is intensified by the lonely quiet of the off season. I can imagine the bustle of summer filling up the space -- trails of sand from little feet tracked in from the beach, brightly colored umbrellas stacked up on the deck, all the various sounds that people can make from within hotel rooms -- but in the emptiness of winter the rooms seem tired. Why are hotels decorated in brown and beige? Are there people who are offended by color? Or is it just to mask wear and dust and dirt? Is the bored eye less likely to see?

There are few opportunities in my life to sleep in but today I could have slept until 8:30am, which as all parents of toddlers can attest, is the new noon. I went to bed early last night, in fact, because I wanted to experience the sensation of restedness this morning, the feeling of waking up out of readiness instead of necessity. But because the universe has both good wisdom and a good sense of humor, my eyes opened at 5:45am -- the very time that my alarm will ring tomorrow morning -- and I couldn't go back to sleep. At first I was filled with a familiar sense of cynical irritation, the "why me" and "well isn't that always the way" that residency has brought to my life despite the comforts and advantages that I enjoy. But then I thought to myself, how often do I get a chance to walk on the beach as the sun rises? According to the sun would be rising at 7:01AM. I put on several layers and slipped out of my shared room, through the muzak in the lobby, and out towards the ocean.

There was no one else in sight. I walked toward the ribbon of pink spreading up from the horizon. The hard, frozen sand up near the beach grasses gave way to the satisfying sink of each step into the wet shore. Several gulls circled and dipped. I looked for shells to bring home to E -- not too small, not too sharp -- and came across some of the odd hints that the ocean delivers up to us about itself. Cracked orange crab shells and dismembered legs half buried in the sand. Plant fronds of various colors and textures and widths. A foot-long brown spear that widened up to what looked like the end of a bone with some white and yellow flesh still attached -- tooth? spine? tail? Breaking the smooth contour of the shoreline, a sudden small pile of sea sponge. I walked for an unknown distance. The sky became lighter and lighter beneath and around the layers of cloud. I wondered to myself when the sun would rise and what would mark the sun's rising. I looked at my watch and it was 7:13, already past the appointed time. The part of my legs between the top of my boots and the bottom of my coat began to tingle and sting with cold and I turned to walk back to the hotel as the daylight continued to bleed into being around the edges of the sky.

*         *          *          *          *

How should I say this? I am worried about the state of health care. I am worried about the state of my own heart. I am worried about the way doctors are trained. I am worried about the way health is defined. I have been in and around hospitals for almost a decade at this point and I feel like I know less and less about how to help people achieve well-being. I feel like I'm getting better and better at keeping people alive and less and less good at helping them live well. I am maybe a little depressed or to use the somewhat more socially acceptable term, burned out.

I went into medicine with a desire to be with people in life's most terrifying and difficult and potentially ecstatic moments. I wanted to understand the body, to understand more about life and illness and death. It's a cliche but a deeply felt one: I wanted to be of service. I also wanted financial stability and the ability to provide for my children. I wanted a job that would be meaningful even on the worst days. But mainly I wanted to form deeply satisfying therapeutic relationships -- it's what I wrote my residency application essay about and it is still what I aspire to accomplish, somehow.

Now, almost ten years later, I spend more than 90% of my day in front of a computer. Sometimes the computer is actually physically located in between me and my patients and I have to crane my neck around its unsleeping eye to see them. I type through the majority of my clinical encounters. During a typical day on the wards, I see my patients for -- at most -- 5-10 minutes per day each. My day is filled with entering and reentering orders on the computer, writing endless admission notes and progress notes which recapitulate information that is already recorded elsewhere in the medical record, waiting on hold to talk to primary care doctors' answering services, calling pharmacies and insurance companies for prior authorization, calling subspecialists to address each of the body's organ systems, and coordinating the complex behemoth of a large tertiary care center to get tests and studies done for my patients. I work up to 28 (actually more like 30 but shhhh don't tell) hours in a row every fourth night which wouldn't bother me except that of those hours I spend at most 2-3 in total with patients. Patients turn over so quickly in the hospital that I might be responsible for the care of over 100 patients during a given week. During clinic hours I am perpetually beset with anxiety at how far behind I am, unable to get through a well child visit meaningfully in the 20 minute time frame allotted for this purpose and because of the fragmentary nature of residency scheduling, I often do not see these patients again. I want to form relationships with my patients, but at times it feels like talking to patients just takes time away from the tasks that need to be done for them. It's crazy, but it's true.

Some of these issues are unique to residency, which is time-limited (though formative), but surveys of post-residency physicians suggest that as a group, we are in trouble. In a much quoted and discussed survey of 24,000 physicians by Medscape in 2013, only 54% reported that they would choose medicine if they had it to do over again. Fourty-nine percent of physicians surveyed reported at least one symptom of burnout and 40% reported that they were burned out.

On the receiving end of medical care both as a patient and as a loved one advocating for sick family members, I know what it's like to receive care from a system of overwhelmed and/or burned out providers. Test results are not communicated. Small details are missed. You wait 7 hours to speak with the doctor, then that person does not know some of the basic details of your case. The care you receive addresses a symptom or a part of the problem, but rarely the whole problem, and rarer still, you as a whole person. I fear being that kind of provider yet I have been that kind of provider despite my fervent desire to avoid it. There are just too many patients, too many data points, too many notes to read and write. There is so little time for relationships to form. There is no magic there.

Doctors are a hard group to sympathize with. Once we finish training (it's long, but let's face it, life is longer) most of us land in the top 10% if not the top 5% or 1%. Training is hard and the hours are long but we choose this life with full knowledge (as much as you can have full knowledge) of what we are getting into. We hold a lot of societal and political power and on an individual level,  in hundreds of thousands of exam rooms across the world, we have the power to examine, to question, to diagnose, to prescribe, to get it right and heal or get it wrong and harm. But if we as a society want to get the kind of health care that not only cures but heals, we are going to have to look at how doctors feel, how they are trained, how their work-life is organized, what we ask of them, and how we support them in their work.

*          *          *          *          *

If you work around sick children long enough, there will be a death that crushes you, that doesn't let go, that you can't let go of. Little O came into my care last month and a few hours later passed away under the most difficult of circumstances. Oddly enough, I don't remember her name -- perhaps because the intensity of our efforts to keep her alive and the adrenaline coursing through my body erased it from my data banks, perhaps because I have been afraid to reopen her chart. I think of her as little O, the little O of her mouth, the round moon of her little face which I saw for weeks every time I closed my eyes. If I will it, I can hear her mother's screams in my mind's ear as vivid as the sounds of my household humming around me as I write: "No es justo! No es justo!"

I want to make contact with her family, to tell them that I feel for them, that I think of her, that even though our lives touched for only a few short hours, I feel the weight of their loss. I have never done such a thing before and I'm not sure if it is even appropriate. Who should I ask? Do I need to get permission from my program director? Do I need to run it by risk management? In the end, the question comes down to one of the nature of my relationship to that baby and her family. Was there one? And if so, what was it? I have been training for many years but have received no apprenticeship in this most important aspect of my profession.

So many hundreds of children pass through my life and I through theirs and we are like ghosts to each other. There are so many layers between me and my patients, layers of bureaucracy, legality, scheduling, vulnerability and power traded back and forth in a complicated dance. Was this always so? Sometimes I fantasize about becoming a small-town doctor, about being part of the community I serve, of knowing my patients and allowing them to know me.

I will likely never send a card or see little O's family again, but this is what I would want to tell them: I will hold your daughter in my heart forever.

*          *          *           *          *

Meanwhile, back at retreat, I am surrounded by the loveliest people. My co-residents are intelligent, accomplished, funny, and kind. To a person they are motivated by the desire to be of service. They are scientists and humanitarians who hold as sacred the trust placed in them by children and their families. They are also spouses and parents and children and friends who struggle to balance the commitments they have made in so many domains in their lives. I feel lucky to know them and I think children are lucky to have them as their doctors.

What I wish for them and for myself as doctors, what I wish for myself as a patient, for my patients, and for my loved ones who are someone else's patients, is a system that allows us to be healers, that helps us to heal. I want a system that allows me to express my compassion, that gives me the space and time to care for people in a meaningful way. Unrealistic? Selfish? Possible? I hope to find out.

Friday, December 13, 2013

For the better and for the worse but mostly for the better

How has medicine changed me? The honest answer is: for the better and for the worse. Let's start with the latter.

Before medicine, I inhabited time slowly.  I spent a lot of time writing, a lot of time reading, and a lot of time engaged in no task in particular. I would make a salad with a friend and then eat it with her and then linger over the empty bowl talking about love and then seven hours later get up to make dinner and start over again. Before medicine, stories were as much about the how of the telling as the content. I loved words. I loved spending time with friends. I walked and sometimes even ran. I meditated. My memories from before medicine are of a particular way the light used to fall on the floor in the afternoon, of sitting at the kitchen table in the middle of the night reading a novel and crying at its beauty, of falling in love. Whatever work I was doing at a particular time was not what defined my life. It was never a day off or a day on, it was just a day.

Now I can never seem to have enough time. I am always behind on charts. There are always at least two more patients on the board waiting to see the doctor, both literally and figuratively. I am always aware of time. If I am off, I am aware of the need to take full advantage of that. Am I using my vacation time efficiently enough, I wonder? Am I relaxing enough? When I am on, there is the pressure to see patients faster, discharge them faster, order their antibiotics faster, think faster and talk faster and faster faster faster. When my formal work day is over, then there is the research work, the studying and reading, the charts to finish. I am no longer able to be at peace with time. There are too many people who need too many things! When I listen to a patient tell a story, I am waiting for the details to click into place that will allow me to identify their disease. Though I wish it were otherwise, I am not always really listening as they describe the dinner they were eating the night before the symptoms started. I am typing the things they have already said and waiting for the salient details to arrive: When did the pain start and where? How many times did the child vomit? Oh, a few days of cold symptoms and then barky cough and noisy breathing? Croup! Done! The story can be reduced to a sentence. I used to be a poet, enamored of the space between things, now I am a master of pattern recognition. I used to appreciate good novels, now I appreciate good historians, patients who can recall a sequence of events in roughly chronological order, people who have an innate sense of what is important and what is not.

Now for the better: Before medicine, I was anxious a lot of the time. Scared of public speaking. Scared of illness and death. Scared, ironically enough, of hospitals. I remember as a child seeing an elderly person in a wheelchair at the park vomiting into the bushes and feeling weak with a kind of existential nervousness about what life might bring. I took a long time to make decisions, worrying over the potential consequences of a wrong choice. I didn't like novelty. I didn't like surprises.

Now I can walk into a room with a child who is gasping for breath and it is still very scary, but my adrenaline translates into action. For me, it turns out that the drive to help a person who is suffering is stronger than fear. Medicine has organized me around a purpose, and even when that purpose feels daunting, exhausting, or completely impossible, I just do it. After presenting on rounds hundreds of times and being asked hundreds of questions publicly to which I didn't know the answer, I am able to accept that I am a work in progress. I used to worry what people would think of me if I made a mistake. Now I worry what will happen to patients if I make a mistake, and that change has been profound. I still worry a lot, mostly over the things I did or failed to do for patients, but this kind of worry makes me better at what I do. I am still afraid of illness and death, but I understand in a way I could never have understood before that these things are the way of life. When they find out I am a pediatrician, people often say, "I could never be around sick children. It would make me too sad." And I think to myself, "Someone has to be with those children." Children get sick, children die, and creating distance between ourselves and that reality does not change that reality. Medicine has taught me how to be strong for other people.

Sometimes it is hard to remember, or re-enter, the world of everything else, by which I mean the world in which things are happening that are not related to how the heart and lungs and kidneys are functioning. When I go to a performance or concert now, sometimes I have an intrusive thought about what I would do if the performer collapsed, if they were pulseless and needed compressions, if they had a seizure. In the midst of watching a person accomplish an incredible act of beauty or physical agility or creativity, I find myself mentally reviewing the ACLS guidelines for cardiac arrest or wondering if the venue has an automatic defibrillator and if so, where. I have trouble relaxing out of the life of the body and into the life of the mind. For me, beauty used to be the highest calling. Now I just want to make sure that everyone makes it through the night. I have to fight the impulse to turn to whoever is sitting next to me at the show and whisper something along the lines of, "Don't you realize our bodies could fail at any time?!" Then I have to remind myself that there is more to living than maintaining physiologic homeostasis, even if nothing would be possible without it.

To summarize: I feel less and do more. I spend less time contemplating and more time problem solving. I am both farther away from and closer to life. I miss the person I once was and am proud of the person I am now. Maybe one day, when my own journey in a body is nearing its end, I'll return to the light on the floor in the afternoon and the spaces between things and the lunches that turn into dinners. In the meantime, I am going to work on getting better at taking care of sick children and will probably always be behind on charts and will spend my vacations trying to get as much done as possible with only minimal success. 

Friday, October 25, 2013

The me-time problem, or rather the no me-time problem

Recently, I have been having a me-time problem. The problem is, I don't have any. Now, there are pressing and non-modifiable external reasons for my lack of a life, namely residency, which severely limits the total number of hours that I can devote to non-work activities. Then's there is parenthood and I know I don't have to go into detail here at MiM about the ways in which that limits me-time. Let's just say: Last weekend I turned on the shower and read a New Yorker article while sitting on the bathroom floor and telling my daughter through the door in a sing-song voice that I was almost do-one with my show-er. So my expectations in the me-time department are not lofty. I'm not talking about daily me-time and there are months when I resign myself to the fact that I might only get a few hours per month to myself. But I'm beginning to see the toll that no me-time can take when it begins to stretch from months to years. My best friend in the world has been with her "new" boyfriend for almost a year and I have never met him. One of my other dearest friends had a baby over a month ago and I have yet to talk with her in person. The list of friends and relatives whose birthday I have under-celebrated or whom I owe calls, cards, gifts, or visits is long. I have not formed very many lasting social connections with my co-residents because I never attend happy hours, dinners, or trips.

Also I am just so unbelievably tired. I am locked in an almost compulsive cycle of sleep deprivation. I race home from clinic to be with my daughter then finish notes late into the night when I should be sleeping. I get up with her at 5:30am on weekends even when my partner offers to let me sleep because I want to spend every last minute with her. I wake up only 2-3 hours post-call so I can pick her up from day care. My sleep deficit feels as insurmountable as my student loan debt, something I will be paying off until I die. Will I ever be able to go to a movie or a play without falling asleep two minutes in?

Don't get me wrong, I love spending time with E. It is my favorite thing to do without even a close second. The delight and pleasure I take in even the simplest activity with her is beyond anything I have ever experienced before. Let's load the dishwasher! I say, and her little face breaks out into a beam of excitement and suddenly arranging bowls on the rack takes on a new quality of magic a la Mary Poppins. But I do miss myself. And see above re: I am really tired. I'm beginning to feel a little wan and a little crazed and very, very grouchy in the mornings and sometimes in the evenings and sometimes in the middle of the day. I know rationally that it would be good for me, for my daughter, for my marriage, for my career, for my health -- good all around -- to take breaks and keep from getting burned out.

The problem is, I feel deeply conflicted every time I am faced with the decision of leaving my daughter for any reason other than work and especially if the only reason is my own comfort or enjoyment. When I have only four days off a month, how can I spend even part of one day away from her? When I might have only one hour with her at the end of a day, how can I decide instead to go to a bar with my co-workers? When she is cutest in the mornings and I almost never see her in the mornings, how can I roll over and let my partner toddle down the stairs with her and get all the sweet toddler action? In the abstract, I know I should do all these things at least once in a while, but when I'm in the moment a noose tightens around my heart, part guilt, part sheer hunger to be near her and hug her and listen to her talk and watch her grow up, which I increasingly find is a quantity-time and not a quality-time activity. So I end up deferring or canceling plans or bringing E along and spending the time chasing her around rather than socializing.

I have a vacation coming up in December and I'm toying with the idea of planning a one- or two-night trip by myself to visit a friend but I'm nervous that when the day comes and it's time to drive to the airport, I won't want to go. I won't be able to go. I will end up "getting sick" and canceling and wasting money I don't even have on lost tickets and hotel reservations. Or going and feeling unsettled the whole time and regretful about time lost with my daughter when I have to go back to my 80hr schedule the following week.

Fellow MiMs: How do you handle the me-time dilemma? Should I suck it up and reclaim some me-time or suck it up and realize that these years are precious and schedule a reunion with myself in a couple of years after residency and toddlerhood are over? What strategies do you have for fitting in time for yourself? In other words: help!

Thursday, August 8, 2013

First Call

It's my first overnight call in the hospital. It's 7pm and I've been at work for 13 hours. There are 16 more hours to go. My arms are halfway through the portholes of an isolette and my hands are cradling the tiny hand of one of my patients who needs a blood culture and screening labs. I am shush-shush-shush-ing the baby as I choose my spot, swab it with alcohol, and pierce the skin quickly and definitively, trying to cause as little pain as possible. My pager phone is buzzing and beeping against my hip, the nurses are mobilizing, talking, helping each other do all the things this sick baby needs done, but for the moment it is just me and this hand and the artery that is hidden a few milimeters beneath the skin. After a few adjustments of the needle, the red arterial blood flashes into the needle, travels up the tubing, and begins to fill the syringe. My shoulders start to unknit themselves and I take what feels like my first breath in a while. Thirty seconds pass as the syringe slowly fills. There's nothing else I can do for the moment but stand here. I haven't stopped moving and doing and thinking and worrying for the past 13 hours, so this feels like a break. The baby is chewing on his pacifier, looking around for the source of the sting, and our eyes meet for a moment before the blood hits the 2cc mark and I retract the needle into its hub. "Thanks, little man," I whisper to him softly, grateful to have gotten the blood, grateful that I don't have to cause him more pain with a second stick, grateful that I don't have to call the fellow to come and help me, grateful for the couple of breaths I took and whatever small thing passed between us. In the time it took for the stick -- no more than three or four minutes -- four new pages have come through and I am needed in four places at once and I don't breathe again until well after midnight.

*          *          *          *          *

The most recent change in the ACGME medical training rules happened when I was a fourth year medical student. At the time, all the protest over the limitation of interns to 16 hour shifts seemed silly to me. How could anyone protest a seemingly more humane schedule? What was the big deal? Then I got to intern year and began to understand the widespread dissent. The day-float, night-float system featured constant signout -- on long call days, I would spend 2-3 hours of my day signing out. I worked 13, 14, 15 hours six days a week, enduring the pain of long separations from my child, often staying up late working on notes and discharge summaries -- and still there was never enough time to see patients, with rounds and conferences and notes and sign out and the endless to-do lists. Most disturbingly, I felt like I wasn't learning as much as I expected. Admitting a patient was more a matter of administrative work. There was never the opportunity to travel with the patient through the process of diagnosis and treatment. At best I would put in the initial orders, then sign the patient out to the night person. Nights were a little better, with more opportunity to actually see patients and think about them, but six consecutive 15 hour days left me feeling exhausted and was hugely disruptive to my family. I began to feel resentful all the time. Worse, I began to forget why I went into medicine in the first place.

As second year neared, I was filled with both apprehension (would I actually be able to function for 30 hours in a row?) and excitement for the switch to a Q4 overnight call schedule. What was I looking forward to? The time to actually see patients. The chance to spend at least one out of every four afternoons with my daughter. The chance to admit and then follow my own patients instead of picking up overnight admissions and shuffling patients when one or another team member switched to nights. The sense of mastery that would come with being able to manage patients by myself overnight. I was hoping to fall in love with medicine again.

*          *          *          *          *

It's 3:30am and even though I should be trying to catch a little sleep during a lull, I am worrying about sodium. One of my patients has a sodium of 129. It's not low enough to panic, but it's not normal. It's not low enough to call the fellow who has probably already gone to lie down but it's low enough to make me lie awake in the dark, wondering if I should intervene or not intervene, wondering if I should call the fellow or not, feeling like this is the kind of problem I should be able to solve on my own. I get up and turn on the light in the small call room and set about reading about neonatal hyponatremia, which confirms that the baby is not in danger. I could go down on his fluids, but he is losing more than the typical amount of fluid through his unrepaired myeloschesis and there has been concern all day for poor urine output. On the other hand, it's hard to imagine that he is fluid down with a sodium of 129. I go around and around in my head, weighing the sodium level against the risk of insensible fluid loss. I decide to recheck a level in the morning and leave the fluids where they are. It's a small decision but it keeps me tossing and turning for the interrupted hour and a half I have to rest before the morning work starts. When the BMP pops up at 6am, my heart catches in my throat for a moment. What if his sodium is 121? It's 130. On rounds later in the morning, we decide to leave the fluids where they are. For the team it's a small decision -- no one even notices -- but for me it's the end of an arc of learning: how to tolerate the anxiety of uncertainty, how to make a clinical decision when there are no protocols to follow, how to think through a problem and come up with a safe solution. If I had been there with a senior resident, I would have just asked them and they would have changed the fluids or not changed the fluids. I would have slept better. But I would have been no farther along in my ability to take care of patients independently.

Post-call rounding is a whole new experience. I know all the patients and what has happened to them over the past 24 hours. I was there yesterday when decisions were made on rounds and I watched these decisions play out. I have listened to these lungs, stared at these monitors, felt these bellies all night long. I am the one who was here. For the first time, none of the patients on rounds are new to me -- they are all mine. I have the opportunity to get feedback from the attending about my overnight decisions, learning that will stick with me forever. Even though I am exhausted, it is exhilarating. I go home, sleep for a few hours in the afternoon, then have the incredible treat of going to pick my daughter up at day care, something I could almost never do on the intern schedule. I have a normal evening with my family, full of all the quotidian details of dinner, bath, and bedtime that are my secret paradise. By the next morning, I am ready to dive back in.

*          *          *          *           *

The new duty hour rules were well intentioned, designed to keep patients safe and minimize the ill effects of sleep deprivation. But I think there needs to be some consideration of what may have been lost. The danger of sleep deprivation has to be balanced again the the burn-out associated with the relentless march of long days without the high-yield learning and sense of connection to patients bourne of the shared journey of an entire day. Being awake for 30 hours is hard. But feeling like a mediocre doctor while seeing my family for an hour a day for most days every month was much, much harder.

I'm curious to what other people think about the "new" (now not so new) duty hours.

Saturday, May 4, 2013

The Bear of Shame, or the Story of the Mother Who Didn't Have Wipes

Today was a beautiful day. This winter has had a long and unexpected and not entirely welcome coda this year which has only sweetened the anticipation of spring. Today the sun was out, the sky was cloudless, the temperature was just warm enough for short sleeves but not warm enough for sweat. I got out of work early--I am in the Emergency Department this month, so am working half the number of hours I usually work, though at odd hours--and raced to pick up my daughter early from day care. The thirty minute drive from work to day care has a sweet, crazed quality to it--never am I so eager to reach a destination, never am I so irrationally angry at anything or anyone who causes the moment of arrival to be delayed. After picking E up, I decided to take her to a nearby park in the adjacent but much ritzier neighborhood a few minutes from our house. Instead of the space-age shock-absorbing pseudo-gravel that carpets most playgrounds these days, this playground is carpeted in sand, ye olde original shock absorber. It was E's first encounter with sand and while initially tentative, she was soon letting out excited squeals and hurling sand into the air and by extension into and onto every part of her, including the area between her nose and her mouth in which snot has taken up semi-permanent residence since she started day care. There I was in my barely-nice-enough-for-work-but-certainly-not-casual-enough-for-the-sandbox attire, with a toddler whose face was covered in snot-stuck sand. All I had with me were my keys, my smart phone, and E's hoodie. I did not have wipes.

The playground was full--mothers, father, babysitters, grandparents, nannies. I walked over to someone who seemed to be a nanny--surely they come prepared!--and asked if she had a wipe. "I'm still learning," I said, by way of explanation. "Oh, that's why we're here to help each other," she said, and I felt good about humanity. She opened the child's blue elephant backpack which I could see was meticulously arranged. "Her mom sure knows how to pack a bag," she said, pulling out a travel-size package of all-natural hypoallergenic wipes.

Well, there it was. Her mom sure knows how to pack a bag. I imagined the woman out there in the world of work somewhere, calm in her knowledge that should her child be caked in a mixture of sand and snot while at the playground, there would be a wipe at the ready. As I walked back to my delighted daughter and wiped her face, I thought to myself: Am I ever going to get my s&*t together?

Sadly, it's a familiar refrain. My thank you notes are still not done from E's birthday and the holidays in December. I sent off the ones that were truly socially dire (grandparents, great aunts, co-workers) and now I'm wondering if it's even polite to send the others. Is there a statute of limitations on gratitude? Speaking of the holidays, I just couldn't make a holiday card happen this year, so you won't find my daughter's adorable face on a refrigerator near you. The baby book I lovingly bought when I was pregnant remains half-finished, with only the pregnancy section filled out. When it came time for my daughter to go to day care, we were not on any of the right waiting lists. A year later, we still aren't. When it comes to potlucks, I either bring store-bought hummus and a loaf of bread (from Whole Foods, though, so maybe a couple of extra points there) or I just decline the invitation upfront because I foresee that the guilt of not having made a homemade casserole will just be too much for me. I have even shown up to a potluck with my daughter having brought nothing and proceeded to feed her everyone else's food because she was hungry and I hadn't even brought snacks for her from home. On Valentine's Day, my 14-month-old returned home with a Valentine's goodie bag from one of her classmates and I just had to throw up my hands. Am I supposed to be cutting Valentine's hearts out of construction paper after my child goes to bed to give to her barely ambulatory classmates? And if so, who is going to finish my notes from clinic? Most nights, I go to bed feeling like a there's a bear hibernating next to me -- the bear of all the things I'm supposed to be doing, am late doing, don't know yet that I'm supposed to be doing -- and I just try not to wake it up. Just give me one more day, bear of shame....

But here is what I will not do: I will not waste any of the time I have with my daughter on the bear of shame. Our time together is not an expansive as I would like it to be, so I am going to use it to delight in her and in the world with her. I will try to get better at the thank you notes and the day care waiting lists but I will do that after she has gone to bed and if I'm too tired, I will go to sleep instead. I will probably never show up at a pot luck on time with home-baked goods. Many things will remain undone or not perfectly done. But E and I, we will do lots of fun and interesting things together. I may not have my s*%t together, but at least I know what's important to me. I'm probably never going to get rid of the bear of shame, but it's not going to eat me either.

So the Story of the Mother Who Didn't Have Wipes is actually the Story of the Fun Afternoon at the Playground. Instead of remembering that I didn't have any wipes and some other mother had remembered to pack them, I will remember my daughter's gleeful shriek as she wiggled her toes free of the sand piled on them. I will remember her little finger pointing up at the sunlight seeping in between the leaves of an enormous old-growth tree. I will remember her look of surprise as I blew the seeds off a dandelion and her subsequent earnest attempt to locate and un-seed every dandelion in the neighborhood. And hey, maybe I'll put a packet of wipes in my glove compartment tomorrow, because  I may not be perfect but at least I can learn.

Saturday, April 13, 2013

When shared parenting means you are no longer number one

Recently, my daughter went through a period of preferring my partner, her other parent. For about a week, I would come home from work, starved for time with her,  and she would run to my partner and make a big show of hugging her and demanding to go into the kitchen with her. At dinner time, she refused to be fed by me, accepting food only from my partner, her Baba. At bathtime, I would have to pry her from her Baba and endure her bitter tears as we trudged upstairs for what is usually our most joyful time together. I was on a particularly miserable month, working the longest days I've worked all year and feeling resentful, bitter, and guilty almost every waking moment because I was spending so little time with her. When this theater of cruel preference happened for the first time, I went upstairs, turned on the bathroom faucet, sat on the tile floor, and sobbed for fifteen mintues. Then I came downstairs and tried to be as cheerful as possible as I sat next to the high chair and watched dinner progress without my participation. The situation was no fun for my partner either, as my time at home is the rare window of relief when she can check her email and recede into her own mental world for a while. Only E seemed to be having a ball, cocking her head to one side and making flirty toddler eyes at my partner while pushing my hand away from the food on her tray.

A male colleague once complained to me that his son prefers his wife, even to the extent of screaming and pushing him away when he goes to to pick him up in the morning or comfort him at night. As he told me this, I'm ashamed to admit that I thought, "Well she is his mother," as if motherhood is synonymous with being a child's primary go-to, as if a father should be resigned to being second pick. Well, here I was faced with the same situation and I was not resigned. 

I am not my child's primary caregiver. As an intern, I work until 6pm on the best days which are few, 7pm on most days, and 9pm on the worst days which happen at least 1-2 times per week. I have a week each month where I am gone from 6pm - 9am six nights in a row. The rest of the time I leave the house before my child wakes up and then I do bath and bedtime whenever I can, which is 3-4 days per week. Every day I have off, every evening hour that can be squeezed from the stone, every hour I can delay going to sleep post call, I do, but it still doesn't add up to 50%. Not even close. So I am not my child's primary caregiver, but up until the aforementioned week, I was pretty sure I was her go-to, her first draft pick. After all, I carried her and birthed her and nursed her and I am the only one in this family who takes rectal temperatures, let the record show. Prior to this episode, she had always been pretty happy with either or both of us, absorbing the love and care and attention of whichever of us was available at the time, so the assumption I had made about my being somehow more sacred and important had never been tested.

It was not a pleasant situation. In fact "My child will prefer her other parent" is probably number 2 on my list of top fears about being a working mother, right after "My child will be maimed or die while in someone else's care." I googled "My child prefers her other parent" and discovered that this happens to lots of people. Some children prefer their working-outside-the-home parent to their working-in-the-home parent and for some it is the other way around. In families where both parents work, the preference cannot be so easily explained away. Sometimes the preference is temporary and sometimes it is more deeply ingrained. In families with multiple children, one child might prefer one parent while another child prefers the other parent. None of these preferences seem to fall easily along gender lines. It was comforting to read post after post about this problem, but none really addressed my fear which was that by working so much, I was losing the right to be my child's number one. (Of note, I encountered not one post from a man complaining about this. Do men just not post on online parenting forums? Is this something that does not disturb them? It's an interesting question.)

When I was forced to examine my need to be number one, I realized that the whole construct is flawed and not relevant to our family. I was our daughter's primary caregiver for the first six months while my partner finished graduate school, now she is the primary caregiver while I am in residency. We have divided the work of parenting in a way that feels natural to us and that has nothing to do with traditional divisions of labor. My partner cooks. I deal with illnesses and sleep. We both work and make money, though my job is currently more time-intensive and less flexible. I'm good at helping our daughter achieve developmental milestones, my partner is good at structuring her days and giving her the downtime she needs. My daughter has two parents who work cooperatively to meet her needs and I'm very proud of that.

I'm not going to pretend that this transition in my thinking has been seamless or complete. There are still moments of panic and jealousy that my partner is so much more present in my daughter's life, for now. Thankfully, the phase passed and my daughter is back to taking the love from wherever it cometh, but I can't deny that I am secretly pleased and relieved when she leaps ecstatically from my partner's arms to mine when I come home. But I am teaching myself to be just as happy when she leaps from me to my partner, because the net of safety and love that protects her is so much stronger than it would be if she were relying on only one person to meet her needs. If I weren't working so much, things might have played out very differently in the dynamics of our family, so in a way I'm glad that necessity has created the opportunity for a more shared model to evolve. Ok, I'm not glad. But I do think some good has come of it.