Is this really news?

I turned on the computer today to see this from cnn.com. The headline for a companion article trumpeted "Bravo to Sheryl Sandberg for Leaving Work at 5:30!" For those who don't know, Sheryl Sandberg is the COO of Facebook and a frequent speaker on topics of women's equality, particularly in business. She's a dynamo--a Harvard business grad, who was Chief of Staff at the Treasury Department (at age 29), a VP at Google (at age 32), and all that before leaving to become COO of Facebook in her late 30s--as well as a mom of two young kids. She's more than impressive and likeable. She's frankly kind of irresistible. Journalists gush on and on about her. And it's hard not to get drawn in to the videos of her public speaking.

So it wasn't surprising to me to see yet another article about her on cnn.com today. But what made my jaw drop was reading this quotation from her in the article:

“I walk out of this office every day at 5:30 so I’m home for dinner with my kids at 6:00, and interestingly, I’ve been doing that since I had kids,” Sandberg says. ”I did that when I was at Google, I did that here, and I would say it’s not until the last year, two years that I’m brave enough to talk about it publicly. Now I certainly wouldn’t lie, but I wasn’t running around giving speeches on it.”

I was shocked. It wasn't that I found her leaving at 5:30 so shocking (ok, a little shocking...she IS the COO of one of the hottest companies in the world). It was that she was admitting it, publicly, on cnn.com of all places, where you can never ever take it back! And, almost immediately, I began to question WHY this should be: 1) shocking or 2) even news to begin with.

There are clearly some professional cultures in which leaving early--and by "early" here, I mean "while it's still light out"--is a no-no. Surgery, venture capital investing, and corporate law come to mind. Even in kindler, gentler fields, including many of the general medical fields or medical subspecialties, many of us leave work at an hour the rest of the world would consider normal or even a bit late--i.e. in time for dinner with our family--like fugitives with the sunglasses on via side exits, hoping to encounter no one. Why should this be?

Over the course of the day today, I have been thinking about the implications of Sandberg's self-outing for my own life. I have a part-time physician job, and I love it. It is a fantastic balance of academic/non-academic, clinical/non-clinical, and at 3 days per week, a rare gem of work/family life balance too. You'd think I would be advertising this job all over town. But I'm not. Sure, I have held court on this blog about the joys of working part-time before. I've even gone so far as to post instructions on how to get a part-time job as a mother in medicine. But none of those things really count in the way I mean here because they're anonymous.

As recently as a few weeks ago, I was giving a lecture to a group of trainees and junior faculty at a prestigious medical center. The person introducing me was briefly reviewing my bio aloud for the audience and said, "In 2006, she accepted her current position as..." He followed that up by saying that he didn't know how I had ended up in my current position, which is somewhat unusual, and suggested that I briefly elaborate on how I came to take that job and what I do there. I explained that the job enabled me to do all of the things I really enjoy about medicine--think about important questions in oncology and design trials to answer them, see patients, etc--without many of the things I find unpleasant about medicine like having to write grants or rush through patient visits. What I didn't say was that the job also offered me a ton of flexibility. I didn't mention that it's the norm where I work for doctors to work a flexible schedule, that it's the rule not the exception for doctors there to work from home a couple days per week, and that, importantly, my boss-to-be had not only been persuaded to make the position part-time for me but had continued to advocate for me in that regard over the ensuing six years, spontaneously reminding people to be sure to schedule meetings on one of my three work days and asking that they be moved when they had been inadvertently scheduled on one of my "mom" days, etc. I had a chance to stand up at a major medical center, where I had been invited to speak because I have achieved some degree of expertise and respect in my field, and out myself as a working mother doing what it takes to make it all work for my career and family. And I blew it. When someone made a comment to the effect that I had two full-time jobs (because my appointment is a joint ones that spans two institutions), I smiled politely and accepted the obvious unspoken kudos. I didn't say, "No, actually I have two part-time jobs that still add up to less than a full-time job." Why not?

Like most part-timers, I have busted my tail at my job for the last 6 years. This is probably the result of some combination of typical doctorly compulsiveness, genuine career aspirations, work ethic, and desire to "prove" to my boss that letting me start and remain part-time was a good choice, both for myself and for future employees. But the truth is that it also allowed me to remain productive enough that colleagues in my field at other institutions never questioned whether I was full-time, and I was just fine with that. I had a sense, rightly or wrongly, that if they knew I was part-time, I would be in some way discounted as not as serious or not as dedicated as the almost exclusively full-time male doctors, or even the full-time female doctors. I'd be in a class all my own, and not in a good way. To this day, many of the people I work with at my own institution have no idea that I work part-time! Almost none of my colleagues at other institutions know.

With the publication of the cnn.com article today, I had a realization that, although I am not now and will presumably never be the COO of a large corporation, I have to some degree arrived in medicine. Whether it's my age or my productivity or ideally both, I am officially mid-career. And I owe it to my colleagues, both those at similar places in their careers, but more importantly those who will follow in our footsteps, to talk explicitly about work/life balance and physician/parenting challenges and solutions so that we can finally walk out the main entrance and call out a cheerful goodbye to all we encounter. It's time to end the stigma of working parenthood. I have decided, it's time.

Must the doctor ALWAYS be in?

First of all, for any of you who decided to read this post because you thought it might be a follow-on to the discussions about whether it's ok to work part-time in medicine, nope, that's not what this is about. Rather, it's about the tendency to wear our doctor hats even when we're off-duty, when it comes to our own health.

It was a Facebook status update, or rather a string of them, that first got me thinking about this issue: the epidemic of medical hypochondriasis among doctors and other folks in medicine. (For my friends in psychiatry, let me apologize for using hypochondriasis in the lay sense, not with any DSM criteria attached, and for my friends in epi, I know it's not really an epidemic.) A friend of mine, who is a mom of three and a critical care nurse practitioner in the PICU of a large academic center, often posts on FB about her anxiety related to her kids' health. One of them has a fever, and she wonders aloud whether she is the only mom checking for petechiae. Another says she's too tired to bike (in the 98 degree weather) and wants to come in and watch TV in the air conditioned living room instead, and she frets about whether she is severely anemic--it could be acute leukemia! It is easy to witness someone else do this and see the absurdity in it, but when it's YOUR lymph node that you think you might feel in your neck or YOUR lumpy breasts or YOUR bone pain, etc, it becomes a lot easier to let your mind spiral off into the crazysphere.

Most of the mothers in medicine with whom I have discussed this freely admit, "Oh yeah, my thing is cancer" or whatever. Everyone seems to have something she is convinced she is going to get, and it's often what she's surrounded by, not what she actually might be at increased risk for due to lifestyle or family history, that seems to drive the fears. My good friend from medical school who is now a pulmonologist in a tertiary care center became convinced that she had pulmonary fibrosis when she found herself out of breath in kickboxing (after taking off 2 mos from it). Another friend who is a high-risk OB attending just about drove herself insane with fear that she would have fetal death in utero. I have seen her on multiple occasions in all of her (3 healthy) pregnancies sitting in the hospital cafeteria with a sugary drink in one hand and the other hand on her gravid belly, brow furrowed, checking for fetal movement. Another who is a rheumatologist is obsessed with developing lupus, and given that lupus can cause any number of symptoms/signs, she gets a near-weekly dose of affirmation that THIS TIME, she really does have lupus. Kind of ridiculous, right? Except when you're in it rather than on the outside looking in.

I find myself worrying about cancer mostly, which I guess isn't shocking since I'm an oncologist. Every patient I see--well, except for a fortunate few who have been misdiagnosed--has cancer, 100% of them. And I see mostly second opinions, so they are usually pretty sick and often complicated patients. Though they all come with a big, thick chart, I always take my own history, and even in patients with several years of metastatic cancer, I always start with how the cancer first presented. I am struck again and again by how subtle the first signs were--that little twinge of pain in the chest that only lasted for a few minutes or noticing that she was slightly winded, just slightly, after dashing up a couple flights of stairs. Or whatever. I don't see the zillions of people who also had little twinges of pain in their chest or mild dyspnea who turned out to have costochondritis or an albuterol deficiency or absolutely nothing at all. I don't see ANY of those people. In other words, I have no denominator to provide me with perspective. Of course, these histories I'm taking are all retrospective, and maybe the "first signs of cancer" patients report were in fact utterly unrelated to their diagnosis, but have taken on significance in the wake of being diagnosed and repeatedly asked these questions by oncologists. All of this, I know, but I can't seem to remember any of it when it really matters.

So, I wonder: does this worry simply come with the territory when one works in a field where life-threatening diseases are the price of admission? Would I still worry if I were a primary care pediatrician, where the majority of my patients are so healthy they are actually labeled "well child"?

Do you find yourself worrying more than you feel is reasonable about your own health or that of your family/friends? Do you worry about the diseases you see in your own practice, or do you have "a thing" like cancer that you worry about, even if it's outside of your usual practice? And if so, how can we do a better job of being a voice of reason to each other? Because we are doctors. And we are mothers. Which means we have more than enough REAL things to worry about!

Virtually living

So, I guess this post is kind of an apology. KC periodically sends out gentle reminders to post on MiM, and I receive them with all good intentions. Despite a number of ideas for posts, I just haven't been able to bring myself to write them. It's not only my blogging really that has suffered, but dictating notes on patients, taking/organizing photos of the family, and a whole host of other things. I have had a growing sense of disquiet that we--people living in 2011, Americans, mothers, bloggers, doctors, any number of groups to which I belong--are so caught up with documenting that we have, in some ways that matter tremendously, stopped living.

This all started when I was attempting to declutter my house last fall. I had decided to try to scan some of my kids' artwork to jpg files on our computer, with the eventual goal of making a little bound book for each of the kids. My two older kids were at school and my 3 year old was coloring on her craft table next to the desk in our home office, the very same sort of artwork in the making. She said, "Mommy, look at my picture." I responded "Mmm-hmmm, that's beautiful" or something absentmindedly, trying to finish what I was doing first. "Mommy, it's a picture of you," she persisted. "That's wonderful, honey," I said, giving it a quick glance and rushing to save the work on the computer as I sensed my personal time was coming to a close. "Mommy, LOOK!" she said. "LOOK WITH YOUR FACE." And it stopped me in my tracks because I knew she had, in the way that kids often do, spoken a truth that troubles me about our generation.

This wasn't the first time I have been a little exasperated by our generation's compulsion to document and report. I tried to tell myself: it's just that I'm kind of a Luddite, and the notion of blogging doesn't come naturally to me. I confess that I signed up for a Twitter account about 2 yrs ago, but have never actually tweeted anything or followed anyone. I watch exactly zero TV shows. I have only the vaguest idea of what Glee or any number of reality/competition shows are about, gleaned entirely from snippets of overheard conversation or references on NPR. These are aspects of popular culture that just hold zero appeal for me. I sometimes wish that I could bring myself to want to partake--the same way that I forced myself to learn to like tea in college as a non-coffee drinker because I felt the need for a hot "social" drink I could have with my friends (ps I now like tea a lot). I was also a very reluctant, very late adopter of Facebook. I have come to realize its charms, but I remain suspicious. In my heart, I know that the time I devote to tending my FB friendships has detracted from time for actual friendships with live friends and even people living in my own household. It alarms and frightens me that meeting friends "IRL" (in real life) has become somehow quaint and exceptional.

This issue of documentation for the sake of documentation has threatened much of what I love and value in medicine. I see it everywhere. The most obvious examples, of course, can be found in all of the things we now find ourselves forced to dictate to justify billing codes or levels of care or to avoid malpractice claims, but what I see happening in the exam room is what unsettles me most. When I got pregnant with my first child in 2003, I remember my OB visits as 10 minute conversations with my doctor. She sat in a chair, I sat in a chair, we looked each other in the eye, and we talked. Yes, she referred to my (paper) chart from time to time--how was my hematocrit? what was the last fundal height? how many cm dilated was I last week?--and yes, I often waited 30 minutes for that 10 minute visit, but I still felt that at my check-ups, a human being was, well, checking up on me and my baby. When I got pregnant with my last child in 2007, a mere 4 years later, I went back to the same OB. She came in and stood for the entire visit every visit, swinging down a new computer suspended by a metal arm from the ceiling so that it partially obstructed our ability to see each other, and proceeded to click and type until the 10 minutes was up. I felt as though I had been doused with a cup of ice water at the start of every appointment. If I had concerns (and I had some: exhaustion caring for my two toddlers with my husband deployed, and my failing pelvic floor to name a few I still remember well), the new style of appointments provided no invitation to express them. I had more than a dozen visits with her. I never mentioned any of those issues. The point of the check-up now appeared to be checking boxes. The humanity had been lost, and I wasn't sure we could get it back.

On the playgrounds and at birthday parties, I see it too. Everywhere, mothers with their gigantic SLR cameras, frantically snapping photos of their kids. I have literally watched them shoot and review pictures the entire time, ignoring or maybe not even hearing their kids' requests to be chased or tickled or pushed on the swing or helped with blowing out the candles. I wonder what kind of memories they will be creating with these photos. Surely when the kids are young, they will remember very little. They'll get older, look at the family albums, and invent memories that string together the images. But what about the kids who are already a little older? I fear what they'll remember is their moms taking their cameras to the playground and allowing them to come along for the ride.

I received a throw-away journal in the mail recently that had a "spotlight" on a woman--a dietician and Shiatsu practitioner who blogs about wellness. Over the course of the interview, it came up that, in addition to the wellness blog, she also writes a private blog about her kids for family and friends, a culinary on the cheap blog, a craft blog, and a blog about the challenges of reinventing herself to return to the workforce after years as a stay-at-home mom. The interviewer marveled at how she and her husband manage the demands of now being a dual career family with four young kids and maintaining all of their blogs. (Her husband is apparently an independent consultant who writes a high-profile blog about business/pharmaceuticals and travels frequently for work.) The interviewer asked how they cope with the separations and whether it's been a positive or a negative in their marriage. The woman reflected that it's been pretty neutral from a marriage standpoint and that she mostly feels the pinch as a parent; it's a little more work to get the kids to sports practices, to corral the kids into bath and the bed. What made my heart sink, though, was when she quipped something to the effect of: "If he's in town, we spend our evening on our laptops. If he's out of town, we spend our evening on our laptops. Now if my LAPTOP starts having to travel overnight for business, then I'm going to be distraught." Wow.

I know we have to document. It's a medicolegal necessity, a method of communicating our thought process, and a means to avoid retracing our steps unnecessarily with patients. It's a legacy for our families and a way to ensure that precious moments are not lost in the midst of years of perpetual exhaustion parenting small children. It's an opportunity to connect with family and friends we cannot see often because of the limitations of geography or time. It's a hope for finding community or support or fellowship in the small, dark hours of the night from your family room once all of your kids are asleep or your spouse is working. But I also think it's time for us to pause to make sure we're not letting the tail wag the dog. We need to make sure that we are documenting to capture and celebrate the life that we're living and not just living to document.

Please hold

Nothing like seeing an old picture of yourself to serve up a big plateful of truth. You might thing I'm talking about aging, and I've certainly had my share of those moments--wait, I DID once have a waist, and other favorites--but no, I'm talking about delayed gratification. We went on vacation this summer to the beach near my sister's home. While we were there, we spent a day at her place. I wandered through her house, looking at pictures of us together from 7 or 8 years ago. And then, it hit me. The clothes. I had packed light for our weeklong trip since the kids had oodles of things they wanted to bring and we were driving. I had brought only 4 shirts. I was wearing 3 of them in the pictures on my sister's table. I suddenly realized: I HAVEN'T BOUGHT ALMOST ANY NEW CLOTHES IN 8 YEARS (maternity clothes excluded).

Now at least part of the reason is that I hate to shop. For anything. Truly hate it. I think clothes are fine, and occasionally I have been known to fall in love with an article of clothing, but I just cannot bear shopping, especially for clothing. Maybe it's the unforgiving dressing room lights. Maybe it's the chafing of taking on and off 2 dozen dresses. Maybe it's frugality, knowing that I will one day fall out of love with whatever I just spent that money on and will regret that I ever bought it. I don't like it much better online than in person, so maybe it's all sorts of things. As I looked at the pictures, I told myself, it's just that you don't like to shop. But here's the big plateful of truth that I grazed on as I drove home to our beach house that evening: I have come to think of delayed gratification as a way of life rather than part of life.

I think this problem began when I was a medical student. After 22 years of living largely in the moment, I was suddenly having to wait to satisfy even the most basic needs. Need to go exercise? Big exam in 48 hours, I probably should focus on that and exercise this weekend. Need to pee? Well, unfortunately I'm on the far end of a retractor in an abdomen, so I'll just hold it for about oh, 4 more hours. It only got worse as a resident. Need to eat? Oh, I have to pre-round, I'll just wait until lunch. Need to rest? Oh, 3 more admissions for in the ER, I'll sleep when I get home post-call...in 30 hours (this was pre-work hour restrictions). Want to go home for Thanksgiving or Christmas? Oh, I'm on call for Thanksgiving and taking every other night over Christmas, maybe next year. And on and on.

And then came kids. Suddenly there was a whole new set of things to postpone and a whole new set of reasons for the delayed gratification. I gave birth to 3 children in rapid succession, which meant that I was pregnant or nursing or pregnant AND nursing for literally almost 7 years. Want to get back in shape (not getting back to the original number on the scale, which has never been a problem for me fortunately, but REALLY back in shape...as in NOT looking like a mom)? Why bother? Hardly worth busting my butt for 6 months to get sixpack abs only to stretch everything out all over again a few months later. I'll wait. How about new carpet? Well, the toddler is potty-training. And the baby spits up milk every time she is vertical and sometimes when she's not. We'll do it in a few years once the kids are older. Maybe a nice bra purchased this decade? Oh, I'm nursing, so I'll just stick with this worn out one that I can pull down to nurse or pump and wait to get something pretty until I'm done and know what size I will end up. Ok, well, you can at least have some lunch. Hungry? Yep, starving, I'll eat in a minute...right after I nurse the baby and put her down for a nap, unload the dishwasher, switch the laundry to the dryer...

I have come to the conclusion that medical careers and mothering represent the perfect storm for training women to put off their own needs and desires eternally. Are you living in a state of delayed gratification? Is it necessity? Or habit? And if you're not, please tell the rest of us your secret!

And bringing up the rear...

Ok, so in honor of our birthday here at MiM, I thought it would only be fitting that I chip in my tribute about a week or so late. Though I have been repeatedly accused of making readers cry on this blog, and in fact my favorite posts admittedly DO fall into the category of tear-jerkers, I'm not completely a one trick pony. Occasionally I find comedy in the intersection of medicine and mothering, and here's my proof. If I should be known for anything on this blog, it would have to be lateness. Every topic day/topic week, I am dead last to contribute if I manage to contribute at all. Usually it comes at about midnight on day #7, but since it's our birthday, I thought I would sleep in and make my contribution a whole week or so late. Happy Birthday, MiM! And many more!

Forget 50-50

Yesterday I saw a new patient in my clinic, an elderly woman with metastatic breast cancer for several years. In oncology, the only part of the history that interests me more than the HPI is the social history. It is often where I start when I meet the patient, and not only because it's an ice breaker and comforting territory (most patients come to oncologists scared out of their wits). It is there that I learn how educated my patients are and whether they work in science, accounting, or engine repair, which helps me to decide what "level" of explanation of very complicated stuff will best serve them and whether I might be able to draw analogies with things that are familiar to them. It is there that I get some early prediction of compliance and ability to cope with the disease and its treatment: does she have family to bring her to appointments?, does she have someone to go across town to the 24 hour drugstore for her at midnight when she needs more nausea medicine? The social history is my gem.

The patient I saw yesterday had been married for almost 70 years. Wow! You don't see that often. Many people don't even live for 70 years all total. I congratulated them on it and remarked about how wonderful it was, but the conversation quickly turned to their concerns: their kids and grandkids and greatgrandkids (can I still be around them if I am on chemo?) and vacationing in Florida every winter (is is still safe for her to do it?)

At the end of our visit, my last of the day, her husband said, "May I ask you a personal question?" "Sure," I answered. "Are you married?" "Yes, for 8 years, 3 kids 6, 4, and 2." They beamed. Then he said, "So, don't you want to know the secret to staying married for 7 decades?" I thought about that for a moment. Of course I wanted to know. I am in a profession with a high divorce rate. I am married to someone who is active duty military, a group that also has a high divorce rate. I am the child of divorced parents. I hadn't really given it much thought before, but if I had, I might have felt doomed. So suddenly, the social history felt more like a gem than usual. "ABSOLUTELY! PLEASE!" I replied. He said, "Forget 50-50." I must have looked confused because he went on. "Your generation has come closer to equality for women and men than any in the history of our country. And that's a wonderful thing. Only trouble is that now everyone thinks everything, every minute, should be perfectly equal, perfectly divided, 50-50. And the reality is that, in a marriage, it just about never is." His wife had been listening quietly, but then piped up. "It's the truth. When our kids were very young, I was at home with them, and he traveled most weeks Monday through Thursday or Monday through Friday. There were years there where I felt like I was doing 90% of the work of our home and family." He interjected, "You didn't feel like you were doing 90% of the work, honey. You WERE doing 90% of the work." She nodded in agreement. She went on, "Even after he changed jobs and was home more, I still was the one who ran the carpools and worked the bake sales and double-checked the homework. It was 70-30, maybe 60-40 at times, but never 50-50, though we didn't really think or talk in those terms back then." He admitted, "There were times when we thought it wasn't worth going on. Mostly she thought it wasn't worth going on. But we stuck it out." She said, "It's true. There were times when I thought the tables would never turn. But...the last 8 years, Henry has done everything. He cleans our house. He gasses up our cars. He weeds the garden. He shops for the groceries. He makes every single meal. He even buys the cards for all the kids' and grandkids' birthdays and anniversaries and so forth, brings them to me with a pen to sign, and gets them into the mailbox on time. I still remember the day I was told I had metastatic breast cancer almost 9 years ago. I never thought I'd be sitting here having a conversation about it in 2010." Her eyes filled with tears. "We're taking one day at a time," her husband said, clasping her hand in his. "She's long ago beat the odds everyone gave her. And if she keeps it up, we MIGHT actually end up 50-50 after all. And that's the secret."

So, there you have it, folks. Quit counting beans. Forget 50-50, and perhaps you'll find yourself still married 70 years from now. And you might even realize on your 70th anniversary that you are, finally, in fact 50-50.

Lessons learned on the wrong side of the stethoscope

I was walking down the hall at work on a very ordinary day in December. I had sudden onset of excruciating right shoulder, neck, and upper arm pain. For the first time in my life, the "...if 10 is the worst pain you can imagine" finally had meaning. It took my breath and brought me to tears. I took the Tylox I had been given after childbirth (two years ago) with little relief. By the following evening, I was markedly weak in my (dominant) right arm abduction and external rotation. I couldn't even lift a fork to my mouth righthanded without using my left hand to prop up my right elbow. The next 48 hrs were a whirlwind: emails, calls, and pages to my internist (I am usually a once a year-ish whether I need it or not patient), a possible diagnosis of multiple sclerosis, MRIs of my brain, spinal cord, shoulder, appts with ortho, neuro, and ultimately neuromuscular, including the test that provided a diagnosis: an EMG/NCS. The diagnosis was something rare called Parsonage-Turner Syndrome. I had never heard of it before (which is a very bad feeling as a doctor).

So, what have I learned from this experience of being on the wrong side of the stethoscope? A lot that I am still struggling to put into words and a lot worth sharing.

First, no matter how exciting a case is, how rare, how great a learning opportunity for you, etc, you MUST NOT say this or show your glee in front of the patient. I know such excitement can be hard to contain as a newbie medical student or doctor. I, in fact, have a very experienced internist who nonetheless said "Isn't this cool?" to me during my annual appt on multiple occasions once the diagnosis had been established. As a doctor, I know what she meant. I do recall my days in general internal medicine, when I thought I might fall over dead before the end of clinic if I had to fiddle with the dose of one more antihypertensive. I KNOW what it's like to need a good case to spice up the day. I KNOW this was an awesome medical mystery with a rare diagnosis and ultimately a good long-term prognosis. What could be better, right? But the bottom line is that I am still markedly weak, now 4 months later. I still can't pour milk for my kids from a gallon jug, hold my 2 yr old in my right arm, or lift my work bag right-handed out of the passenger seat when I get out of the car. If I were, for example, an orthopedic surgeon, my career would be over or at least on hold for probably a year or more. It has been life-changing for me, and not in a good way. So, yeah, it's cool for the doctor. Yeah, it's a great case to present (and yeah, I agreed to suffer the indignity of being presented as a case in a conference I used to attend showcasing rare diagnoses at my former residency program, at the hospital where I am still on faculty). But, as the patient, it was decidedly NOT cool. I cringe to think about all the times I presented patients on rounds or in conferences with what I'm sure was obvious excitement over this "great case". Patients, please forgive me.

Second, a little kindness goes a long way when you're in a medical crisis. When I had my first C-spine MRI without contrast, it had motion artifact but was read as potentially consistent with demyelination. As I lay there alone on the MRI table having my repeat C-spine MRI and brain MRI with contrast to look for MS and other badness on a Thursday afternoon, I had a lot of time to worry and grieve for the normal life that seemed to be receding into the past very quickly. When the tech, whom I knew could spot an MS plaque or a met on those MRIs as well as any radiology resident, came in afterwards, I begged her to tell me if she had seen anything bad. She told me that she wasn't authorized to give me any information and that I should be able to get the report in a day or so. I knew that, of course, as a doctor. But, as a patient, I couldn't bear another moment of waiting. My eyes welled up with tears as I went to leave. She hesitated a moment, then put a hand on my shoulder, looked right in my eyes, and said, "Dr. Tempeh, you have a WONDERFUL weekend." It was her code to tell me that things looked ok to her eye. I remember it as one of the greatest acts of kindness I have ever experienced.

Third, it is a really worthwhile and eye-opening question to ask a patient how a medical condition is impacting her life. The first and only doctor to ask me that to date (and I saw several along the way) was actually the neuromuscular specialist. I think that question got him the most accurate picture of the extent of the neurological impairment--I told him that I could no longer use a pitcher of water to rinse my kids' hair in the tub because I was too weak to lift it, that I had quit blowdrying my hair because I could no longer do it right-handed and it turned out weird if I did it left-handed, and that I had quit leading a certain conference because I couldn't hold my right arm above shoulder height for more than a minute or two to write on the dry-erase board. It didn't take him long to ask or for me to answer, but it felt much more "real" than his assessment of my strength through a standard neuro exam, even though the neuro exam ultimately showed the same. I didn't realize how frustrated I felt by these losses until I had a chance to reflect on them and share them with a doctor who showed an interest. And the sharing was therapeutic for me in and of itself.

Finally, validate your patients. As an internal medicine resident, I was never good at taking care of the patients with fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome. I had always been taught that the best way to approach these patients is to validate their symptoms--telling them "I know that you are in real pain," etc. I couldn't ever do that, or not very well anyway. In my heart, I wasn't even sure these were real diseases. I have to tell you that although I have never been eager to hear my name and the word "disability" in the same sentence and that I still hope never to take advantage of the disability policy I have been paying for since residency (which you should get by the way), it was a relief when the neuromuscular specialist said after examining me and doing my EMG/NCS, "You have a real disability. This is something called Parsonage Turner Syndrome." It all happened so quickly, the development of weakness literally over the course of hours, to the extent that I struggled to wash my own face and dress myself. For days as the diagnostic workup went on, I vacillated wildly between being convinced that I had something devastating--a demyelinating disorder, brain metastases, something--and that I, a previously healthy person, had for some reason actually gone crazy. Just hearing from someone in a position of medical authority that I was not crazy--that this was real and had a name even--inspired my total gratitude. I wish I could go back and have a do-over now with all of those patients. I could have done so much better for them.

Humility is hard-won.

What IS the secret?

My husband and I awoke last Weds to a text message on my cell from my father-in-law saying "Hope this doesn't mean you are single-parenting again." We had no idea what he meant--had we been attacked? were things escalating in Afghanistan suddenly? Over the next few hours, we learned of the earthquake in Haiti and came to appreciate the seriousness of it, which was so remarkably underestimated by the first reports. We have both done international medical work. It is part of who we are. We hope to return to it as a couple when our kids are through with us. So, I told my husband (a military physician) that if he wanted to or had to go, I was behind him and the mission 100%. I said the V word with my blessing: Volunteer. Eight hours later, I got another text, this time from my husband, telling me he was leaving on Saturday evening and would be gone for 1-2 months. We began to scramble. The next day, yet another text from him: he was now leaving on Friday morning and would be gone for 5 months. Within this time, our nanny of more than 3 yrs gave us notice that she planned to leave ("just ready for a change"?!?!?!) in the middle of his deployment. I was having my own little tiny earthquake with little warning at home. At times, the only thing that kept my problems in perspective was the catastrophic enormity of the real earthquake, of which the people of Haiti had no warning at all.

My husband's last two deployments were planned, which gave us months to make all sorts of arrangements, time to ready our kids and ourselves emotionally, time to get the house and cars in good repair, etc. We had a nanny who gave no signs she might leave us. We got things in such order before his departures that I could keep up our usual family routines and standards for the most part. My husband just returned from his second deployment in two years 5 months ago. We thought we were going to be living normal united family life with solid childcare for at least another year. Who could have predicted all of this?

Ok, here's the weird part. Things are easier than usual. Way easier, strangely. Colleagues at work, neighbors, friends, people at my gym, checkout people at Costco who know us are all gawking and expressing condolences as they see me traipsing everywhere with our three small kids in tow with a fairly relaxed smile. "You are making this look EASY! What is the secret?" a lot of fellow moms have asked conspiratorily. Finally, after not answering the question enough times, I realized: I DON'T KNOW. But they are right. And it's not just an appearance. It is kind of easy.

The last two days, I have been preoccupied with this. Why IS life easier during this unplanned deployment of uncertain duration with childcare that now feels tenuous? It certainly shouldn't be. But it is. I finally made kind of a log of my day for the last few days and had a EUREKA!! moment. It's just a few things:

1) I am doing everything with my kids instead of for them. There is too much work in the household to be done now to do it all alone. I would never sleep. Or finish. Usually, I would be making dinner while the kids watch a TV show or unloading the dishwasher while the kids play after dinner or folding the laundry when they go to sleep. Now, we are pulling chairs up to the counter and they peel or mash while I chop--we are making dinner together. We are unloading the dishwasher together. Each kid even has a post-dryer laundry job (the 2 yr old finds all the socks and collects them in a pile, the 4 yr old sorts the clothes by owner and does some folding, and the 6 yr old does most of the folding with me). They love the independence and the chance to be involved. Suddenly the work doesn't feel as much like work to me or to them. I'm less resentful that I am a 24/7 servant because I'm not, and they are less resentful that Mommy is preoccupied 24/7 with chores and can't play with them because it's no longer the case. The work of our family has become a family activity. And because it's divided more ways, there is more time left over for real play. The results aren't all perfect, and it's not all being done the way I would do it, but it's good enough. And, at the moment, good enough is perfect. The new perfect. Which brings me to...

2) I have let go of perfection. Completely. Now, let me be clear, I let go of perfection to a large degree with the birth of my first child 6 yrs ago. But I mean REALLY REALLY REALLY let go. So the floor has dried Cheerios and who know what else stuck on it from breakfast. Yesterday. Who cares? The reality is that if I stay up late at night and clean my floor, the kids will just get more Cheerios on it again at breakfast. Of course, we can't leave it there forever, but we can leave it there for a day or seven. There is a pile of mail mounting on the dining room table like a volcano. Who cares? Maybe it will prompt me to write to that place in Farmingdale NY again and get off all those junk mail lists. Friends are coming over and the house is a mess. Who cares? Either they will be bothered, in which case they will feel sorry for us and we can have the playdate at their house next time (sounds good to me), they won't notice because their houses look like that too, or they will be secretly relieved because their houses look like that too. Everybody wins. And having let go of perfection brings me to...

3) I have more free time. Given the emotional impact on the kids of this deployment(my 4 yr old is taking this the hardest, but my 6 yr old has also struggled since his Daddy left the day before his birthday), I feel an urgency to sit down and play with them, read to them and not just for bedtime, be more engaged than I might otherwise be. Though I am not a fan of filth or clutter, I have to tell you that it's frankly kind of a relief to sit down amidst the dried Cheerios and piles of mail and read a book to my kids on the giant beanbag in front of the fire instead of cleaning up the house. It feels like I'm finally living the way I should have been living all along, focusing on what really matters. And, I would be remiss not to mention...

4) I am saying yes. Kids want to go see Princess and the Frog, on a school night--why not? The kids stare with wide eyes and big smiles when I say yes. They're in kindergarten and preschool. They'll probably still get into college. Friends invite us for dinner, I ask what time with one hand on my cell phone and my other hand shooing the kids out the door and into the car. If anyone offers help, I am accepting it. And not feeling bad about it. If they offer, I am assuming they genuinely want to help. And if they don't, well, that will teach them for offering! I find that we are spending a lot more time with friends, not just for the token Saturday playdate, but dinner on a random Tuesday evening, an impromptu s'mores party right after school for no reason whatsoever. And our extended family is offering to come for weekends that they otherwise would feel too busy to pull off. It occurs to me: I miss our friends. I miss our family. I don't see them enough. My kids don't see them enough. It shouldn't take an earthquake to make us spend more time with people who are important to us.

So, there you have it. I love my husband to pieces. I can't wait to have him home. And when he does come home, I think home is going to be an even better place. But since he left, I have been forced to change the way we do business. I am happier, the kids are happier, and bonus: since I am no longer a perfectionist, I don't edit or proofread, I just post. Which means I am finally posting again, too.

A day in the life of a part-time medical oncologist

Note: I am a medical oncologist who works part-time, two full days and one half-day at work and the rest of the week at home with my kids (almost 2, 4, and almost 6). We have a part-time nanny who comes on my 3 workdays. This is my half-day, which probably captures a little bit of both of my worlds.

5:10am Wake up to sound of husband opening drawers as he gets dressed. Open eyes briefly to see gorgeous man a few feet away. Too tired to appreciate him aloud, I smile blissfully and fall back to sleep. I'm married to that guy!!!

5:55am "Mama, milk please. Milk, Mama!" on the monitor. Go get my youngest from her crib who greets me with a toothy grin and nurse her in my bed. Wonder if I am still nursing her (usually once a day, either morning or bedtime, but occasionally both) because I am tired and this gives me a few minutes of snooze or because she likes the bonding or because I like the bonding or all of the above. Fall asleep wondering how I will wean her--she will be 2 in a couple months.

6:15am Wake up to youngest saying "Shhhh! Listen...mourning dove!" She's right. How does she know what a mourning dove cry sounds like? Aren't they supposed to fly south for winter? "Read Tick-Tock, Ears Hear a Clock!" Hop up, make the bed, change diaper, get her dressed for the day, and read her about 15 board books in her glider under a pile of blankets.

7:10am My 4 yr old wanders in with bedhead and slides under the blankets with us. We reread half of the stack of books, as well as two Fancy Nancy books she brought with her. Kids finally tire of reading and start to play together. I pee and brush teeth.

7:50am My 6 yr old wakes up to the sound of his sisters playing together very loudly. He is grumpy because he's still tired. He needs 12 hours of sleep per night or more and seldom gets it because he is such a night owl. Vow to do better at coaxing him to bed early. Start his Pulmicort neb.

8:00am Big kids use the potty and get dressed while I supervise. Dispense kids' Calcium chewables and son's asthma medicines and ask them to identify the pattern (my son's latest kindergarten task): "pink, purple, purple, orange...A, B, B, C" the older two shout in unison. Brush 3 sets of teeth. Start washing machine, loaded up and forgotten at bedtime last night.

8:15am Cook oatmeal while big kids decorate Christmas cards for friends and classmates at kitchen table and baby drives her doll and Curious George around downstairs in shopping cart. Empty dishwasher and finish packing lunches for preschool and school. Think it would be better if I emptied dishwasher and packed lunches the evening before.

8:30am Breakfast with kids. Baby insists on sitting at table, not in high chair.

8:40am Baby dumps bowl of oatmeal and raspberries everywhere. Clean up floor and notice that there's also a LOT of dried-up dinner remnants from last night and random fuzz down there, too.

8:45am Load dishwasher up, then chase kids around downstairs with the Swiffer Vacuum (incidentally, they love this and don't realize that I'm actually doing housework since I run with it like a maniac...try it.)

8:55am Walk 6 yr old son to bus stop for kindergarten. Kiss goodbye. Nanny arrives and drives 4 yr old daughter to preschool with my 22 mo old daughter along for the ride.

9:00am Grab charts, work papers, laptop, gym bag, lunch, cell phone, and wallet. Check email. Move clothes from washer to dryer. Get into car to head for the gym.

9:05am Back at home. Forgot my glasses. On the way to gym again.

9:15am Pilates.

10:20am Surprise preschooler by joining her preschool class in the pool for last half of their rec swimming time (preschool and our gym are adjacent and share a pool). Asked nanny to bring the 22 mo old up to the pool, too, so we all swim around together.

10:45am Shower, dress, dry hair quickly, no makeup (which is the rule rather than the exception lately, though I try on workdays...). Drive a mile to my son's elementary school.

11:15am Help my 5 yr old son and 22 of his classmates stamp snowman shapes onto t-shirts using glitter paint and potatoes.

11:45am Eat a sandwich in the car while driving to clinic. Conference into a meeting about clinical trial design issues, listening through the car's speakers via Bluetooth. Feel glad that we did not trade in our Prius for a second giant family truckster when we had our third child.

12:05am Sign clinic notes, bill outstanding visits, discuss patients with fellows, review two abstracts on which I am a co-author, read and respond to work email. Overhear fellows talking about the new breast cancer screening guidelines. They ask what I think about them. I explain that I can see both sides. Note that all of the female fellows are somewhat sympathetic to the pro-screening side of the argument; none of the men are. Interesting. Wonder how that impacts our counseling of patients. Note that inbox is now over 2000. Wonder what would happen if I just emptied it. Nurse asks if I had exfoliation or something. Thinks I look younger today. I tell her thanks but no. Remember that I'm not wearing any makeup. Look at my reflection in the exam room mirror--maybe she's onto something. I do look younger without makeup.

1:00pm-5:00pm New patient consultations, all breast cancer, often alone, occasionally with fellows. A representative sample:

32 yr old woman with high-risk early stage breast cancer. Recommend a clinical trial. She will need to travel to participate. Could also do aggressive chemotherapy outside of a trial, but not my first choice. Offer tissues to her as she cries periodically and entire tissue box, flashlight, reflex hammer, tape measure, and rolls of gauze to her 13 month old son who is toddling around the room and holding it together remarkably well for the lengthy visit. Mother, also in attendance, expresses outrage over the new breast cancer screening guidelines, which could have killed her daughter. I explain that her daughter is only 32 and wouldn't have been affected by these guidelines, which refer to women age 40 or older. That her tumor was palpated and not visible on the diagnostic mammogram even after the mass was felt. That these very aggressive tumors, such as her daughter's, tend to develop over months, not years, and often appear between annual screenings anyway. Cases like her daughter's are part of the case AGAINST mammograms in young, premenopausal women. She reiterates that no one seems to care that the guidelines could have killed her daughter. I decide I am not being a very effective communicator.

43 yr old woman with a smallish focus of ductal carcinoma in situ. Has had genetic counseling and isn't a BRCA mutation carrier. I recommend lumpectomy with radiation and tamoxifen for 5 yrs, which will reduce her risk of recurrence or a new breast cancer by nearly half. She wants bilateral mastectomies to save her life. Tell her that her prognosis is excellent, that there is no data to suggest mastectomy will improve her survival, and that bilateral mastectomy is absolutely overkill. She has two small kids and doesn't care. She wants them off. Wonder if I might not make the same irrational decision if I were in her place. Print out a patient education sheet from one paper showing no survival benefit for mastectomy. She shrugs and I give her the name of a good reconstructive surgeon. She declines the tamoxifen.

78 yr old woman with a recently resected very large, node-positive neglected breast cancer. Really, really, really don't want to have to give her chemotherapy. Wonder why she ignored this thing for so long. So I ask her. I was hoping I'd die before anyone ever told me I had cancer. Does she want to die? No, of course not. Does she want treatment for cancer? Of course. Recommend chemo in addition to hormonal therapy. Hold breath and hope chemo will do more good than harm. Think it will but never know how old a 78 yr old really is until she gets chemo.

35 yr old woman with stage 1 breast cancer, no family history, diagnosed by screening mammogram. Recommend chemo and hormonal therapy. Talk about fertility preservation and the chances of having a successful pregnancy in her 40s after chemo and 5 years of tamoxifen. She is angry about the new breast cancer screening recommendations. Her life has likely been saved by a screening mammogram, at age 35 no less, that her GYN recommended based upon several years out-of-date guidelines. She asks what I think about the new guidelines. I can't tell if it's a challenge or not from the tone. I spend 15 minutes explaining how there are valid points to both sides of the debate. Again. She seems unsatisfied. I think she was hoping I would agree with her or disagree with her but not both.

42 yr old woman with locally advanced breast cancer that was diagnosed by a screening mammogram, but must have been palpable months before. Wants a second opinion about the choice of preoperative chemo. Also asks what I think about the new breast cancer screening guidelines for women in their 40s. Think maybe I should put what I think on a shirt and wear it to clinic. I tell her that it's kind of like playing the lottery. You'll probably buy a ticket every week (i.e. get a mammo every year) and nothing will come of it. It will definitely cost you, but probably not that much. If your number gets picked and you win, you will think you clearly made the right choice to play. If you don't, maybe you'll regret all those tickets you bought and maybe you won't--that's kind of a personality and values thing. It's the shortest and least meaningful commentary I have made on the breast cancer screening guidelines (which I have discussed about a dozen times a day at work and socially) since they were released. I am tired. "That's the clearest, most thoughtful way of summing it up that I've ever heard," she tells me. Sigh.

5pm Grab charts and rush out to Tumor Board. Run into (literally) an out-of-town patient in her early 40s I had seen almost two years ago with a very high-risk, inoperable triple negative breast cancer. She had flown down to see plastic surgery about reconstruction and decided to stop in to surprise me. When I saw her in 2007, I had recommended that she go on a clinical trial that involved traveling hundreds of miles from home frequently. It would take her away from her school-aged kids. I had agonized about whether it was the right choice--it was a long shot--given all the time away from her family and her potentially short survival if it didn't work. She had been lost to follow-up at our institution. She had done the trial, had the preoperative chemotherapy, had an amazing response. At the time of mastectomy, she had a pathologic complete response (no tumor left in the breast or lymph nodes). PET scans every few months had all been clear. It is likely that she is cured. YES!!!! She hugs me and cries, cries, cries. Tells me that's the first time she's cried since the original call from the surgeon telling her she had breast cancer. I think I might cry too--a combination of joy, exhaustion, and hypoglycemia.

5:10-5:45pm Slide into Tumor Board 10 minutes late. Eat a disgusting pastry left over from some conference earlier in the day. Regret it. Think I should really plan better and bring a healthy snack. I am always famished after clnic. We have plenty of food in our fridge. Why is that so hard to pull off? Discuss my and my colleagues' challenging cases. Surgeons are running the show and have little patience for the medical oncologists yapping on and on, so we end 15 minutes early.

5:50pm-6:10pm Commute home. Listen to NPR for a few minutes and then call my best friend, who also commutes home at this time, via Bluetooth stereo speaker. Love the Prius again!!

6:10pm Enjoy the hero's welcome at the front door by all the kids and hubby. (Incidentally, no hero's welcome for me from the kids on the days I stay home with them!)

6:10-6:30pm Make black-bean pumpkin soup with 5 minutes of prep and quick-steam string beans in the microwave. (Love Aviva Goldfarb's Six O'Clock Scramble website for fast, healthy meals that everyone in our household will actually eat--check it out!) Mix up banana bread from scratch (6 yr old has food allergies, so no mixes for us) and put it in the oven. While dinner cooks, sit down at our kitchen table with a family-sized bowl of strawberries. Help 6 yr old with his phonics homework, congratulate 4 yr old on being selected "Top Dog of the Week" at preschool, and collect a few dozen random items on my lap, brought to me by my 22 mo old.

6:30pm Dinner with the whole family.

6:45pm Chase kids with Swiffer Vacuum again (they could do this all day) while husband loads up and starts dishwaser.

6:55pm Bath time!

7:10pm Everyone in PJ's. Back downstairs to have a bedtime snack of banana bread and apple cider. Love the fall treats!

7:20pm Help son with a Lego dragon he is building. Girls come into the room wearing dress-up clothes and costume jewelry (pajamas off). Make up a story that incorporates princesses AND dragons. Agree to tell the exact same story a second time, by popular demand, if girls will get back in pajamas. Make this request about 10 times. It eventually works.

7:45pm Everyone BACK in pajamas. Teeth brushed. Play Tickle Monster, also by popular demand. The baby old slips in her footie PJ's and falls. Big tears, overtired tears. Boo-boo buddy and special blankie. Evening saved.

7:55pm Husband starts reading bedtime books to all 3 while I fold the laundry on the floor in the room with them. As I finish up, little one comes over to sit in my lap with her thumb in her mouth and a longing look.

8:05pm Nurse 22 mo old in her room. Wonder if I am nursing her because it gives me a chance to sit down and unwind in a dark room or because she likes the bonding or because I like the bonding and decide it's all of the above. Wonder how I will wean her--she'll be 2 in a couple months. Fall asleep wondering. Jostled into the land of the living by my son, who wants me to read the last book.

8:15pm Put little one in crib and tiptoe out. Read the last book. Put my 4 yr old in bed and sit in her chair, her nightly request, for 10 minutes to talk about her day. Kiss her good night.

8:25pm Flop on my son's bed and beg him to join me. He draws portraits, dinosaurs, robots, all the items he would like at his next birthday party (including details of the party favors, pinata, cupcakes, and juice boxes), and does math problems standing at his dresser. I get snapshots of his day with answers to every third question.

9:00pm I tell him I will give him math and spelling problems if he will get in bed. We lie there together in the dark. Ok, how about CHICKEN? Um, C-H-I-C-K (it's CK, right, Mommy?)-I-N. Close, it's E-N. What about THICKET? T-H-I-C-K (it's CK, right, Mommy?)-I-T. Close, it's E-T. Ok, try CRICKET. C-R-I-C-K-I-T, no wait C-R-I-C-K-E-T!! Hey, is this a pattern, Mommy!! Let's do more patterns. Ok, try 2,4,6, blank, 10? He yells out 8. How about 10, 30, 50...? He says 70, 90, 110, 130, 150...I fall asleep while he's still counting. Apparently counting sheep works even when there aren't sheep and even when you count by 20s. At some point, I notice that he has gotten back up and turned the light on to draw again. When he sees me wince, he dims the light but keeps drawing, standing at his dresser. We should get a desk for his room, maybe for Christmas, I think. On second thought, maybe not--he'll never go to bed again. I fall back to sleep.

9:50pm Wake up in my son's bed to my son, now back in bed, asking me to scratch his back. I do and he falls asleep. Vow to get him to bed earlier tomorrow.

10:00pm Find my husband flipping between sports channels and playing Scrabble on computer during commercials. Sit down to watch 30 minutes of stand-up comedy (Brian Regan, totally hilarious). Laugh really hard, but fall asleep at the end of it.

10:25pm Husband shakes me awake, and I get in pajamas, brush and floss my teeth and wash my face. This wakes me up. I decide to go downstairs to pack lunches for the next day, notice that we need their thermoses which are in the clean dishwasher which I then unload, notice that we are out of yogurt and napkins so start a list for the store, sift through the day's mail and notice two bills that I need to pay. Too busy to let them wait, we might forget. Get online to pay the bills and realize that I also need to do our bi-monthly nanny payroll, which I do. Notice on our office desk a receipt for Motrin and Benadryl and fax it into our FSA. Look on travelocity at plane tickets for Christmas, which are now too expensive for the 5 of us...guess we'll be driving. Speaking of Christmas, I still haven't written our Christmas letter or done almost any of my shopping. Get on Amazon.com and order gifts for the nieces and nephews since they all have to be mailed, as well as a few things for the kids. Try to figure out what to get my husband (don't know) or what I want (keep getting that question from my family, don't know). Send my sister pictures for a calendar she is making for my dad for Christmas. Spend 20 minutes on Facebook reading about who is still eating their kids' Halloween candy and who says The Gentleman from Connecticut had better not filibuster, buster and who has found a lonely cow on their farm.

12:05am Join sleeping husband in bed.

12:06am Realize it's cold in the house. Go cover up the girls and put my 6 yr old, who falls out of bed every single night, including tonight, back in bed.

12:08 am Join sleeping husband in bed. Look at the window and realize the Christmas lights are still on. Go down and turn them off. Feel pretty awake again. See New England Journal and Real Simple on the chair by the door. Decide to read Real Simple for just 10 minutes. Read for 15 minutes. Feel guilty. Start reading "Case Records..."

12:30am Wake up when my head jerks forward. Re-join my husband in bed and fall asleep.

Live for two months!

A few weeks ago, at the end of a very trying day with the kids, I saw the Mark Twain quotation, "I can live for two months on a good compliment" at the end of a newsletter. How true it is. As I thought back over my day, the high point was a pretty random, but apparently heartfelt, compliment from a stranger. "You are so patient with your children! That is JUST WONDERFUL to see!!" said an elderly lady in passing in Michael's as I quickly picked out 50 cent treasure rewards while playing rhyming games with the two older kids to keep them from running off and attempting to stop my toddler from eating through all the packages of cupcake decorations in the cart. I'm sure she has long forgotten me and that interaction, but I have channeled her repeatedly since then.

I recently started a sticker chart for my 5 and 4 yr old kids at home in an effort to improve behavior. I used a plain piece of colored paper and wrote on it 12 things I wanted them to do (or in some cases, stop doing). Each time they do those things, they get a sticker on the chart. Ten stickers earns a trip to the candy box, twenty stickers a trip to the treasure box (see Michael's above), and thirty stickers a choice between a family trip to our local ice cream shop or to Blockbuster for a family movie night (school night or no, we honor it) with a movie of their choosing. Each time one of the kids gets to thirty, I make a new chart for him or her which may include some of the same behaviors or new things, depending on where we have made progress. It has worked AMAZINGLY well, so I have been thinking about why that is. Well, there's the obvious: Kids love candy. Kids love treasure. Kids love family trips, but especially those that involve movies or ice cream. But they got candy from time to time or little trinkets at stores or trips for ice cream or movies long before we instituted this reward system. So clearly, that's not the whole story. What they are really responding to is being acknowledged and praised, in some cases for things that I expect of them anyway (e.g. be kind to your sisters). They like the fact that my husband and I are pausing long enough to say "Great job", to stop what we are doing to go choose a sticker with them from the sticker folder, to mingle in more compliments amidst the unavoidable "no"s and redirections and scolding that go along with being a little growing human testing the boundaries of the world.

One of the things I like most about my boss is that she is a reliable complimenter. Her compliments are never insincere. They are never excessive. She just makes a point of acknowleding reliability or patience or meticulousness or creativity or kindness. It isn't that those qualities are so remarkable either--indeed, they are expected in physicians and scientists--but she still appreciates them. And that is probably what should drive a lot of compliments, appreciation of another human being, even if they are doing exactly what you expect of them and not one iota more.

I have decided to make a concerted effort to follow her model for a month and see how I feel and how my relationships with others change. So, when my husband found the dishwasher full of clean dishes and took 5 minutes to empty it before leaving for work at dawn during an awful attending month, I called him to tell him how much easier it made my morning with the kids to find it empty and ready for the breakfast dishes before we dashed out to preschool and school. It was empty the next morning too and the one after that. When my son reminded me back at home of something good his sister had done while we were out that deserved a sticker, I stopped and hugged him and said, "That is true kindness. It makes Mommy so proud when you are kind." He beamed and has been what I can only call excessively, concerningly kind to his sisters for the last 24 hrs. And when I told my clinical associate today that I appreciate how friendly she always is to the patients when taking their vitals because it sets such a nice tone for our visit, she looked at me like I was from outer space. But I couldn't help noticing that she walked off with a little spring in her step. And it was only a little smaller than the spring in my own.

Third time's a charm...Tempeh's 11th hour topic day post on childcare

I always remember Topic Day at 11pm on...Topic Day, so here I am, dead last.

Wow, I could write thousands of pages on this one, but since it's late and I am leaving for work in t-8 hrs, I'll focus on the nanny issue.

We started out with my firstborn in a reputable traditional daycare down the road from our house, which is about 45 minutes away from our jobs. With no traffic. That lasted all of 7 weeks, during which time my son (a winter baby) was sent home for three distinct infectious illnesses. When he started there, I was an oncology fellow and my husband was an internal medicine resident doing his ICU rotation. When we would get the alarm bell that my son had a fever of 101 and needed to be picked up within the hour, it was a panic to figure out if we could even GET THERE in an hour if we dropped the chart in our hands and ran. Not to mention that you really can't just leave as a resident or fellow. It was constant stress. When I walked in to pick him up one day unexpectedly early and found him lying on a mat on the floor crying while his "teacher" balanced her checkbook, that was it. I took him home and we never went back. Thank God it was a Friday!

After I finished crying for about 12 hours out of guilt over leaving him there, we called my mom to come and contacted a wonderful local nanny agency. In our desperation to find someone to watch our son in our home ASAP, we tried to persuade ourselves that her references, who said our nanny-to-be "was more emotionally needy than our preschool aged kids" and "left us abruptly when we told her we were pregnant with a second child," must have had an axe to grind. She was kindly and at ease with our almost 5 month old son, and he seemed to take to her even at the interview. SOLD! Within a few months, she self-referred for PT for "the earliest signs of carpal tunnel syndrome" and started scheduling her PT appointments during her work hours because that was the time slot her preferred therapist in the practice had open. It would often take me an hour or more to get out of the house in the morning because she wanted to talk about some, usually quite minor, mishap in her day. Invariably, she would cry and want hugs--like actual hugs--which I would patiently deliver day after day while watching the minutes of my already very short workday (the fact that we decided to hire her only 26 hours per week will be a topic for another time) tick down over her shoulder on our kitchen clock. When we unexpectedly got pregnant with our second child when our son was 9 months old and shared this news at about 20 weeks gestation, she told us the following morning that she was quitting due to her worsening carpal tunnel and was gone a week later. She did stop by a couple of months later reportedly just to say hello. I noticed she was still wearing her splint. She told me that she missed nannying and had just come from an interview with another family who had one baby boy and lived just a few minutes from us. That was what had made her think of us. They called for a reference shortly after she left. When they asked why she had left us and I mentioned that her carpal tunnel had gotten worse, the mom said, "What carpal tunnel?" I asked whether she hadn't noticed the splint. Turns out she wasn't wearing the splint at the interview. The mom mentioned that she was almost 40 and wanted to try to get pregnant with another child within the next few months. My advice to her: "Run! Save yourself!" Lesson 1: Believe the references. Nanny history repeats itself!

For our second nanny, we decided that it wasn't worth paying the steep nanny agency referral fee a second time. We used an online DIY type of nanny agency called enannysource. It let us post a family profile with as much or as little detail about our family and our needs as we wanted. And we could search nanny profiles by the same details in our zip code. Like magic, a 36 yr old woman, the mother of a 9 yr old boy, saw our profile and emailed us to express interest within 24 hrs. She came to interview the following day. She had a degree in early childhood education but had never worked because her son was born shortly after she graduated college. She had gotten divorced due to marital stress over her son's medical issues (he was deaf, bipolar, and on the autism spectrum) when her son was a toddler and had remarried within the past few months. She was young, energetic, direct, and clearly a very devoted mom, which I thought would bode well for us since we were hiring her to be sort of a part-time mom. We were a little worried that her son's issues could cause her to be pulled in two directions, but what mom isn't? So we put it out of our minds. We needed a nanny, and she was otherwise perfect. I was visibly pregnant with my second child, which did not daunt her one iota. Ahhh, I thought, she'll stay with our family forever. So we hired her. Flash forward a few months, and there we were: scrambling to get home over and over because her son needed to be picked up from school or because he had a doctor's appointment or because his school was closing early for snow, etc. All reasonable, all issues we ourselves faced as parents. We felt like hypocrites to say anything about it. We knew how hard it was. A few months later, I gave birth to my daughter, and she fell madly in love with her. So in love, in fact, that she decided she actually wanted one too. Six weeks later, she unexpectedly dropped in at dinnertime with her husband and son to tell us that--GREAT NEWS, YOU'LL NEVER BELIEVE IT!!--she was about 1 minute pregnant, and they were over the moon. The next several months were a marathon with hurdles--morning sickness that made her unable to stand the smell of our kids' diapers, insomnia making her emotionally unable to deal with our tantruming toddler and colicky daughter, and ultimately, the deal breaker, back pain that got worse with having to carry our kids around. Lesson 2: If your nanny has kids of her own without iron-clad childcare, and you/your spouse don't have a VERY flexible job, you are in for trouble. Lesson 2, subpart 1: It may be illegal to ask a nanny of childbearing age if she plans to get pregnant (unless she brings up the topic first), but it's not illegal to talk about it at night in bed with your husband if your nanny candidate is in her late 30s and newly married. Especially if you have or are about to have a delicious little newborn who could plant such a seed in her fertile brain.

For nanny #3, we again went back to enannysource. This time, I was wiser. I spent hours and hours every night after our kids went to bed sifting through nanny profiles, word-smithing our family profile, reading between the lines both ways. It took us almost 5 months to hire our next nanny during which we officially used up every favor we were ever owed and got a 40 yr or so advance on future favors with our parents, siblings, friends, and a few babysitters turned temp nannies where they were available. To say that it was stressful doesn't even begin to describe it. Fortunately, we had reached a point in our training when we had more flexibility so we could arrange to go in early and come home early and the other spouse go in late and come home late. It wasn't easy, but we made it work. When we met our third nanny, whom I had emailed back and forth repeatedly and interviewed by phone (along with dozens of others) for about 90 mins before bothering to invite her to our home, we knew that was it. She was 26 yrs old, single, energetic, had taught in the public school system but wanted to work with kids on a more individual basis, and she shared our values. Her references, which weren't really in childcare, loved her across the board. Over and over, they described her as loyal, reliable, honest, flexible, optimistic. Music to our ears. Our only reservation was that she was kind of...well, sloppy. But, we said, we can live with that. And when she described what she had done with kids at an in-home daycare she had worked at several years prior, we noticed that all of the activities sounded like...well, a huge mess. We had a moment of reservation as we surveyed our light carpet and pastel-colored sofa and chairs, but, hey, kids are washable, and that's the fun of being a kid. Our shy then 2.5 year old son kissed her goodbye at the end of the interview! We hired her. That was 3+ yrs ago, and she has been an absolute joy to have in our family. She loves our kids, makes them handmade gifts for every birthday and Christmas, remembers my son's Epipen and chases me up the driveway with it when I forget, and is more patient and creative than I will ever be. She even makes us dinner when she knows we are going to come home exhausted, which is more often than not. She joined the Y so she could take our now third child, who is a complete water baby, swimming while the older two are at kindergarten and preschool. She is loyal, reliable, honest, flexible, and optimistic. Our only complaint: she's...well, sloppy. And the things she does with the kids--things like painting refrigerator boxes with non-washable tempera paint on our kitchen floor--are...well, a huge mess. But, hey, we can live with that. Lesson #3: Trust your instincts. Know the things that are deal-breakers for you. And the things that aren't. And see lesson #1!

Which reminds me, A, that you deserve a raise!

Thanksgiving

Forgive me for getting carried away here. I know it's the first day of September, but I stepped outside, and it was CRISP today. School buses were lumbering down the road, which I noticed more than usual since I have a kindergartener today for the first time. Regardless of when the autumnal equinox is, it's fall. I can feel it. My favorite season. And close to Thanksgiving, my favorite holiday.

In a half-hearted attempt to get our chaotic home in order before school started, I cleaned out our file cabinets this weekend. Well, actually just one of them. And just one drawer. But as JC points out, you've got to start somewhere. I picked an easy one, our "professional" drawer, with copies of diplomas, DEA forms, board certifications, licenses, transcripts, and hospital privileges forms, that usually doesn't require excessive discarding. At the back of this drawer was a folder I had almost forgotten about in the overwhelming busy-ness of my life as a doctor mom of three. It is labeled "Feedback" because that fits on the tab and is less embarrassing if discovered than "Affirmation" or "What you are doing does matter, Dr. Tempeh" or "Yes, your doctoring career has taken some hits because you have small kids, but take heart-- you have been good and will be again, and this is the folder to prove it". The folder includes glowing letters of recommendation (possibly intended for someone else) from when I was a young, energetic, childless resident applying for fellowship, over-the-top attending evaluations (clearly intended for someone else) from when I was a 36 week pregnant first-year fellow continuing to moonlight to save up for our first baby, and mostly a lot of thank you cards and letters from patients. I love this folder, and not only because it buoys my spirit when I wonder if I am losing my way, navigating these two lives that often run parallel and occasionally collide head-on. It is a little time capsule of my former doctor self that resides in our home. And it can bridge the gap when there is a dry spell of gratitude at home and at work.

As I sent my little guy off to full-day kindergarten today, I found myself wondering if I should have done these last 5 years differently in some way. I started working part-time 3 years ago. The extra time it has given me with my 3 kids is priceless beyond measure. But, at times I have wondered if it was worth it from a career perspective. After all, it wouldn't be that long until all of my kids were in school with full-time jobs of their own in some sense. Would I have sacrificed so much in my career by that point that I wouldn't be able to "get back," whatever that means?

The truth is that my career has changed for having kids, and it is probably kind of irreversible. Much like your body before and after children, you don't have to take the changes lying down, but you do need to come to terms with the fact that you won't ever get back to exactly the way you were before you had kids. And if you want to get back to something that closely approximates it, you are in for a long road and a lot of hard work.

But today, as I watched my little boy walk into his kindergarten classroom, then turn around to come back, kiss me on the cheek, and say, not "I love you" but "thank you, Mommy," I realized that I was in no rush to get back to my old life. I am happy right where I am. Fellow Doctor Moms, Happy Thanksgiving!

Ladies, don't panic!

Just a couple days ago, I posted about the decision my husband and I are struggling with about whether to try to have a fourth child. The piece got a lot of comments. The one that struck a chord the most, though, came from an anonymous reader who commented:

"At the risk of being the Cassandra here, how well would your life work with a fourth child who has Down's?? You know how high the odds are climbing for you at age 37. Your family size is clearly not my decision, but in my family of origin I was the youngest by a large margin, and my parents wanted a sibling "for me" close in age. My un-named baby sister had Downs and its most severe cardiac manifestation when she was born via emergency C/S to my then-37 year old Mother. She never left the hospital, and her death tormented my Mother the rest of her life. And selfishly, I know if she had lived MY life would not have been the same. Just some food for thought...."

First, let me say that I think Anonymous' intentions were good, and I appreciated the willingness to share a personal story to provide the devil's advocate viewpoint to the general tone of "Keep the love goin'" comments I was hearing. But the truth is that that comment struck fear in my heart. I immediately thought "She (or he?) is right! We have been so fortunate to have 3 healthy kids. We should quit now." And then, "Actually, no, I don't know 'how high the odds are climbing' for me at 37." I know that 37 is advanced maternal age, but I had no idea what 37 really meant for my risk in cold, hard data. So I did what I always do in moments of personal medical crisis--I did research and I called my baby sister (not an MD, but a pediatric physical therapist and a voice of reason).

From a career standpoint, I wear two hats--one as a clinician treating breast cancer patients and one working in a public health role. For both, I spend a lot of time thinking about risks and how we convey them to patients and people in general. What is most understandable by a lay person? How do we shape perception of risk, and in turn behavior, when we express risks one way versus another? It is fascinating and, at times, disturbing.

Note that, due to some formatting challenges for my elderly brain at 12:30am, I am indicating risk of Trisomy 21 in bold and risk of any chromosomal abnormality in italics rather than figuring out why my tables come out garbled in the post.

Maternal age Risk of Trisomy 21 Risk of any chromosomal abnormality

25 1 in 1250 1 in 476
30 1 in 952 1 in 384
33 1 in 625 1 in 286
35 1 in 385 1 in 192
37 1 in 227 1 in 127
40 1 in 106 1 in 66

For any of you who aren't 25, I am guessing this looks pretty scary. I know I can feel the sand slipping (or more accurately, gushing) out of my hourglass when I look at that table. But now what if I put it like this instead? (Same formatting convention with the bold and italics, but note the difference in the headings)

Maternal age Chance of NO Trisomy 21 Chance of NO chromosomal abnormality
25 99.92% 99.78%
30 99.90% 99.74%
33 99.84% 99.65%
35 99.74% 99.48%
37 99.56% 99.21%
40 99.06% 98.48%

Kind of takes the zing out of it, doesn't it? For those who don't know, 35 is called Advanced Maternal Age because that was the age (historically...amniocentesis is a bit safer now than it used to be) at which the risk of fetal loss due to amniocentesis was approximately equal to the risk of detecting a chromosomal abnormality, and therefore, the benefit of prenatal detection was felt to justify the inherent risk of the procedure. The fact is that, at the large academic medical center where I practice, they now consider advanced maternal age, for those purposes, to be 32 and routinely offer amnio to women who are 31 or older at the time of conception. This has caused all sorts of angst and dismay amongst the female residents and fellows who feel that they are now somehow at higher risk because of this change in definition. One physician even lamented to me: "It's not fair. How come advanced maternal age changed to 32 for us? I thought I still had 4 years, and now I only have 1!?!" Ummm...because amnios are safer.

Now, don't misunderstand me. I am not on a soapbox to get everyone to delay childbearing willy-nilly into their 40s and 50s. That is the terrain of Hollywood stars. For every successful story you hear of someone who had all 3 of her kids in her 40s with her own eggs and got pregnant in a month each time (and those people exist, for sure), there are also many, many often untold stories of women who endured multiple miscarriages or fertility treatments, who tried to get pregnant unsuccessfully for years with all the heartbreak that involves, etc. But the fear of Down's syndrome, or any other chromosomal abnormality, should not be what drives someone to get pregnant (or not).

So, as I said, I also called my sister to get her take on all of this. Wise as always, she said something that really hit home for me. She has a clinic brimming with children who have physical and cognitive challenges of every variety, including Down's syndrome. But, far and away, the most common cause of the disabilities she sees are things that happened after birth: near-drownings, meningitis, head injuries from biking without a helmet, car accidents. Patients with Down's or other chromosomal abnormalitites represent a minority of her practice. Which brings me to my next point: there are no guarantees in life or in parenting. To be clear, I am all for prenatal testing. I think it is critically important for couples to have the opportunity to know before birth if their baby has a chromosomal abnormality, whether that allows them to make the agonizing choice to terminate a pregnancy or to prepare for how their lives will change with the addition of a special needs child. But it's not a guarantee of a "normal" child. There are plenty of things that can't be tested for prenatally, and there are plenty of things that can go wrong--both diseases and accidents--after birth that will change the life of a child...and his siblings...and his parents forever. One of my own best girlfriends from college is currently struggling to come to terms with how their lives have changed since her previously healthy and incredibly athletic 7 yo son had several catastrophic strokes for which no explanation has been found. That uncertainty comes with life and with parenting, and if such uncertainty is too much for an individual to bear, parenting is going to be a very long, very hard road.

Everyone always says that pregnancy prepares you for being a mother--the sleepless nights of back pain and leg cramps and inability to breathe and peeing and rearranging closets during pregnancy are training for waking every 2 hours to breastfeed ad infinitum, to comfort the colicky baby who cries half the night, etc. The truth is that the lost sleep of pregnancy is just the tip of the iceberg compared to the lost sleep with a newborn. Worry is no different. You will no doubt worry as a woman trying to conceive and as a pregnant woman, but I can tell you from experience that you will worry a thousand times more once you are a mother. It is understandable. It is probably evolutionarily conserved so that our species will survive. But it cannot be all that you do, or it will become all that you are.

So ladies, don't panic!

Are we there yet?

I have 3 kids ages 1-5. I have taken 4 flights alone with said 3 kids in the last month, so I find myself attempting to answer "Are we there yet?" often lately. But guess what? I'm actually the one who has been asking it and not just because I was READY to get off that plane (though I was READY to get off that plane, too). My husband I are struggling with our future childbearing plans. With 3 kids, is our family complete...or not?

Now ordinarily, I'm not a huge fan of the overshare and I wouldn't take these musings to a blog of physician mothers, but it feels relevant here.

My med student brother-in-law and his wife and two little girls were visiting this weekend, so I had to drag out the high chair and the pack n play and all of the baby stuff that is still stowed in our attic. And while I had a little familiar wave of nausea as I watched all of our floor space become occupied by clutter, as it has been for so much of the last 5 years, I also had a little wave of nostalgia. Actually a big wave of nostalgia. We are long overdue for a yard sale to be certain. But am I really ready to give away the bassinet? The baby tub? The smallest baby clothes? The boy baby clothes that I haven't had occasion to pull out since my first child was born 5.5 years ago? I'm not so sure.

My son would love to have a brother (no guarantees there, of course, but as a woman who can't imagine not having a sister, I do give a nod to his desire for a brother). We have the space--two of the kids would have to share a room, which none of them do right now, and I'm sure that would generate discord and some night time awakenings, and we would need to trade one of our cars in for the dreaded minivan--but we have the space. More importantly, though, we have the space in our hearts. We love each of our kids more every time we have another one. I know we would be busier, which unfortunately detracts from the individual time each of our kids get with us, but in exchange, they would get the love and companionship of another sibling, and that counts for a lot. And when my husband and I are long departed from this life, it will count for even more.

So why am I struggling? Well, the truth is that it wears me out to think about having to "start over" yet again at the career. Having to make excuses about being late because the baby kept me up all night and then I slept through my alarm. Having to take breaks from meetings to pump. Having to rush out of clinic and skip tumor board in order to see my baby before he or she goes to bed at an insanely early hour that is currently referred to as "dinner time" otherwise in our household. Having to turn down awesome opportunities and excuse myself from obligations because deadlines or conferences will occur when I am 36 weeks pregnant or when I have a 6 week old. And, most nebulously but maybe most significantly of all, having to prove that I can "still do it" as I had to prove I could still do it when I was pregnant as a first year fellow; when I had two children and therefore two maternity leaves during the course of a 3 year fellowship; when I got pregnant with my third child shortly after starting my new job. Presumably, this time it would be having to prove that I can still do it even though I now have 4 kids since I have been told many apocryphal stories of physician moms who "cut back to part-time when they had their second and then decided it was just too much and quit working after the third." I don't know what happened to them when they had their fourth. Maybe I don't want to know!

There is definitely an assumption at our jobs that we are done since we have 3 kids. I have had multiple colleagues tell me jovially and empathetically, "Hang in there. It's going to be so much easier in another year or so all of your kids are out of diapers!" It is a forgone conclusion that we are done to everyone except us. We have already exceeded the magic number (that would be 2) of kids for the two-physician family. On the other hand, I was recently told by a former med school classmate who also has 3 kids that "3 is the new 2". The question that leads me to is: So, does that make 4 the new 3...or is 4 still 4?

But the bottom line is that I just turned 37 a few days ago, and I have 3 small kids. If I am going to have another, I want to get on with it and soon. I would rather keep going with the diaper stage than have to go back. I don't want to be facing paying for college tuition at the same time I am also trying to retire. I want to be able to do things like go camping and hiking as a family, things that are harder or impossible to do when there is a baby or toddler straggling and holding back the rest of the group. I want to be able to plan days without having to accommodate anyone's nap. And I want to do it while I still have the energy to survive sleepless nights and chase my kids around the yard after a full day of work. So while I am not sure what our decision will be, I think the time we want to make it is soon.

So, are we there yet?

The intersection of science and motherhood

Upon learning that we were approaching our first anniversary at Mothers in Medicine, I sat down to reflect upon what I have learned. I am, relatively speaking, a newbie to blogging and to this site in particular. I think I have only posted 7 or 8 things. Most of the other bloggers have a lot more to show for themselves, and Fizzy blows me out of the water. Anyway, what I discovered is that the parallels between motherhood and doctoring are many. It has been fun to notice them, share them, and ruminate on them. But what about the parallels between motherhood and science? Are there any? To quote a one-time VP candidate, YOU BETCHA. Here are just a few of my favorites.

The following scientific definitions come with a nod to Wikipedia.

Heisenberg uncertainty principle, as originally proposed:
"In quantum physics, the Heisenberg uncertainty principle states that certain pairs of physical properties, like position and momentum, cannot both be known to arbitrary precision. That is, the more precisely one property is known, the less precisely the other can be known. This is not a statement about the limitations of a researcher's ability to measure particular quantities of a system, but rather about the nature of the system itself."

Heisenberg uncertainty principle, with children:
In parenting, the Heisenberg uncertainty principles states that pairs of siblings, like "Munch" and "Iggy", cannot both be known to arbitary precision. That is, if I can actually see my 3 year old daughter and reassure myself that she is not coloring on (as in directly on) our kitchen table, I cannot also be simultaneously upstairs to observe my 5 year old son using my two mostly full leftover tubes of Lansinoh to glue ALL of his Lincoln Logs to his closet door (true story). This is not a statement about my limitations as a mother, but rather about the nature of parenting itself. Well, that's reassuring. I love physics.

The Law of Conservation of Energy, as originally proposed:
"The law of conservation of energy states that the total amount of energy in an isolated system remains constant. A consequence of this law is that energy cannot be created or destroyed.
Another consequence of this law is that perpetual motion machines can only work perpetually if they deliver no energy to their surroundings. If such machines produce more energy than is put into them, they must lose mass and thus eventually disappear over perpetual time, and are therefore impossible."

The Law of Conservation of Energy, with children:
With children, the law of conservation of energy states that the total amount of energy in an isolated system, such as when we do not have grandparents visiting for a long weekend, remains constant. A consequence of this law is that my husband allowing me to sleep in on Saturday morning leaves him doubly trashed and incapable of functioning for the remainder of the day, even though I am peppy and grateful and ready to have a big family day. Another consequence of this law is that perpetual motion machines (aka mothers) can only work perpetually if they deliver no energy to their surroundings, which means that I basically have to quit going to work, going to the gym, going anywhere at all actually, in order to keep my head above water with these kids. Apparently, they haven't gotten to this part in preschool science yet. If mothers produce more energy than is put into them, they will cease to exist. Take heed, children and husbands...and note that Mothers' Day is just around the corner, and they don't call it the "Rejuvenating Spa Day" for nothing. It could save a life.

Second Law of Thermodynamics, as originally proposed:
"The second law of thermodynamics states that the total entropy of any system cannot decrease except insofar as it flows outward across the boundary of the system. By implication, the entropy of the whole universe, assumed to be an isolated system, cannot decrease. In fact the entropy of the universe is always increasing. We know this because we can identify processes that produce entropy from scratch, and the second law tells us that these increases cannot be undone elsewhere."

Second Law of Thermodynamics, with children:
With children, the second law of thermodynamics states that the extreme disorder and chaos of your minivan (substitute favorite location: kids' bedroom, playroom, etc) cannot decrease except insofar as you have a successful yard sale, consignment store transaction, or Salvation Army pickup. Note that if you move the clutter from the playroom to the attic or unfinished room in your basement, the entropy of your system remains constant. By implication, the clutter associated with childrearing in the whole universe cannot decrease and indeed is always increasing. We know this because we can identify processes that produce entropy from scratch (baby showers with swings, jumperoos, infant carseats and bases, activity gyms, pack n plays, and diaper pails before you even have anyone to use them). And the second law tells us that once you have this stuff, you will end up holding on to it for an inordinate number of years even once you are absolutely, positively, (almost) definitely done having kids. And when you do get rid of it once and for all--usually because your childless younger sibling, to whom you have ranted that you are "so done" having kids after a particularly frustrating day, tells you she is pregnant and wants your stuff--the empty space vacated in your home and cars will be promptly filled with Matchbox cars, Polly pockets limbs, Legos, and jigsaw puzzle pieces.

And finally, I was a literature major in college, so I am not aware of the corresponding law in physics for this one, but I know it must be there somewhere (science majors, speak up): Children expand to occupy the number of adults present. This refers to the phenomenon that I am currently living as a temporarily single parent while my husband is deployed for 5 months. It takes me half the day to get a shower on the weekend when I am here alone with them. When the grandparents or aunts and uncles come to visit, it takes all of us half the day to get a shower. Even if there are 4 adults present, everyone is occupied. Someone is changing a diaper. Someone is helping to build a pizza shooting robot out of Legos. Someone is cleaning up the food thrown all over the kitchen floor by the 16 month old during lunch. Someone is attempting to catch the muddy child and wrestle her into the tub before she leaps onto the yellow sofa. If this has never been reported as a phenomenon before and you take a notion to scoop me by submitting it to Popular Science, please consider naming it Tempeh's Law.

So, just in case you have decided against becoming a radiation oncologist and now wonder why physics was required for med school, it was because those med school admission committees knew it was only a matter of time before you would want to pass on your genes. And when you did, with Physics 101 under your belt, you'd be ready. Or at least you couldn't say you hadn't been warned...I mean, consented.