Mom Love

DSC_0419

Somehow tonight I got to thinking about all my patients who are moms.  I am filled with love and admiration, and compassion for all of them.  Maybe it was because today that is what I did most—momming.  Chauffer, meal planner, shopper, meal preparer, science project thingy seeker, organizer of the week to come (meal planner, babysitter/transport arranger, meal planner, shopping planner, piano lesson re-scheduler)…

I feel so grateful that I can work part-time.  I accomplish most of these life tasks on days when I’m ‘not working,’ as I used to say.  Now I call them days on which I ‘don’t see patients.’  All moms work; it’s a full time job with intangible and transcendent benefits, as well as hellish hours, often disproportionately low appreciation, and obviously no financial compensation.  Some of you may have seen a popular article this year on the mental workload of moms.  I highly recommend the short read.  Here’s a slightly older article that also includes references to research on the ‘work-home gender gap.’  And I absolutely love this eloquent, hilarious, and heartfelt to tribute to moms from last year, which is basically encapsulated in the first sentence: “I am the person who notices we are running out of toilet paper, and I rock…”

What tugs at my heart the most sometimes are the moms who have chosen to stay at home, giving up, at least temporarily, a fulfilling and meaningful professional career.  So many of them feel conflicted over making this choice, and then shame over feeling conflicted.  Countless times I have heard some version of, “Please don’t think I don’t love my kids, because I LOVE my kids!  …But (sheepishly) being with them 24/7 is so tiring, and I really miss using those other parts of my brain, having conversations with adults, and solving problems that employ my education and training.  But I love my kids, really I do, and I love being with them and I chose this and I know I should feel so grateful that we can afford for me to stay home, I just feel so guilty for ever wanting to be away from them, what good mom wants that??  But I’m so tired, and sometimes (pause) I wonder if I should have kept my job, worked it out somehow?  I never thought I would feel so torn.”  In these encounters I do my best to validate my patients’ choices, to reassure them that in no way do I question their love for their children just because they long for the company of peers and colleagues, and to address the consequences of their inner conflicts on their health and relationships—with self and with others.  I feel sad and angry that anyone would shame a mom for wanting to have a meaningful life outside of momming.

There’s the guilt of the working mom, also—which springs from the same pathological thinking that no good mom would want to be away from her kids.  But somehow these women seem easier to console, in my experience.  They often derive significant meaning from their work, and even if that is not the case, they take pride in providing for their families.  They also often report seeing themselves as role models for their daughters.  Regardless, I hate that these women have to deal with the same social gremlins as their stay-at-home counterparts—that somehow being a mom and having a career are necessarily divergent ideals.  This is an example of a false dichotomy that serves no useful purpose, and causes many of us to suffer unnecessarily.  Thankfully, others have written extensively on solutions; I really like this article on 8 ways to overcome mom guilt, regardless of your W2 status.

In looking up the articles for this post, I also came across this one, addressing the invisible mental workload of men.  I’m so glad I read it, because it reminds me of another fallaciously dichotomous rabbit hole: when we start exploring and addressing women’s challenges, the discussion too easily devolves into man-hating.  I claim my own susceptibility to this mindset, and thankfully this article helps me rein it in.  The same antiquated social pressures that tell women they ‘should’ always want to stay at home also tell men that they ‘should’ always want to be at work, and GAAAGH, it just kills all of our souls, a little at a time.  The author, Josh Levs, writes:

“All women who notice and keep track of their families’ many needs deserve big props and respect for it. So do the men who do this work. It’s crucial, detail-oriented, and never-ending. It makes a home a home.

“For 2017, let’s resolve to put aside misguided gender assumptions and work together to achieve a better balance and healthy work-life integration—for the sake of women and men.”

I wholeheartedly agree.  Let us stop with the guilt trips and shaming, and give all moms, and dads too, all our love for the ‘momming’ we all do!

 

The Movies That Move Us

IMG_6029

NaBloPoMo 2017: Field Notes from a Life in Medicine

The weekend has gone by too fast, and I have done none of the tasks on The List.  Oh well, it’s all good.  I got up this morning and made the green onion pancakes that my daughter loves so much.  We had a very successful shopping binge at Trader Joe’s and Target, woo hooooo!  And in between, we had something of a Christmas movie marathon:

“Love, Actually” (2003)

“The Holiday” (2006)

“While You Were Sleeping” (1995)

I’ve seen each of these movies so many times that I anticipate my favorite lines with giddiness and delight.  But they often end up serving as background on theTV as I accomplish other things.  Today, though, I was able to relax, sit, and watch.  It was touching and emotional, something of a re-centering.

What I love about each movie is how human all the characters are—there is something to relate to for every aspect of humanity in these films.  No one is perfect but all are lovable, all are flawed.  The relationships between characters—siblings, spouses, neighbors, friends, coworkers, parents, children, boy/girlfriends, and ex-es—are all interconnected, interdependent.  Somehow, watching these three movies in a row today, I’m struck by the portrayals of vulnerability, honesty, humility, judgment, love, and commitment, as well as lapses thereof.  It’s all so real, so human.

The hero’s journey is real.  We are all called to our own adventure, inevitably facing challenges and conflicts against our will.  We search for the easy ways out, alternative paths around our problems.  We avoid the hard feelings, the discomfort, the morass.  And then, somehow, we find a way—we meet someone who can help, we marshal our resources, we find the inner strength to do what’s needed, to carry on.  It’s messy and awkward, meandering and stumbling, often also hilarious and worthy of eye rolls and head shakes.  Looking back we find ourselves thinking, “Well why didn’t I just do that in the first place?”  And we can also appreciate the inevitable, valuable learning from the missteps and wrong turns.

Movies are movies, of course, not real life.  They are an escape.  They are also a mirror, as most art is.  They tell our shared stories, remind us of our relationships and connections through time, across nations, between genders and generations.  They’re called “movies” because they are still pictures shown in series to give the illusion of movement.  But perhaps we can think of them as moving us at our core, drawing us nearer to one another through shared experience and imagination.  The best movie experiences leave us a little cracked, a little exposed, a little sensitive—or a lot.  They remind us of our core humanity, inviting us to bring it forth and live it in authenticity.

Many thanks to all those who create and contribute to this art form.  You make us better.

Dr. Jerkface In Context—Healing the Patient-Physician Relationship

DSC_0507

Excuse me, I took an unintended break for Thanksgiving!  Hope you all had a wonderful holiday!

NaBloPoMo 2017: Field Notes from a Life in Medicine

For the past year or so, maybe more, I have increasingly tried to engage my friends in discussion around allied advocacy for physician health and well-being.  Inevitably, however, I’m met with anecdotes from my friends about asshole doctors.  It is a strikingly common experience, I’m sad to report.  And it makes sense:  If a patient has a bad experience with a doctor, ie the doctor behaves badly or the patient feels dismissed, ignored, disrespected, or mistreated, the normal response is to blame the doctor and assume that s/he is an asshole.  In each of these interviews with friends, it took a while for them to come around to the idea that the doctor him/herself may be suffering and therefore not behaving/performing their best.

But the next question is this: Do patients care about doctors’ suffering?  If they knew how the system harms physicians, would they have compassion for us?  What about if they knew how physician burnout and dissatisfaction directly affects their quality of care, all of it negatively?  What would move patients to stand up with and for doctors?  This is my goal for the indefinite future: to help us, patients and physicians, the end users of our medical system, stand up with and for one another, for positive systems change.

Right now I see it as a very personal, grassroots endeavor.  Outside of a one-on-one patient-physician relationship, ‘patients’ and ‘physicians’ in general are abstract groups to us all, and it’s hard to feel compassion for and connection with an abstraction.  “Patients are too demanding, entitled, and ignorant.”  “Doctors are arrogant, dismissive, and profit-driven.”  We carry these overgeneralized internal narratives and others into our encounters, often unknowingly and unintentionally.  Even when we think we see and know the person right in front of us, these underlying assumptions still color our experiences with them.  So whatever conversations we may undertake will take many repetitions to finally reach true mutual understanding.

I have been a member of my church since 1991.  Many others in the community have been there much longer than that.  There are other physicians, and we are all patients, ranging in age from infants to octogenarians.  I have proposed to host a focus group to discuss patient-physician relationship, especially as it relates to the effects of physician burnout on patient care.  The plan is to do it once, with whomever is interested, and see what happens after that.  I picture 10-20 people, patients and physicians alike, seated in a circle.

The objectives will be stated:

  1. Hold an open discussion about people’s experiences in the patient-physician encounter, and explore the context of forces that influence those experiences. Such forces include visit duration, documentation requirements, workflow inefficiencies, patient expectations, insurance status, and clinical setting (hospital, outpatient clinic, etc.).
  2. Participants leave with improved mutual understanding of one another’s experiences in the medical system and more likely to feel empathy and compassion toward their counterparts in the next encounter.

In the long term, I wish for patients and physicians to form a unified platform from which to advocate for policy change.  We, patients and physicians, are the end-users of the healthcare system, the largest combined demographic in the system, and I believe we are the ones who benefit the least from the system.  Health outcomes for American patients are dismal compared other developed countries, despite our exorbitant expernditures.  Physicians kill ourselves at more than twice the rate of the general population.

It’s not enough for medical professional societies to write co-authored, open letters to Congress.  It’s not enough for individual patient constituents to stand up at town halls and berate their representatives.  We must orient ourselves as resistors in series, rather than in parallel.  I think the movement will grow most effectively out of existing connections and relationships, through which we can find shared interests, common goals, and a strong, unified voice for change.

I seek your feedback:

  1. How do you picture this meeting going?
  2. How interested are you in learning about physician burnout and how it affects patients?
  3. If you were invited to such a meeting, what would you think and feel about it?
  4. What would make you more likely to participate?
  5. Would you want to host such a meeting in your community? How would you do it?

Thank you for considering, and see you tomorrow!

Incomplete Thoughts on Suicide

DSC_0029

Not selfish

Not thoughtless

Simply belief beyond shadow that no one will mourn you, people will be better off without you

Unimaginable for those who have not lived it

Most who try once don’t try again

So better to keep guns away

——————–

One of my high school classmates killed himself when we were seniors.  He shot himself in the head at home.  He was the vice president of our Students Against Driving Drunk chapter (I was president).  He was a member of the National Honor Society.  He was well-liked, always friendly, generous, smiling, encouraging.  He was a nerd, and so was I, so I thought nothing of it.  I did not know him well, and I never asked him about his life, that I recall.  I have no idea whether he was bullied or what drove him to take his own life.

The morning we found out, our calculus teacher had to sit down in the middle of the lesson. She was overcome.  One of my other classmates got up and hugged her.  She had more presence of mind than I.  I can’t remember if it was that moment or later, or if it was our teacher or someone else altogether, who said something like suicide is ultimately a selfish act.  That it was inconsistent with our classmate’s character to cause so many people so much pain.  That if he had known how much he would hurt people by this act, he never would have done it.  I can’t say I had thought anything about suicide before then, and I have probably not thought enough about it since, but her words stuck with me.  I’m not sure I would have ever come to this conclusion.

The way I understand (think I understand) it today, suicidality is such dark state, a place so far removed from where we connect with our true selves and others, including (especially?) loved ones, that people really do believe that everybody else will be better off without them, that there is nothing worth living for.  I cannot fathom that kind of disconnection and loneliness.  It feels almost too scary to even contemplate.  I feel totally incompetent to address this kind of pain and suffering.

I saw this video recently and it moved me.  A young man jumped off the Golden Gate Bridge and survived; he tells his story of instant regret for the attempt, and gratitude to be alive.

I pray tonight that if anyone in my circle is feeling suicidal, I may say or do something to help them know they are loved, wanted, and connected, and to keep them with us long enough to get help.

 

I’m the Doctor, You’re the Doctor

DSC_0401

NaBloPoMo 2017: Field Notes from a Life in Medicine

“I’m the doctor, just do what I say.”  I don’t think doctors actually say this anymore, but I wonder how many of us think it?  It’s probably not even a conscious thought, but rather an attitude—paternalistic and directive, a relic from the old days when patients had no power or voice in the relationship because the doctor held all the information and all the expertise.  Today patients are empowered by culture and the internet to participate in shared decision making , and it’s a good thing.

The problem with the “I’m the doctor” attitude is that it inhibits the patient from owning their own healthcare choices.  Then if and when the care plan goes badly, they feel rightly justified blaming the doctor, because they were just following orders.  Sometimes it’s necessary, like in the case of trauma or serious surgery, where the doctor is truly in charge and must make life or death decisions according to their expertise and judgment.  Thankfully this is not my work.

In primary care, if I take this attitude, I miss an opportunity to forge a collaborative and rewarding relationship with my patients.  If I simply issue orders, people don’t feel seen or heard, and they may withhold important information that would help me make a better, more relevant diagnostic and treatment plan.  And if they defy my advice (edict), as they are more likely to do when our relationship is transactional and cookbook, and things go well, then I lose credibility and they are even less likely to follow my advice in the future.

“You’re the doctor,” on the other hand, is something I hear often.  It usually comes up when patients (and I) are faced with decisions involving competing interests or vague risks and benefits.  An example is prostate cancer screening.  Guidelines over the years have ranged from screening every man, every year, starting at age 50, for life, to don’t screen anyone ever.  Most physicians and professional societies agree currently that the best approach is to discuss risks of screening (over-diagnosis, harm from testing in patients without disease) and not screening (missing early cancer, delayed diagnosis, possibly leading to preventable negative outcome), and make decisions based on patients’ individual values and goals.

When a patient in this or a similar situation says to me, “You’re the doctor, just tell me what to do” alarms ring my mind.  What I intend to be a shared decision suddenly falls to me to make unilaterally.  In this scenario, the patient essentially cedes responsibility for the treatment plan, and if it goes badly then it’s my fault “because you told me to.”  Or the patient may choose to ignore my directive and also blame me because “you told me to but I disagreed.”  Either way a patient may then feel justified to blame me for any negative outcome, even though I gave them what they said they wanted.  I understand that this is not how the scenario necessarily plays out, but somehow I’m wary of it.

I had my teeth cleaned today.  The dentist recommends x-rays every year; I politely decline most of the time.  I just don’t understand (or accept?) the rationale and benefits of annual radiation to my face, and I’m cynical about the fee-for-service structure in which providers make more money for ordering more tests (which is a legitimate concern in medicine, also).  Without explaining why it’s recommended for me particularly (it was explained later), I heard, “Well, it’s okay if you don’t do it today, but you have to do it next time.”  [Expletive, not stated out loud.] I am emotionally triggered when people try to tell me what to do without asking me what I think about it first (see my post from 2 days ago).  So I bristle when I witness colleagues doing it, or when my patients demand it from me.

I don’t see my job as telling people what to do—I am not a surrogate.  Rather, I think of myself as consultant and guide, expert, counsel.  It’s my job to discuss, explore, explain, review, consider, negotiate, compare, assess, debate, explain and discuss again, and then make a shared decision.  This includes follow-up and contingency planning, setting expectations, and reassurance about my commitment to the person, regardless of the problem.  I’m the doctor, you’re the patient, we are a team.  We are in this together.

Gratitude Again

Office view 11-20-17

NaBloPoMo 2017: Field Notes from a Life in Medicine

I generally dislike cold, damp, cloudy weather.  I have survived this in Chicago the past 26 years, somehow, by grace.  Usually the second half of fall just feels dreary, wet, and lame to me.  And yet this season, on this drab day, I feel warm and happy inside more than last year.

Can’t say why, really.  Another year older and wiser, perhaps?  Maybe because the kids seem to have crossed some magical threshold on this side of which they seem suddenly much more mature and self-sufficient?  I’m entering my fourth year in my current practice, which is the magic number for really settling in, it seems.  With the patients I only see once a year, the third and fourth times bring a familiarity and rapport that can only come with time.  It’s like catching up with old friends.  I’m grateful for another year of watching my family grow and flourish.  I’m grateful for my work, and the immense personal and professional fulfillment it affords me.

Two years ago for my first NaBloPoMo, I wrote November Gratitude Shorts.  It was a spinoff from a Facebook trend in which my friends and I posted gratitude for something every day.  Writing a couple sentences a day was fun and easy; converting those ideas to full-fledged blog posts proved more daunting than I had anticipated.  It felt like a slog much of the time, though I did write some pieces that I’m still proud of.  Last year I felt more relaxed, less pressured to write profound things.  This year I’m actually having fun, though I can still only rarely make myself sit down to write before 10pm.  That will be the challenge next year.  I am grateful for the chance to practice my writing and share with a community of readers, writers, and friends.

I feel the holidays coming on, a little more acutely this year than last…  It’s been a tumultuous year, no doubt, in so many realms.  And yet we are all still here, relationships intact for the most part.  And many of us, happily or begrudgingly, have learned a little more about our biases, our emotional triggers, our friends’ and families’ hidden beliefs, and similarities and differences we did not know we had before.  The conversations continue, then maybe stop for a while.  Emotions heat up, cool down, heat up again—and hopefully the connections remain or even grow stronger.  I have hope that we can continue to do better, and I’m grateful that the trials of the past year have shown me what courage and resilience we have.  I am grateful for the holiday season every year, and the chance to reflect and advance.

A friend told me recently about marriage advice he received when he was young.  We get beyond infatuation and on to real love, he was told, through commitment.  This past year I have seen myriad examples of people making meaningful commitments—to their families, to their core values, to their ideals, their aspirations, their fellow humans.  The examples are everywhere, if we are open to seeing them.  I am grateful for the persistence of humanity, and for our innate drive to connect.

The holiday season is upon us, and truly, I wish us all peace, love, and joy.  I’m grateful to have so much to celebrate, so many to celebrate with, and so much to look forward to.  May you feel and be moved by all that holds you up, this season and for all seasons to come.

Bring It

DSC_0524

NaBloPoMo 2017: Field Notes from a Life in Medicine

Had my knee MRI yesterday.  I had been looking forward to it for over a week, trying to predict what it would show.  I was thinking a serious meniscal tear, since I have had crackling in my knee for so long and I surely must have arthritis by now, from all the falling on it I did in my youth.  I lay perfectly still and started to get sore where I expected to feel medial meniscus pain.  I could not wait to know the results.  I just wanted to know what I’m dealing with, so I can figure out next steps, get moving.

Since it’s a weekend, I won’t know the radiologist’s report until tomorrow.  Suddenly part of me doesn’t really want to know.  What if it’s really bad and the only option to regain function is surgery?  What if it looks like I’ll be permanently disabled in some way, never able to get back to my previous level of activity?  What if that prognosis totally throws me off and I let myself go, become a sedentary lump, weigh over 300 pounds, and die in five years from heart disease and depression?  Truly, this could end my life, some poisonous voice hisses in the recesses of my mind.

But hubs is the ordering physician and he looked at the images with me tonight.  Lots of fluid/swelling.  Bruises on both bone ends of the joint.  Good news, the menisci are intact and look normal!  Woo hooooo!!  Posterior cruciate ligament also looks normal—thick, uniformly black (swelling and inflammation are light on this image), well-positioned.  Can’t find the ACL.  Huh.  He says 10% of people don’t have one.  That’d be cool, because if I never had one then it couldn’t be torn.  But the bone bruises alone are not enough to explain the swelling and pain.  So either it’s so inflamed that the fluid obliterates it on the MRI, or I have completely ruptured it and the little stumps have retracted out of view.

I had wondered which I would rather have, a serious meniscal or ACL injury.  I had leaned toward the latter, because the ACL can be fixed.  Meniscal tears really don’t heal; the body smooths them over somewhat with time, but the end result is just less cartilage, faster wear, and more tear.  The problem with an ACL injury, however, is that it increases the risk of future meniscal tears.  So either way, the knee will never be the same and now I have to deal with it.

We will wait for the official report, and I may see the sports orthopod.  Here’s what I don’t want from that appointment: For him to tell me, “Cathy, you should stop playing volleyball or anything that requires jumping, sudden movements, or the like.  You’re too old and your knee will just be hurt again.”  I will be polite, but in my mind I will think, “You can’t tell me what to do, I’ll play f*ing volleyball if I want to, and I will do it with or without your help.”  What I would love for him to say is this:

“Cathy, here is what’s going on in your knee.  It’s likely that these factors contributed to the injury (lists possible risk factors that he knows from my history), and also it was a freak accident that can happen to anyone, especially jumping female athletes (which is true).  It’s a good thing you’re pretty healthy to start with, and that you had gotten fit these last few years.  What do you want to do now?”

I’ll tell him that I really want to get back on the court and play.  I’ll tell him I want to keep doing all the training I’ve been doing: elliptical, Kangoo running, TRX, pistols, golf, and Betty Rocker workouts.  I want to take up new things like Orange Theory, kickboxing, martial arts maybe, and who knows what else?  I want to be the most active person I can be, and I want to JUMP.  I’ll tell him that I want to be responsible about it; I’m not going to ignore the risks and be stupid.  I want to know the risks, the evidence as it applies to me as specifically as possible, the 44 year-old mom with lax ligaments and super-flat feet.

Then I hope he tells me, “Okay then here’s the plan.  We gotta rehab the knee really well.  Ya gotta be patient.  Keep up with your trainer, strengthen all the muscles around your knees, continue working on core, posture, and form.  When you start jumping again make sure you know better how to land, train that muscle memory and get it down, own it.  Take your time, and take it easy when you start again.  There are braces you can use when you play that will help keep the knee stable.  And you still might hurt yourself again, there’s no way to predict what will happen. But if that’s what you want to do, I’ll do my best to help you get there.”

Because here’s the deal, my friends:  I own my decisions, but I need help to make them in the most responsible and informed way possible.  I don’t need someone paternalistically telling me what to do, how to live my life.  I need the doctor to explain to me the risks, benefits, and costs of what I may want to try.  Then I need to him to trust that I will make the best decision for myself, based on my own core values and goals.  I understand that nobody can predict the future.  But I also have a clear vision of the future I want.  I want to live a very active life, able to try new things and connect mind with body with spirit, and with other people.  I want to look back in 10, 20, and 30 years and say, “I did what I wanted to do, I made my decisions with the best information I had at the time.”  I may hurt myself again.  I may end up with a knee replacement before age 60, and never run or play volleyball again after that.  But if I get there having thoroughly assessed the risks of my actions, having taken all reasonable steps to proceed safely, and having continued to have fun and enjoy my mobility as long as I could, then hopefully I will regret very little.  I would much rather live this scenario, than get to that age wondering, “What more could I have done?  Did I sell myself short?”

This is how I discuss decision making with my patients, particularly when it comes to screening.  Their decisions must originate from their personal values and health goals, not mine or anyone else’s.  How do they understand the risks, and which worst case scenario of screening or not screening, treating or not treating, will they regret less?  A very athletic yet osteoporotic 65 year-old woman really does not want to take medication.  So we review her daily dietary calcium, vitamin D, protein, and vitamin K intake.  We make sure she continues weight bearing exercise every day.  We pay attention to balance, flexibility, strength, vision, and fall risks.  We reassess her risks and goals every year to make sure that we are still on the path she chooses for herself.  I present her with as much evidence as I can, for efficacy of medication, her personal fracture risk, and potential consequences of fracture.  In the end the decision is hers and hers alone; I serve as consultant and guide.

Meanwhile, knowing what’s likely happening in my knee gives me peace and confidence.  Now I can make a plan.  I’m convinced this is why my knee feels better tonight than it has in days, although the ibuprofen I took this afternoon probably also helps.  I have a new compression sleeve that fits under my dress pants.  I can get back to my workouts, and maybe add on a little every week.  My motivation to eat healthy just got a fierce boost (Betty Rocker really helps with this—I have no financial interests in her business, I just really like what she does and how she does it).  I’ll start physical therapy soon.  No volleyball for likely 6 months.  But I got this.  Bring it.