Documentation

Do you keep a lot of mementoes related to your kids? What about other aspects of your life?

I tend toward the less-stuff end of the spectrum, but I want to keep the special stuff. At home, I prefer calming spaces that are cozy but aren’t teeming with trinkets - it gives me sensory overload. It’s been said that we shouldn’t document our experiences too much, and that with time the most salient features of an experience stay with us, while the lesser details or perhaps the aspects we’d rather forget dissolve with time. I tend to think this is the best approach to take with the past. That’s not to say I never document, but I don’t get caught up in cataloguing everything. And with smartphones, I find my phone pictures act as a diary themselves. 

At work, of course, we document EVERYTHING and often in great detail. As a family physician, my notes range from a sparse, simple visit to a long and detailed assessment. It’s no surprise, then, that with the amount of documentation I do daily, I feel exhausted at the thought of further documenting. 

Long ago I accepted that I didn’t feel the need to journal on a regular basis, as much as I admired those who did. Writing was often what I turned to during challenging times. It still fills that role, and has also become a way to process different kinds of experiences. Recently I did an online writing course that reflected on motherhood that I would highly recommend. But the constant recording of exactly what I’ve done, when — no, that’s too much.

I recently went through old papers at home and found a card from one of my closest friends, written just three months after we’d met back in university over fifteen years ago. Just seeing her handwriting was such a treat, with most of our current communication occurring in fonts. 

With my young kids I’m saving special artwork in binders with page protectors - it’s quick and easy to slip them in and to look through them that way. I let a stack build up then put them in, in my best attempt at chronological order. Overall, though, I'm trying to focus more on the moments.  

On Family Medicine

I wondered during undergrad if I could do medicine and "have a life". I didn't have a lot of first-hand contact with physicians, and had just started to consider a career in medicine, so I really didn't know what a medical lifestyle was like. I knew it could be incredibly demanding and busy, but I wasn't sure how much flexibility there would be. In the end I suppose I still didn't really know, but I figured if others did it, I could figure it out too.

We had the chance to get early clinical exposure at my medical school. I had always planned to do family medicine, so every Wednesday afternoon in my first year, I would take the bus to the family medicine clinic of Dr. B. Dr. B's patients adored her. She truly listened to them, and was clinically excellent too. Seeing patients -- real people with real problems! -- was thrilling. I get a reminder of this from time to time in my office when I have early medical students join me. Looking at a tympanic membrane is exciting to them! It's a great boost. 

During medical school, I went through the "cardiology! neurology! infectious diseases!" rotation in my mind, until it was clear that being a generalist was what I wanted. Internal medicine was tempting, as I actually enjoy learning minutiae, but I loved women's health, pediatrics, and doing preventative care. The flexibility of a career in family medicine was unmatched in my eyes. So from clerkship onward, I continued to feel that family medicine was the right fit for me. 

I now have a family practice of about 1200 patients in a small group practice, and see patients for about 30 hours per week.  Charting, results and other paperwork takes about 8-10 hours a week.  I block one day off every month for self-care or catch-up time - with young kids, if I have to cancel a clinic due to their or my illness, it’s nice to have a day available to re-book patients. I can book off in advance for appointments for the kids or myself, or fit in local CMEs or meetings related to some community health work I do. The demands of my practice - and of home - fluctuate from week to week, but generally it feels like a good balance. 

I ran into a lovely, well-meaning non-medical friend a little while ago. "How's work going?" she asked. "Ah, it's been a long week." I said. "Lots of coughs and colds?" she mused. "If only!" I thought. I tell this to students a lot: family medicine can be very challenging, medically, and very draining, emotionally. So rather than things like a chest cold or plantar wart being boring and mundane, they can be a very welcome break from the challenging things we see at times.  The medically complex cases are invigorating, and the emotionally draining cases, highly meaningful; the "mundane" cases act as a much-needed foil. And above all, when you know your patients like you do in family medicine, it becomes much more about caring for the person in front of you than about the particulars of their issues. 

Reverberations

March 20, 2003. I stand with other students, staring at a television in my university's student union building, watching Baghdad being bombed. Explosions light up the screen. "Shock and awe". I'd spent many hours in the preceding months organizing, marching, due to the pressing need I felt to do whatever my small part was to stop the impending attack on Iraq. In the end, not surprisingly, it went ahead. I was grateful that Canada wasn't a part of it, but still, here it was. I stand watching war on television. 

In the strange happenstance of life, I now spend my days in family practice, seeing Iraqi refugees resettled in my city, still reeling from the effects of the war. Crippling PTSD pervades some of their lives. Yes, they have built new lives in Canada and many are thriving, but the ones who aren’t take up most of my attention. Layers upon layers of trauma. And for all of them, the sense of loss remains. I think of these effects as the reverberations of those initial explosions - rippling out across the world and the Iraqi diaspora, for years. 

This is, of course, not unique — the longstanding, multi-generational effects of trauma are felt within many communities.  But it’s one that’s close at hand to me, almost every day. During the student and community campaigns that I worked with to urge non-violence, I strove to think of the individual men, women and children who would be affected on the ground in Baghdad. Today, I know some by name.

  

What's This Week Been Like For You?

I’m sure we all have an opinion about the election outcome; most likely, a strong one. I was following with intense anticipation as a Canadian. I am utterly despondent with the result. The day after, I met a friend for coffee and together we tried to process the reality. It felt much like the morning after 9/11, where we knew we were facing a ‘new world’ and an uncertain future. 

Our national public radio station’s coverage was filled with interviews with Americans relaying their uncertainties about the future. One gentleman felt a sense of betrayal by his neighbours; that he did not feel he really knew his city as he thought he did. I know that some of you are heartbroken, as I am. Others may be elated, or at least satisfied with the outcome. Some of you may feel conflicted. Still others may be Republicans who feel dismayed that Trump was their candidate. Maybe none of these captures your sentiments. I know many people are struggling to talk to their children about the outcome. Many American citizens and residents of colour and other vulnerable populations are especially worried about the “Trump effect” on their children, and perhaps some of you are seeing its effects in your daily life in medicine. In Family Medicine, it's not uncommon for some patients to bring up political topics, but I try to stay pretty balanced and general.  Personally, I found inspiration here, which cites this great article about talking to your kids about the result. Reading personal accounts and opinion pieces by those who are processing the results thoughtfully is helping me deal with the result. 

I realize that politics in general, and this election in particular, can be polarizing to discuss, and I know this blog does a great job of being a safe space. A refuge from the constant barrage that was so consuming during this campaign, perhaps. I think we can maintain that safe space by respectfully sharing our own personal experiences, fears, and worries. Because no matter your political stripes, I think it’s fair to say that the months ahead are uncertain for the United States, and the world.  

I have great faith in the American people, and the American system, to uphold their democratic values. I believe that most people are decent and that political and social tides ebb and flow throughout history. Let's help one another navigate the best way forward for our families, communities, countries, and the world. 

Living Your Questions

I’m sure you’ve heard Sheryl Sandberg's advice to women, "Don't Leave Before You Leave". Well, several years ago, I faced some choices. I had finished Family Medicine Residency the year prior. As planned, I did a series of temporary positions filling in for other doctors - the usual course of action for new grads in my field and location. These experiences were crucial in showing me the kind of practice style and environment I desired. After a year, though, I longed for "my" patients - to be able to get to know people, and follow them over time, both personally and clinically. It was unsatisfying to frequently step into a new clinic environment, never knowing how complete (or legible) the patients' charts would be, and never being able to follow a patient for very long.

Then, I filled in for a colleague's vacation at a great clinic and I didn't want to leave. Another doctor there asked for maternity leave coverage and I happily obliged. It was so refreshing: the clinic physicians were collegial, the staff was efficient and professional, and the electronic medical records system worked like a dream. The great news was that they had room for me to start a practice there. 

This idea daunted me: was I ready to commit to a practice? I wasn't sure, actually, because Family Medicine has its challenges and those that concerned me most were dealing with patients whose expectations greatly conflicted with what treatment I was comfortable providing, as well as assessments of disability for which I felt woefully untrained and unqualified.  I also had interests beyond clinical medicine - in academics, including medical education and research. Wouldn’t it be great not to be tied down? Many of my colleagues continue doing locums for years, and have great freedom and flexibility. Finally, my husband and I wanted to start our family: wasn't it foolish to start a practice when planning a pregnancy? I had uncertainties, and wasn't sure what was the best next step. 

I went for it anyway. I read and reflected on a couple of things: one, that I owe it to myself and potential patients to try practicing "real" Family Medicine. I knew it was the only way I'd find out whether I liked it. After all, having your own patients and directing their clinical care is so different than covering for another physician -- you set the tone of your practice. Further, I came across this powerful statement during that time - "if your next step doesn't scare you a bit, you're not pushing yourself hard enough”, which further reinforced my decision. This, I might add, is quite uncharacteristic for me - I am a very careful decision-maker. And the truth is, for the first few months, I still wasn’t sure that I had made the right decision.

Nearly six years later, I love having my own practice.  I get to establish a rapport with my patients, and partner with them on their journey to improve their health. I have been able to really delve into the problem-solving that makes medicine so engaging. I was also able to serendipitously find and develop an interest in refugee health.  Skill-building in this fairly new, actively growing field added another dimension to my practice, and allowed me to incorporate teaching with medical students and residents and involvement in community initiatives. 

As it turned out, it took my husband and I longer than anticipated to conceive. We are now grateful to have two young children, and I’m grateful that after each maternity leave I looked forward to returning to my practice. The experience of being completely unsure of my decision brings to mind these lovely words by Rainer Maria Rilke, which I first encountered several years before, during another period of uncertainty:

“Be patient toward all that is unsolved in your heart and try to love the questions themselves, like locked rooms and like books that are now written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer.”

Summer Book Recommendations

Ah, summer. There's nothing like the joy of sitting with an iced tea and a book on the deck... or waiting in the dentist's waiting room reading tiny print from a reading app on your phone.

1. Vaccinated by Paul Offit. It was completely fascinating to learn about the early days of immunization. Even if you've learned the science before, reading about the social context is so interesting.

2. Overdiagnosed by H. Gilbert Welch. This book changed the way I look at my practice, every day. Welch is an epidemiologist and explains the principles in a very accessible way.

3. Crazy Like Us: The Globalization of the American Psyche, by Ethan Watters. A must-read, especially if you work in mental health. I see a lot of refugee and newcomer patients, and do some element of cross-cultural mental health most every day. It's challenging because our entire mental health assessment is rooted in the culture in which it was created, and the very definitions of mental illness vary so widely in different contexts.

4. When Breath Becomes Air by Paul Kalanithi. I know you are hearing about it everywhere. It is beautifully written and helped me reflect on medicine in a different way. "But if I did not know what I wanted, I had learned something, something not found in Hippocrates, Maimonides, or Osler: the physician's duty is not to stave off death or to return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence."

I was on a female memoir kick last year, and thoroughly enjoyed the following:

5. Julia Child's My Life in France. Transport yourself to France and witness the early days of her love affair with French cuisine.

6. Nora Ephron's books of essays, I Feel Bad About My Neck and I Remember Nothing were, of course, hilarious.

7. Laughing All the Way to the Mosque by Zarqa Nawaz. Zarqa Nawaz is the creator of the TV show Little Mosque on the Prairie. She diverted from her parents' expectation for her of a career in medicine and found her way to journalism and the arts instead. As a fellow Canadian Muslim woman, I loved hearing her always-funny perspective on issues she faced along the way.

8. I Was a Really Good Mom Before I Had Kids by Trisha Ashworth and Amy Nobile. A down-to-earth book about the real issues we face every day as mothers, I found it totally affirming to read.

Fiction:

9. On Beauty by Zadie Smith. "And so it happened again, the daily miracle whereby interiority opens out and brings to bloom the million-petalled flower of being here, in the world, with other people. Neither as hard as she had thought it might be nor as easy as it appeared". Filled with breathtaking passages but also dry humour and wit, On Beauty was captivating.

10. Everybody Has Everything by Katrina Onstad. Following years of infertility, a young professional couple takes guardianship of a young child when their friends suffer a terrible accident. The struggles of being thrust into parenthood of a unique sort; with the same truth that we all live with - the uncertain future.

What books would you recommend?

On Five Year Plans

This is a throw-back to a MiM post back in 2013 that really resonated with me at the time, and still does, in which T writes about someone asking her, "Do you have a five year plan?"

When asked this recently, I fumbled. Actually, I tossed back the answer, asking the asker to mentor me through getting such a plan. It wasn’t even someone who knew me well and it had been asked in a fairly casual way. Regardless, I was not able to answer the question. But if I were to answer it, the answer would be, “No I do not.”

The comments that followed included other MiMs stating that they too did not have five year plans. People cited living in the present, and checking in periodically to ensure satisfaction and fulfillment, but not necessarily a structured plan. Others did have plans, which they found informed their present-day decisions. I was on maternity leave with my first when I read this post, and was feeling very unmoored. I felt that I should have a very clear path of where I wanted to go in my career.

I remember being asked the same question by a male faculty member during my first week of medical school. I fumbled too, as I entered medical school interested in family medicine but open to possibilities. My surgeon-keener classmate piped in with his plan for surgical specialty x, making me feel even more self-conscious. In retrospect, I don't blame myself one bit. I think some people do well with a well-defined, honed-in focus. Others, like myself, find the goals harder to identify; my priorities have to emerge - they can't be easily forced out.

I have broad goals - community contribution through medicine and beyond, strong faith and family, a healthy lifestyle. I have diverse interests; one is health equity, which has led me to refugee health. Various other interests have led me to different projects over the years.

I do find it helpful to have short-term career priorities; a necessary honing-in to avoid over-commitment and burnout. Dr. Mamta Gautam, the Canadian physician wellness expert, tells physicians that as people who have plenty of interest and enthusiasm about many things, there will always be more interesting things that we want to do, more than we could possibly have time for. So, it is a matter of choosing and narrowing down options.

Right now, I'm focusing on clinical work, local refugee health coordination efforts, and writing - both here, and on a blog aimed at patients. I supervise learners periodically, but have flexibility. There have been other tempting opportunities recently, but I have declined them in order to preserve family and self care time. Personally, I need regular downtime. I schedule a day off every month, sometimes more. I need some "empty space" on the horizon in my calendar, which can involve self care time, and sometimes catch-up work and projects. With two young kids, I've found the regular days off invaluable for recharging.

With the births of my two children, the last four years have been full of transitions. I think motherhood fits naturally with evolving priorities and goals. I look forward to more changing priorities over time. And I'm still OK with not having a five-year plan.

Are You Suffering from Overcare?

Dear MiM,

This is my first post, so I will introduce myself. Thank you so much to KC and all of you veteran MiMs for this opportunity. I've been a reader for years, since residency, and found MiM so helpful when thinking about my future career. I'm a family physician in a mid-sized Canadian city. I've been in practice for seven years, which still feels very "early career" to me. I work full time - 35-40 hours/week counting clinical plus admin time. I call it full time but always somewhat sheepishly around other physicians! I have a three year old son and one year old daughter, and a work-from-home husband. I'm involved in refugee health work and am community faculty for our medical school. For me, some amount of "big picture" work has always helped me maintain enthusiasm and appreciation for the clinical work. I look forward to reading your stories, and sharing mine!

N.

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A few months ago, I was getting bogged down by excessive self doubt and perfectionism at work. The main way it manifested was in ruminating and worrying over decisions once I'd made them, but there was also over-thinking clinical choices, triple- (quadruple?) checking, and asking for advice when I really didn't need to. I try to take a pretty balanced approach to life, accepting the "good enough" principle and refraining from placing unrealistic expectations on myself. But "good enough" never seems to fit with medicine. I can accept vulnerability and imperfection in other areas in my life, but medicine? There's no room for it. I think our patients and society echo this as well; after all, it's comforting to think that physicians are the ultimate authorities in health and it's disconcerting that we are inherently flawed humans. We are socialized and trained in this mindset as well. Of course, we must be conscientious physicians. I'm not talking about being sloppy or less than thorough. But, recognizing that we are human, even when we are conscientious, careful and keep our knowledge and skills up-to-date, we'll falter.

During this time, I came across an excellent article on the topic of Overcare, written by the late Dr. Lee Lipsenthal and adapted from his book "Finding Balance in a Medical Life". Overcare was a new concept for me, and a useful one. Dr. Lipsenthal talks about overcare as a chronic emotional state that physicians can get into, and it involves agonizing over decisions we have made, and at the core of it, wondering "Am I a good enough doctor?" There are several factors at play. Our personalities tend to be perfectionistic, and we do carry a lot of responsibility. He talks about our addiction to being needed and how the intermittent positive reinforcement we get from patients can lead to us doing more and more, hoping and waiting for the "reward" of a satisfied patient. The perfectionism expectation in medicine is often instilled into us during training, and also informs how we judge others; we in turn also fear being judged harshly by our colleagues. This is especially true for me as a family physician. Any time one of my patients is seen in the Emergency Room or by a specialist I've referred them to, my care will be under scrutiny. I find that Impostor Syndrome often tags along with this overcare and perfectionism. If your expectation is that a "perfect physician" is the default, yet you witness your inherently imperfect self, impostor syndrome can creep in.

How can we counter overcare? Personally, it helps to remind myself that I am competent and doing the best that I can. And that I am human. I try to consciously make a decision, and make peace with the inherent uncertainty. I ask myself a useful question from cognitive-behavioural therapy for anxiety: am I problem-solving, or worrying? If the latter, move on. Do I think about patients after hours or change my mind about decisions? Of course, but I have a better sense now of what qualifies as being conscientious, and what is actually overcare.

Do you struggle with overcare? Are there any strategies you've found helpful?