Let’s be like Sweden...or Why doesn’t anyone talk about paternity leave?

Hi everyone, I’m Anna Plasia.  This is my inaugural post for MiM!   A brief introduction: I am a pathologist with a new baby, but I've been reading MiM since long before I became a mom.  I'm married to my best friend who also happens to be a father-in-medicine.  I'm honored and excited to be part of the MiM family!

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I have to admit that I was reluctant to get pregnant.  I was happy, and I didn’t want anything to disturb that balance.    My husband and I are both physicians, and our relationship up to that point had been that of equals.  Obviously there are things at home that one or the other of us has taken over due to interest or entropy, but overall our relationship was egalitarian.  And honestly, I didn’t really see examples around me of parenting relationships that were what I hoped for.    My own parents were both professionals, but it was my mom who stopped working for several years when I was born and it was my mom who managed all doctors appointments, birthdays, shopping, cooking, cleaning, etc.  I was sure that my parents’ relationship must have been similar to ours in the beginning -- but becoming parents made them became so...traditional.  So is having kids just inherently unequal?  Obviously men can’t actually have the baby, but are women really genetically better at managing doctors appointments and birthdays and cleaning, or is there something structural going on that makes things turn out this way….every time?

It turns out that the seeds of parenting inequality may be sown as soon as the baby comes home.   According to a report produced by Boston College Center for Work & Family in 2014:

When we ask why it is the case that most men aspire to be equal partners in caregiving but often fail to meet even their own expectations, there can be many possible explanations for this shortfall. One cause that seems clear from our work and that of other researchers is that this performance gap begins in the very first days following the birth or adoption of a new child, when the disparities between the experiences of mothers and fathers emerge immediately. In our research, the majority of fathers take only about one day of leave time to bond with their new children for every month the typical mother takes….During that time at home, fathers are seldom “flying solo” in caring for their newborns (Harrington et. al, 2011).  

It makes sense - - if mom is the only one home with the baby for the first three months then of course she is the one who knows the most about baby.  She knows what baby eats, what soothes baby, what baby wears.  When dad comes home from work he’s stepping into mommy territory.  When baby needs soothing it’s just easier for mom to do it because she already knows exactly what to do.  And if mom has been off of work for a few months then she’s definitely the one getting up at night with baby.  When she goes back to work she will continue being the one getting up with baby, leading to exhaustion, burnout, bitterness, and curtailment of professional duties.

So the question then obviously becomes what happens when men take off their own version of “postpartum” time? In several Scandinavian countries (see Iceland, Sweden, and Norway) fathers are provided with paid paternity leave that they must use or the time is lost.  In Germany and Portugal mothers get bonus time if dads take their allotted time.  It turns out when men take more time off with their new babies the benefits last for a long time.  A survey of parents in Iceland which looked at how childcare duties were divided both before and after a paternity leave policy was implemented found that “there is a direct correlation between the length of leave taken by the father and his involvement in care afterwards.”

My husband and I both agreed that equality in parenting likely begins in the first weeks...so my husband decided that he would take two months of paternity leave.  We are lucky that both of our jobs were covered by FMLA, and we did not fear permanent professional repercussions from taking time off.  But this is definitely the exception, not the rule for physicians.  This decision came at a significant financial cost as both of us took unpaid leave, but we decided some things are priceless - money be damned.  Because it’s unusual for a man in the US to take off a significant amount of time for a new baby, no one could wrap their head around it.  The reaction was...confused.  “Wait, did you say two weeks - or two months???”  No one had ever heard of a father doing this...especially not a physician with an “important” job.  No one tried to dissuade him from doing it, but it was definitely seen as an unusual request.  I am so proud of him for sticking to his guns...honestly it takes courage for a man to buck the trend.

My husband’s extended leave was one of the best decisions we made about having a baby.  We spent the first month at home together.  I can’t imagine being left at home alone with a new baby a week or even a few days after giving birth.  That first month we woke up together for every nighttime diaper change and feed.  Those first nights are long, lonely, and dark, and I can’t imagine going through them without my best friend beside me.  At the end of my leave, my husband took his second month off, and it made the transition back to work so much easier.  Every morning I left our baby with my husband - who knew what to do since he spent that first month at home.  There was no mommy guilt about returning to work with a 10 week old.   And now I really don’t feel like one of us is the primary parent - we are both just parents.

Unfortunately, our experience is not the norm for physicians.  As a physician, unless you are employed by an academic center or a large hospital, your job is often not covered by FMLA.  Many physicians are employed by private practices with fewer than 50 employees or are self-employed and cannot afford to put their business on hold for an extended period of time.  I was told up-front at several (private practice) job interviews that I would only be able to take vacation time for maternity leave.  If it is this hard for physician moms to take medically necessary maternity leave, imagine how much harder it is for physician dads to take off extended paternity leave.  At the same time I am sometimes surprised when I hear of physician dads who take off less time than they would for a vacation when their partners have a baby.  Obviously there needs to be a shift in both the cultural expectations surrounding paternity leave as well as the law in the US before this becomes a more commonplace occurrence.

I also realize that we are very privileged that we could afford to both take off time from work.  The sad truth is that for many Americans this is not a choice they can afford to make.  Ours is the only developed country in the world whose government does not guarantee any paid leave to new parents (source).  Due to exclusions built into FMLA, only 60% of workers are eligible for the unpaid leave guaranteed by FMLA.   Only around 25% of US employers offer paid maternity leave, and even fewer offer any paid/partially paid gender neutral family leave (which includes paternity leave).  It is the lowest paid members of the workforce who generally have the least access to paid or unpaid leave.  And since family leave is usually unpaid, fathers are even less likely to avail themselves of it as they are often the higher earners (source).   Most families can barely scrape by on one salary for any amount of time, never mind three full months.  Having an egalitarian paid parental leave policy in the US would go a long way toward making parenting a more equitable experience.

Did anyone else’s partners take off extended paternity leave?  How was the request met?  Do you think this is viewed differently in medicine than in other fields?

Doctor Day

Recently, I had the opportunity to teach my younger daughter’s preschool class about being a doctor. Sometimes I think that part of the reason I became a doctor was just so I could get to do that.

I was nervous. I’m not sure why I was quite so nervous, considering in retrospect, I can’t honestly think of anything that could have gone wrong. It wasn’t like I was lecturing to a bunch of Harvard professors--these are individuals who pick their noses and eat it. In public. This was like the least discerning audience of all time.

I started out by introducing myself and asking the kids, “Do you know what a doctor is?”

One kid’s hand shot up and I called on him. “A doctor gives us s-----,” he announced.

I couldn’t make out the last word he said, so I took a guess. “A doctor gives you socks?”

The kids burst into hysterical laughter. He said “shots.” How did I not know that? That is literally the only thing children know about doctors.

I had this brilliant idea to bring in a pile of rubber gloves for the kids, so they could each put on a glove and feel like a doctor. Except this turned out to be the worst idea of all time. Kids are apparently unable to put on gloves on their own. Several teachers had to be recruited to help. This ate up, like, ten minutes.

After that, I had the kids listen to each other’s chests with my stethoscope. They came up in pairs of two so I could help them. Except about a quarter of the class was completely deaf.

Child: “I can’t hear anything!”

Me: [adjusts stethoscope] “How about now?”

Child: “No! Nothing!”

Me: [able to literally feel small child’s heart pounding with my hand on the diaphragm of the stethoscope] “Um… sorry?”

Then I broke out my reflex hammer. You want to hear something sad? I actually bought a new reflex hammer just to use in my daughter’s class. The fact that I was using it on patients wasn’t motivation enough, apparently.

The teachers looked a little nervous about that hammer. Understandably so. It was fine though. Nobody was beaten senselessly with the hammer or anything like that.

Soon after, we ran out of time, which was a shame because I was just getting into it. The teacher asked the children, “Do you have any questions for the doctor that aren’t stories?”

A boy raised his hand: “I went to the doctor and I got a shot.”

“Questions that aren’t stories,” the teacher clarified.

A girl raised her hand: “My mom took me to the doctor and I got a shot.”

And it just sort of went on like that.

In any case, it was a really fun experience. Highly recommended.

Diagnosis

This is a Daughters in Medicine post.

(which really does describe me - I'm a third-generation doc. And that is and isn't relevant to this post.)

When my grandmother was in the last years of her life, she fell out of bed. They took her to the ER, where she was Xrayed, pronounced intact, and sent home (where she lived with my grandfather, the retired internist, and a full-time caregiver.) The next morning my mother called me and said "Your grandfather is upset because your grandmother refuses to get out of bed." This was in the 1990s, before digital radiology and Nighthawk came along. I said "Tell him to call the hospital and ask for the radiologist's interpretation of the film. She might have a non-displaced fracture that the ED doc didn't pick up." Mom called me back several hours later and said - in a deeply suspiscious voice - "How did you know that?" I said "You sent to medical school. I learned stuff."

It's now 25 years later. My mother is the one with dementia, living at home with 24-hour care. No retired internist in sight; my father died nearly ten years ago. Last week Mom fell. The caregivers thought she was OK; a few days later, the pain was worse and she was refusing to bear weight. I said "She needs Xrays; she might have a nondiscplaced fracture." And sure enough. She sent me to medical school. I learned stuff.

Mom doesn't need surgery, thank heavens; we'll get equipment into the house and she'll stay in bed most of the time for a while. She's not having any pain.

But I know what it means when someone with moderate to advanced dementia breaks a hip. I'm a palliative care doc. I know where we're going. She sent me to medical school. I learned stuff. And some days, that stuff breaks my heart.

My cherries are damaged!

Ingenious idea, I thought! Youtube, my trusty friend, came through yet again with a genius how-to video to answer some mundane question of mine. We bought some yummy delicious cherries, and TC, my little Toddler Child, loves fruit. I didn't want him to aspirate a pit in a cherry fueled excitement. Last time he had cherries was several months ago when grandma methodically cut the goodness around the pit. But grandma has time and patience that I completely lack. I needed some quick and easy way to pit lots of cherries. Supposedly such gadgets as cherry pitters exist. But (a) I was sitting with a bag of cherries and a hungry toddler, and I needed something NOW and (b) I hate buying useless one trick pony kitchen equipment. Youtube how-to video to the rescue!

An empty wine bottle. Check. Chopsticks. Check check. So I spent the next 10 minutes pitting a lot of cherries. I may gone a little overboard, but there is something oddly satisfying about excising the pit out of a cherry with precision in one swift motion. Ten minutes later I proudly presented TC with a bowl full of "safe" cherries whose pits he wasn't going to aspirate or break his newly sprouted teeth chewing on. At first, TC let out an excited "Chays!". Yes, TC, delicious chays, dig in! TC picked up the first cherry, and his smile was quickly replaced with confusion. How strange, the first cherry was damaged with a hole. He continued to pick up cherry after cherry and putting them back, now with full-on disgust. I knew it was coming, and there it was! TC tossed the entire bowl of cherries on the floor, laid his head on the table and sobbed his lungs out for half an hour. Because his cherries were damaged.

Anyhoo, with that story as an introduction, I am excited and delighted to be writing for the MiM community! I found MiM a few years ago when I was pregnant and freaking out about how I was going to swing this whole motherhood thing while going through med school. As for all life advice, I turned to Dr. Google, who directed me to this blog. Through the years this blog provided me with some  reassurance that this whole mothering and medicining process doesn't always look pretty but there are others out there in the same boat who are making it work. And they are willing to share those messy stories. I felt that it was time to stop lurking and start giving back and putting my stories out there. You can find more about me in the about page of this blog. I also write my own blog, Mrs MD PhD, where you can find more about me. Feel free to regale me in comments below of how your toddler (or not so toddler) child(ren) laid waste the fruits of your labor and/or cunning.

Fighting back

Oh, the astounding advice that comes to you on a daily basis during a time of crisis. 

I cried in my boss’s office today. Like one of those bad, ugly kinds of cries that you just don’t want to do as a woman in front of your male boss.  Except, in the case of my particular male boss, it’s sometimes borderline acceptable because he is a kind, wise soul. I would never overuse his kindness in this way. I’ve cried exactly two humiliating times in front of him, today being the second.  The waterworks started while we were talking about something I’m struggling deeply with these days -- my professional persona in light of my personal life collapse. See, I work in a leadership position in an academic institution. I’m one of few women in leadership positions, and there is a bit of a propensity at this place, and particularly in my field, for young female physicians-in-training to pass by my office informally and ask questions like “how do you make it all work?” And, in that nonchalant passerby question, they are referencing things like simultaneously juggling knives while also making it work with marriage, kids, teaching residents, and taking care of a panel of primary care patients.  And, so, in a world where I trained with very few female role models who were “having it all”, I took it upon myself to be that kind of path builder. It was a conscious decision to open my life up to the generations of female physicians who were maturing into their multi-faceted roles as women, doctors, mothers, partners, and allow them the freedom to pass by my office and come in when the door was ajar, and ask me what it was all like in “real life”.  I certainly never sugar-coated it -- it’s hard for everyone -- but I wanted to give them faith that a fulfilling life, both personal and professional, was possible. I did have that for a time, until I didn’t.

Today, in my boss’s office, I reflected on my failure to be this person I aspired to be, and who I thought I was. I also talked about my failure to be the role model I wanted to be for my residents.  I humbly asked his advice about how to handle it. It wasn’t so much that I wanted his advice on how to handle my divorce and all of the emotional muck that goes with that (it is so deep), but how to negotiate this space where most of my trainees know me as married, two kids, physician, teacher, academic. At this moment, my new identity is single mom with two kids, physician, teacher, academic. And I’m struggling on every single one of these fronts. And frankly, it’s hard for me to struggle. I’m a perfectionist by nature -- good survival trait for a physician, but it turns out to be a harmful trait when everything in your life goes up in smoke.

Poof.  

I’m noticing that I’m deeply clinging to my sense of self as physician and leader, but I feel this person (or who I thought she was) slipping away. In the last nine months, I haven’t lived to my own standard, nor been the person my residents think that I am. So, am I a fake? A fraud? An impostor?  

Poof.

At one point during this talk with my boss, with tears and eyeliner cascading down my cheeks, and both nostrils completely clogged with snot, I said “I’m fighting my way back. I’m doing the best I can right now (sob, sob), and I know it’s not my best. But I’m really trying. And it’s super important to me that you know that, and you don’t lose faith in me.” He sat there. He nodded. And he sat there some more. And I cried a little more. And, you know, like a good primary care doctor, he just let the silence be the space between us for a while.  And then he said softly “I think, really, if I was going to give you any advice, it would be to let go of the concept of fighting to come ‘back’. You’ll never, ever be back, Frieda. You will be somewhere, but let go of the idea that you will be back where you were before. Nothing is ever going to be the same.”  

Poof.

And, so it was burned in me, under my skin. These words. This wisdom. It was so right. How come I hadn’t thought of it before? In some ways, a liberating thought. In most ways, it deepens my grief.  I’m a fighter. A bootstrapper. A resilient woman. I’ve been putting all my energy into paving my way “back”. Literally every ounce of my soul, strength and breath have been put toward getting one foot in front of the other everyday to get back to where I was -- and I suddenly realize I’ve been deluding myself. It’s so simple, in fact, but I’ve just been unable to see it. It begs the question, so just where am I going? Forward? Then what?

"Why didn't you just go to medical school?"

I'm guessing this is a common question posed to ARNPs/PAs, and one I figured I'd take a moment to answer personally, because I find it irksome. Well, I didn't go (or even apply) because....I didn't want to be a doctor!  I don't think it's a compliment to ask an RN/NP/PA that question, but I'm thinking it's meant to be one (i.e. you're really smart, you could've learned more/done more). But the question presumes that becoming a doctor is The Best Option for those interested in a professional graduate level healthcare career (and that the smartest people in medicine are always the doctors).  But becoming a doctor is one of several medical career options out there, and it's not always The Best One for everyone. So for this post I'm going to recount how I got to ARNPLand, given other possible paths-and how a key factor in going to ARNPLand was motherhood. Doctors are awesome (duh), but not all of us are destined for DoctorLand--for a variety of reasons.

My undergrad education was in liberal arts, which was interesting but frankly not very useful at all (a classic tale). I worked in social work right after I got my degree, and worked in social work/corrections for a while...but I wanted a job where I could DO things, and PROBLEM solve and really FIX things. And not be stuck at a desk all day long shoving paper around.

I knew that I wanted a job where I could do the following:

• Be a big nerd, and be in an environment where nerdiness was celebrated 

  

  What a cute ARNP!

• Fix things or people (or both)
• Make a good living, i.e. to support a family of at least two kids. Oh crap, we have three now; we've debated selling one but the kid market is in a slump. And yes, the third pregnancy was planned. And yes, we had an OB ask us this. We changed doctors. Think about that question for a moment...Anyway, my goal wasn't to be rich but to have enough. Comfortable enough to be like the Cleavers (well, the interracial lesbian family suburban version). Ah, but "enough" is so subjective, isn't it?

The Cleavers, "then"..

The Cleavers, "now"

• Be a mom who could go to choir performances, be home for dinner most nights, have dinner with my mom, go out to dinner with my wife, walk my kids to school sometimes,  have time to email my twins' teacher about schoolwork (and kvetch about common core math, that is a whole different post...), cook dinner on my off days, and so on. 
• Be able to have kids closer to 30, not 35 or 40 (I had twins at 29--overachiever!!). 
• Completely gross out my kids and wife with graphic descriptions of medical procedures, bodily fluids, and so on. 
• I wanted to be able to say nonchalantly, "It's just a flesh wound!" (please click HERE if you understand that allusion...you're welcome!)
• Pay $800 in student loans per month. Actually, this is a heck of a deal-ask a physician (or a lawyer). Gotta pay to play, right?
• Crap my pants as I mumble  confidently say the the words "Call a FREAKING code !!!" as I run to the room, after the RN calls me and I hear the words "EKG changes" and I see the heart rate go from 120--100--90--70--50 in 5 seconds on the tele monitor, while my amygdala fires repeatedly and my brain says "ARGHHHHH!! You totally know what to do, breathe...". Begin CPR....
• Have an unlimited supply of graham crackers to sneak from the nutrition room when the charge nurses aren't around to notice (and peanut butter, oh MAN, that stuff is good).

I also took into consideration how much I'd be able to see my kids, day to day--it was important to me to be around as much as possible...consistency. In some subspecialties (that involve years upon years of fellowship), fellows put in so many hours that it's a real challenge to balance the demands of motherhood and work--and year after year they face these dueling demands--and hats off to these women for taking it on! I see fellows in particular who FaceTime their kids nightly, because they're rarely home in time to say goodnight--especially those with young preschoolers. And sure, it's temporary--because kids grow up, stay up later, and so on--and fellows finish their programs. And fellows do have days off, of course, during which they can love their kids (in person) to pieces. But for me, I wanted more of the day to day mom stuff. The stuff that makes me crazy and the stuff I love.

My point is---to each her own. I have as much respect for the mother who is a general surgeon as I do for the mother who stays home full time. And really, it's great that those of us in medicine can FaceTime now to say goodnight to our kids so that we can maintain the daily connection despite our wacky schedules; I used to do it frequently when my twins were toddlers--I'd leave for work before they were up and get home after they were asleep. It was hard, we missed each other a lot. And it was a lot of extra work for my wife when I was gone, as she'd get through multiple 13-14 hr days on her own. So for any woman who is embarking on a medical career it's incredibly important to consider how one's choice of career will affect one's ability to parent in a way that works best for you, for years.  It's a huge, huge consideration. It's a years long balancing act--how on earth are you going to mix these two awesome things (motherhood and medicine) together successfully and keep your kids alive (and your patients)?! 

I needed the work:life balance that I thought an ARNP career could best provide, and I was concerned that I wouldn't have been able to find had I chosen medical school. Or, I suppose that I could have found it eventually, but I would have had to put off having kids for several years--and I didn't want to do that, for many reasons. I couldn't be the kind of mom that I want/wanted to be had I chosen a different career path. And what about the difference in salary, you might ask? The money is great, I think. The starting ARNP salary in outpatient oncology around here is about 100k. Inpatient oncology at private hospitals around here? Around 130k. That's enough for me, enough for my family to live well. So I'll never be The Boss, I'll never be famous, but it's enough--I'm home over half the month (I work 10-12 12hr days a month), I often pick up the kids from school, I have the time to make dinner frequently (and lunches for school, ugh), I have a challenging/brain stretching/ emotionally taxing job and it's all enough. Score.

So this is my corner in the medical world, and I'm happy in it. And frankly, ALL of us are awesome for making our lives work-however we get it done. So here's a toast to getting by with FaceTime, nannies, dads, moms, friends, support groups, childcare centers, vodka martinis, grandparents, Munchery/Pizza Hut/Whole Foods/Amazon Fresh--we're getting it done--mothering AND medicine.


Later,

ZebraARNP

Trading fake patients for real people

MS2 Terrible Twos here. New to MiM, so here is a quick introduction. I am mom to a sweet nineteen month old boy who is into everything and lacks even the faintest inkling of self-preservation. In a former life I received a Bachelor's of Fine Arts from an art school here in the Bay Area, and worked for over a decade in advertising, marketing, corporate event design, apparel, and retail packaging design until I decided that pursuing a career in medicine was truly my dream. Thanks to a lot of hard work, a loving and patient husband, and tons of emotional support from friends and family, that dream has materialized and I am (as of last week) a second year medical student in the Bay Area in California.

Having just completed MS1, one of the most challenging aspects of the medical curriculum this year has been seeing through the text books, algorithms, power points, Quizlets, acronyms, mind maps, case studies, and patient vignettes and remembering that the purpose of all this learning is to support real, actual people with rich histories and complex emotions. The majority of my patient interactions feel so forced and so awkward – so robotic, scattered, and disjointed. I hear standardized patients describe their symptoms and feel myself responding stoically, without empathy to concerns like, “is this serious?”, or "am I going to die?" as I systematically wade my way through OLD CARTS and FED TACOS and remember what a relevant ROS might include for the few differentials I know to consider.

Throughout every standardized patient interaction, every practical exam, and even every time I have performed an H&P on a "real" patient in my school's student run free clinic, I feel as though what limits me from truly developing any sort of rapport with the patient in front of me, actual or standardized, is the tunnel vision that comes from trying to dot every i, cross every t, and check off each and every box on the syllabus.

I understand that there is a learning curve with all of this. As with many professional practices, the only way to get better at them is by doing them over and over again and I recognize that I'll be working toward that for the rest of my medical career. I suppose that what worries me is the fear that throughout my medical practice there will always be a syllabus to consider, be it a QI evaluation report, an insurance audit, filling in every blank on the EMR, or tending to some other system to which I am held accountable.

I would like to believe that all the the awkwardness of MS1 will start to subside as early as this summer when I volunteer at the free clinic -- that the relief of having completed one full year will allow me to relax a little and try to integrate the systematic thinking of MS1 into just another part of my experience and knowledge. My hope is that the breadth of my other experiences prior to coming to medical school, including being a mother, will begin to materialize within those interactions, allowing me to truly connect.

When did it happen for you? When do patients, even standardized ones, cease to present solely as a collection of their signs and symptoms and emerge as actual people, and what tools have you used to transcend the awkwardness of your early medical training?

Mother duties = father duties

I recently realized something.  Something I don't like, that I've been doing without even knowing it.  I have been thanking my husband for doing fatherly duties.  Example:  He says he is going to pick up our daughter from daycare, and I say thank you to him.

Does anyone else see something wrong with that picture?  He never thanks me for picking her up the majority of the time.  He doesn't thank me for loading/unloading the dishes, or for doing the laundry.  But I thank him when he does anything more than go to work and come home.  

I have friends who have clear division of labor in different ways, where their husbands are actually expected to do laundry, dishes, wake up with the baby, etc.  Mine has never had such expectations.  The tasks are all mine, with him helping out when he sees fit and convenient.  The dishes will not pile up if he doesn't touch them for days, I will put them away.  The food will not run out, I will make sure we are stocked up.  The kids will not go hungry, I will make sure they're fed.  I don't blame him at all for any of this, because it is the precedent I have set in our marriage and home.  But I wanted to ask fellow MiM's:  What kind of precedent do you have in your homes?

think zebras, not horses

Hi MiM aficionados,

I'm ZebraARNP, and I'm so pleased to be the first non-physician contributor here! I'm a nurse practitioner in a big hospital in a big city. I've been an ARNP for about 8 years now, and I've spent all of those years in oncology. I can't imagine doing anything else, to be honest. I live in the 'burbs with my wife, to be known here as The Wife, and our three kids, to be known here as Jaybird, Hedgehog, and Egret. More about the family in my next post.

The other day on rounds, as my team was heading out to see our first patient, we encountered a large group of petite Filipina women, dressed in the green environmental services uniform provided by the hospital. Our team greeted the group then as we passed them my (tall, white) attending said to me "They're so cute, they're all so short!" At the same time in my mind I was thinking "Dammit, they're all people of color..." and I felt a wave of...disappointment? Sadness? Irritation? Hard to find a word to describe the exact feeling. I'm not even sure that the two (white) MDs with me even noticed that the ENTIRE group of custodial staff we encountered was Filipina. All that my attending appeared to notice was that they were "cute." Sigh.

The flip side of the above experience is when I see another African-American/multiracial ARNP/PA/MD in the hospital. In those moments, time slows down, music starts to play...(Chariots of Fire, in case you're wondering. It's ok to click on it..) I want to run up to them to see if they're actually real!! Should we hi-five? Cheer? OK, no. Maybe next time...

For such a big city (although <10% African-American), and such a big hospital (>300 beds), there is a dearth of African-American professional staff. Over the years I have been mistaken for kitchen staff, janitorial staff, nursing staff, but more than that people have often looked genuinely surprised when I explain my role on their healthcare team and what I actually do on our team (admissions, write orders, take first calls from the RNs re patient issues, etc). And my point is not that any of the above mentioned jobs lack importance at all; my point is that no one assumes that I have the job that I have and mostly that they express surprise at my actual position. Food for thought. That surprise? It doesn't feel very good on my end.

Always check your assumptions....because we all have 'em. Women as surgeons. Men as nurses. Someday I hope that female surgeons, African-American physicians, male nurses, etc--I hope none of that even raises an eyebrow.

More about me, since I'm a newbie-->
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ZebraARNP is an oncology ICU ARNP with three children- school aged twins (girl, boy) and a preschooler (girl). That brief sentence vastly oversimplifies the amount of joy/pain/money /insanity/Band-Aids/love/maniacal laughter it requires to raise three human beings; it’s a doozy sometimes. Anyway, this is ZebraARNP's first public/non-academic/not Facebook writing experience, or writing that isn’t a daily progress note of a critically ill oncology patient. ZebraARNP is married to a pediatric SLP who isn’t in fact really that interested in oncology but who has acquiesced to the fact that she will indeed continue to learn about it (or at least listen to random factoids) year after year simply out of love for Zebra. Dinner time conversation in our demographically complicated yet still shockingly quotidian suburban home (interracial lesbian marriage, anyone? Can someone say “intersectionality” ten times fast?!) may or may not include how much CPR was done that day, palliative care conferences, cdiff vs VRE, who did well on his/her math test (or who did not), who will go grocery shopping next, what MRSA is, what exactly IS pus made of, what actually happens when you die, arguing over who gets the last muffin/cookie/etc, reviewing hematopoiesis, and questioning whether kid # 1, 2, or 3 really did wash their hands after using the bathroom. When ZebraARNP isn’t at work or with kids, she enjoys gardening, chicken keeping, reading books (or the NY Times), and wasting time on her iPhone (oh the Amazon app…)…and not being at work or with the kids.

The Bottom Step

My six year old was crying. She has a flare for the dramatic, but this was real. She had just come home from dinner with her dad at his house. We are newly separated, though I feel as though it’s been an eternity that I have been emotionally and psychologically separated from him, and the person that he used to be.  The physical separation is only a few months old for my three year old son and six year old daughter, but they have settled into a new “normal” and have managed better than I thought they would. But tonight was a difficult night. Instead of kisses and hugs and a quick goodbye at the front door, my daughter wanted to be with her dad. She followed him back out of the house to the car, and the hugs and kisses continued as she tried all her tricks to prolong the goodbye. After some prodding, she eventually came inside, shut the door and fell to the kitchen floor, first with a “Hmmmph!” and a face of real anger, followed quickly by tears.

My three year old son, fairly oblivious at first to all of the evening’s drama, was playing with his trucks in another room and was calling for me to play with him.  My daughter was still crying in the kitchen. After a long day of work, multitasking every minute, I find myself pulled between the two most important people in my life -- wanting so badly to just play with my son and keep everything “normal”, and being drawn into the sadness and fear that was so openly being displayed by my daughter. I quickly settled the little one, and picked up my daughter and brought her to sit on my lap at the base of the stairs.

As we sat on the bottom step, I held her and she cried. Slowly, she calmed herself and the tears were less frequent and the sobbing slowed. I continued to hold her and quietly tell her I love her.  And daddy loves her too. And this is a hard time for all of us.  I don’t have anything more to say to make it better, though I desperately want to. I started to cry and I told her “I’m so sorry you are hurting. I wish Mommy could take all the hurt away. But we are going to be ok.”  Sometimes I believe we will be ok, and sometimes I don’t, but I always tell her we will -- and then I go back and think about it late at night, and wonder how I could have landed here. Me? But, then I remember that the how doesn’t matter anymore now. I’m a mom, and I have to guide these two little delicious, precious people through this storm. They don’t deserve this, and I didn’t plan this, and I never ever would have willingly put them through this, but we are here and we will be ok. We have to be.

M wanted to know why we all can’t be together. “Why can’t Daddy live with us anymore?” And then she asked me, “Remember all those special things we used to do all together?” From there, like a window opening on a cold day, her memories of special times blew in and they startled me. How did she have such vivid memories of these times at just six years old? “Remember the time, Mommy, when we were at the beach and we found all those sand dollars, and we went on that long walk together? And Daddy was with E, and we just did that together.”  And I told her that the beach was a special place, this hideaway in Maine we’ve traveled to as a family every summer since she was a baby, and that Daddy was still going to take her and E this year.  They could look for shells and sand dollars and hermit crabs and do all that fun stuff this year. During most of this conversation, she sat in my lap, with a downward gaze. Then, she looked up with her big, blue eyes and said “Won’t you be coming with us this year?”  I lost my breath.

 
This is just one of many, many, many difficult conversations I’ve had with M over the last 5 months.  They break my heart a little bit more each time. It’s that pain that only a mother knows -- when your child is sad and you can’t make it better. The kind of pain that makes you start to well up, breath deep, pause, and swallow hard while instincts tell you to suddenly “keep it together” and you figure out the right thing to say or you give a hug of just the right warmth and length and you get through the moment.  What’s worse about all this, and perhaps the hardest to bear, is that I feel responsible for her pain.  A fall on the playground, an illness, an argument with her friend -- all of those hurt, but they are the acceptable challenges of childhood, the kinds of things you expect to shoulder as a mom.  I never thought I’d be here. I never thought I’d get divorced.  How it all happened is a story for another day, though I’m certain with the deepest of conviction that I could not stay in my marriage.  But, she doesn’t understand that now. My friends and my family tell me “someday, when she’s older, she’ll get it. She’ll understand why you had to do it.” I think that’s true, but someday is a long way away. Right now, I have a six year old, with a six year old heart and brain, sitting in my arms crying over her “broken family” -- her words.  I tell her it’s not broken, it’s just different. I’m not even sure what I believe, but that’s what I tell her.

The moment passes. She feels better talking it through and looking at some pictures of a family trip from a few years back.  I take a moment and think. Silently, E crawls in on the other side of my lap, instinctively cuddles in to my chest, and asks “why are you cryin’, mama?” In this moment, we are all here sitting on the bottom step of the stairs of the house we are about to sell and move from.  And, it feels really real that we are on the bottom step of our new life.  There are 12 steps to the second floor of our current house.  We all walk up together to get ready for bath and bedtime, little E on my right hip, M holding my left hand. I can’t help but think that 11 more steps will be hard to climb, and I don’t know how we will do it, but we will get there.    

Don't forget they are someone's baby

Living in DC and taking the metro regularly provides me with ample fodder for social analysis and ample opportunities to be upset and amazed by humanity. For example, I get upset when able-bodied people see disabled, elderly, or pregnant people standing and sit in their seats anyway. Especially while pregnant, I spoke up very loudly (ex. As able-bodied men crowded on an elevator as I waddled to catch the door for a man in a wheelchair. I stared everyone down and said someone needs to get off so he can get on; we were obliged begrudgingly.). I am amazed when folks step in and help someone in need during an emergency.

An issue of growing contention in my neck of the woods is middle and high school students getting onto crowded trains. They are loud and there is often cursing involved. However, I have noticed that most of the adults regard them in a very unfriendly way or simply ignore them. The local listservs I am a member of are far worse; the disdain for these children is palpable and I have had to step in several times when the racism and classism became unbearable as well-to-do grown folks called children thugs, crooks, and goons. It literally hurts my heart!

I personally make it a point to acknowledge these teenagers every chance I get with a smile or a hello; sometimes I’m ignored or begrudgingly acknowledged, but oftentimes you can tell these young people relish the positive attention and are surprised to have been seen. I remind myself regularly that they are someone’s baby no matter how “hard” they are appearing to be. No matter how many tattoos they may have on their young skin. No matter how many curse words they and their friends yell. And I try to remember that someday my little Zo will be one of these students taking the train and I hope that others will treat him well knowing that he too is someone’s baby. My husband and I are well-read in the studies that show that Black boys like my Zo are seen as being older than they are by the majority and less innocent than they are by police (see FURTHER READING below). We know the sickening statistics of disproportionate violence against boys that look like him. We pray that folks will remember these children are someone’s baby and that he is ours.

To bring it back home to the DC metro, the other day on the train a handsome young man with beautifully styled locs and sagging skinny-jeans and a uniform high school shirt  entered the train with a young woman I assume was his girlfriend. His new-aged rap music (the kind old hip-hop heads like me can’t understand and abhor due to the crazy amounts of auto-tune) was blasting. Adults bristled. Some sucked their teeth. He walked on the train and I smiled at him, he was visibly surprised, smiled back sweetly and sat directly behind me. Every other word of his song was f--- this and blast that. I turned and said as gently and respectfully as I could “Sweetheart, don’t you have headphones or something? My old ears just cannot take all of that cursing.” He said quickly “Ohhhhh my bad! My headphones broke and I don’t have another pair, My bad!!!” I pulled out a set of headphones from my bag and said “here, you can have these!” He smiled and said “For real?!? You serious?!? Thank you so much!” And just like that - connection. Respect. Compassion. His mama would be happy.

It could have ended differently. Someone else could have started cursing at him. He could have rebuffed my offer and cussed me out. But it ended wonderfully. And I modeled appropriate, compassionate behavior for children and adults alike.

I exited the train at my stop and wished him and his lady a good day and he did so too.

___________________

FURTHER READING:

http://www.npr.org/2014/03/19/291405871/consequences-when-african-american-boys-are-seen-as-older

http://www.apa.org/news/press/releases/2014/03/black-boys-older.aspx

http://www.theatlantic.com/national/archive/2014/03/cops-tend-to-see-black-kids-as-less-innocent-than-white-kids/383247/

Are You Suffering from Overcare?

Dear MiM,

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

N.

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

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

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

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

Learning to Talk Back to the Voice in My Head

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

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

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

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

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

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

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

Love After Love

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

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

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

Gratitude

Not my gratitude. My kid's gratitude.

I will preface this by saying that Eve is almost always a delight. She's smart and funny and passionate about her friends and deeply upset about injustice; she usually does what she's asked without (too much) complaint and she is almost completely self-sufficient (laundry, room, homework, etc.)

And she's 16, and so she sometimes asks for things that she's not going to get, and when it becomes clear she's not going to get them, she has the typical adolescent reaction. This includes sighing, eye-rolling and detailing the ways in which her life is soooo harrrd. Our five-bedroom house is too small., Our backyard lacks a pool. We've only renovated one bathroom, and it's not hers. The hundreds of dollars she is given for a clothing budget is inadequate. You get the idea. She's not grateful.

I am not alone. A lot of my friends have the same experience. Our kids are incredibly privileged; they have rooms of their own, clothes with the right labels, and money to spend. At a more basic level, they have loving parents and safe homes and electricity and food and drinkable water. And we are shocked and somewhat hurt that they aren't grateful.

This reaction troubles me. I have the same impulse - tell me you appreciate all this. Tell me you recognize how lucky you are, how many children around the world have nothing, how many children in this country go to bed hungry while you're complaining that we don't have a backyard pool. I hear Eve rail against injustice and wonder why she can't make the connection to her own complaints. And then I answer myself: because she's 16. Because she still thinks she's the center of the universe. Because the terrible reality of poverty and war and famine and racism is too much to bear and she wants to look forward to being a grownup.

I wonder why it's so important that they be grateful. For some reason, this makes me think of Oliver Twist. "Please, sir, may I have some more?" Eve is not a waif on the streets, thank God. I trust she will never have to cower and beg for favors, and be grateful that someone granted them.  Eve was adopted; there's an extra layer of all the people who tell me she's so lucky to be our child, and she should be so grateful that we took her, and how we rescued her. Since I think we're the lucky ones, and I know we didn't rescue her - she has two biological parents who love her as much as we do - I shrink from that idea.

I realize that what I really want is a kid who appreciates - who appreciates her parents' efforts to make a comfortable home, and the work we do that makes the money to buy the clothes, and the thoughtful choices that mean we went to Paris and don't have a pool. I also want her to appreciate her privileged place in the world. I also want her to claim what is hers without apology; I want her to feel that she belongs so that she can use her secure base to advocate for the justice of which she speaks so passionately. She's sixteen. Sometimes her pendulum swings over into the petulant. I will try to take the long view and trust that it will land in the balanced center.

Why I Fired My OB/GYN

I apologize in advance that this story is a little bit TMI. Then again, I live in a world where about a third of the time, a cat or a child comes into the room to watch me pee, so nothing is really TMI anymore.

When I moved to a new town and found myself newly pregnant, I knew I had to find an OB/GYN practice. So I basically googled “OB/GYN” and picked a large nearby practice that popped up and selected a doctor with decent reviews. My first visit was pretty good, and I decided to stick with the practice.

Unfortunately, things went downhill. The worst thing was the wait. I’d come in for increasingly frequent pregnancy checks and end up waiting an hour for my five-minute visit. The most aggravating visit occurred when they called me to come in early because they were running ahead. I dropped everything at work to show up early, and STILL waited thirty minutes, until the time of my original appointment.

Also, they did the worst blood draws ever there. Any time they needed blood, I would end up with bruises all over my arm and severe pain for days. When I objected to doing the glucose tolerance test there for that reason, I felt like I was treated like a criminal by the staff and the very un-understanding OB/GYN.

But the straw that broke the camel’s back happened about a year after I delivered. I was having my annual exam done by a male OB/GYN that I’d seen a few times before and liked well enough. After he finished the speculum exam and the bimanual exam, he said to me, “Now I’m going to do a rectovaginal exam.” And then two seconds later, he just DID it.

I’m sure somebody could present me with a body of literature on the importance of the rectovaginal exam. But I don’t care. He didn’t give me fair warning. He didn’t ask if it was okay. And it was certainly not something I ever expected, considering in my 15-odd years of annual exams, not one doctor ever deemed it necessary to perform. Plus he was a man.

I’m not saying I’m traumatized or anything. I’m not having recurrent nightmares over it. I wouldn’t report him. I mean, let’s be real here—rectal exams happen. But I didn’t like the way it happened, and I would never go see that doctor again. And since I hated the practice so much, it gave me the impetus to finally leave.

(And my current practice has never made me wait more than five minutes.)

I do have to say, if you’re a male doctor, I think you do need to be careful about that sort of thing. You can’t just go around sticking your fingers wherever you like without warning your patients. Not that I can do that as a female doctor, but I think there is a little more wiggle room. (Literally and figuratively.)