MiM Mail: Evidence-based skincare? Maybe?

I had to renew my passport the other day and send in my previous one with my new passport photo. Man, what a difference 10 years makes! It was there, as plain as day, the effects of 2 children, 4 years of medical school, 5 years of residency and fellowship, and way, way too many nights on call. I've never been one to spend a lot of money on skincare, but I now feel like my regimen may need an upgrade.

This coincided with no fewer than 4 of my friends on facebook now selling Rodan and Fields or Beauty Counter products, both with glowing "before and after" pictures. None of these are cheap! And I found myself asking- where is the evidence? Do any of these products really work? I can't escape my medical brain skepticism!

I thought this might be an area where some of our derm MIM might be able to shed some light. Or other MiM who have just done more research on this than I have. Your recommendations are much appreciated!

Yours truly,
Tired eyes and dull complexion

On Quacks, and Cold Clinical Facts

Genmedmom here. 

We all have patients, friends, and family members who fervently believe that they have a diagnosis that we know doesn't exist. Or rather, for which there is no current reasonable believable scientific evidence.

I refuse to cite specific examples, because it's useless to refute someone's pet diagnosis. You may have examined a large body of research, read reams of textbook pathophysiology, spoken to respected specialists, but no matter what, if you attempt to disprove the entity they blame for all of their symptoms, and the treatment upon which they have pinned their hopes, they will hate you.

It's unfathomable to me that there are providers out there, some of them medical doctors, who blithely and blatantly practice non-evidence-based medicine on unsuspecting and vulnerable humans.

Infuriating.

And it sucks to sit there and listen to someone you care about describing quacky tests and (at best) useless and (at worst) potentially harmful charlatan treatments. Especially when they are paying dearly, and out-of-pocket.

Of course, I've tried to take down these totally false medical problems many times. It's what you do when you care about someone, right? And I've watched their faces shut down, as they mentally walk out the door. Or, saw them get red-faced and argumentative, unable to hear another word I said.

Sigh. So now, for the most part, I nod and smile and murmur something about how modern science can't answer all the questions and I hope that's working out for them.

After all, I can see why this is happening. Modern day M.D.'s are obviously missing something. Patients aren't getting what they need from us.

It used to be that folks had a local doctor who knew them well (and possibly also their families, neighbors, and friends). Office visits were longer, and paperwork was practically nonexistent. There was more listening, and less prescribing. The pace of the research world and life generally was slower, and slower to change. Hypotheses, explanations, and medications were more stable, things you could get your head around and use for a long stretch of time. The doctor-patient relationship was a real thing.

All that's a fever dream. Now, we docs are SO on the clock. Productivity numbers are in- you need to see more patients! And more! Twenty minutes to address all of your patient's medical problems and questions, examine, order, NEXT! Then, the deskwork. Administrative burden outmatches face-to-face clinical time two to one. It's a team of nurses doing callbacks, if the patient gets a call at all. Nowadays, it's mostly messaging through the "patient portal". The, the general public is fed research study after study after study. Papers and pundits contradict each other, data is manipulated, organizations release conflicting guidelines, medications get pulled. Textbooks aren't even printed anymore because they're outdated so fast. What a mess.

These are the cold clinical truths: There's no time to build trust. Our system prevents real connection. The scientific information world is fast-paced, chaotic, and confusing.

And so people are looking elsewhere.

Our medical system may or may not be headed in a better direction, what with the Patient Centered Medical Home movement and all. We'll see.

But meantime, behind the scenes, I am on a bit of a campaign. I recently wrote a patient-friendly article in support of evidence-based medicine for Harvard Health Blog that was well-received. At least, I didn't get any death threats.

Death threats, you say? Yes! Plenty of qualified critics of particularly trendy fake diagnoses suffer angry trolls throwing cyber-insults or writing letters with intent to harm, or kill.

So I'm trying to educate generally, not specifically. Trying to teach people how to tease apart the "fake news" from the safe news, how to be thoughtful, and consider several sides of a story. Their doctor sees it one way, but the internet says it another way. Okay, let's figure this out.

Doctors, we won't win the battle against the snake oil salesmen using facts and figures. We need to be gentle. Tread lightly. Nod and smile and murmur something about how modern science can't answer all the questions and you hope that's working out for them.

And then, if we can, listen. Try to cut through the requisite logistical bullshit and reach out to our patients. If they are feeling heard, they may trust. And if they trust, they may listen. It will take time, and open minds on both sides. But the patient may get the expert help they need, that the doctor is able to give.

The Goddamn Mayonnaise Jar

You know that little gimmicky demonstration where a person takes a mayonnaise jar and puts in some golf ball or rocks that are supposed to represent the big things in life, like your family and friends and health? And then they add pebbles to represent your job and house and car, and then sand, which is all the "little things," and finally they pour in some coffee to point out that you need to fill your time with the big things first, but that you'll always have time for a cup of coffee with a friend? You know the one, right?

I hate that thing.

I like to think that I have my priorities straight. First, above anything else, is my family: my sons Bean and Teeny and my husband. Next is my career; not so much the fact of being a physician but the dedication I feel to my patients given the privilege that it is to care for them. And I know that it's also important to take care of myself, both because I deserve it and because it allows me to do my very best at caring for others. And below that, though still important, are the things I need to take care of to keep our lives running: paying the bills, working on my research for my fellowship, doing the laundry. 

But I also like to think that I'm an excellent time manager and multitasker. I have lists. I have reminders. I can take home call while folding laundry and feeding my little men, provided they cooperate by using their inside voices. In our house, my husband and I have a saying for being super-duper-productive: Getting Shit Done, or GSD. And I, hands down, am the master of it. 

Except that lately I've been having that feeling in the pit of my stomach, the one that tells me there's not exactly a crisis looming, but there is something - or multiple things - that need some adjustments. And it's going to keep nagging at me until I stop and pay attention.

I'm doing a good job at work. I feel connected to my husband and we're honest with each other when things need work. My boys are thriving. Sure, there are moments of frustration, like when I see firsthand why threenagers get such a bad rap, or when Teeny decides that, despite being nearly a year old, he really would prefer to nurse multiple times overnight. And it's not like everything else is going off the rails - the bills get paid, the house gets cleaned (sort of... and with help), and we get together with friends and even have the occasional, not-frequent-enough-but-still-happening date night.

But maintaining things at this current, pretty-good level requires that nothing comes up. No hiccups in our home renovation (because, oh yeah, we're doing that, too). No accidentally backing into a recycling bin because I'm extra exhausted from all of the overnight nursing and then needing to get the car repaired. No last-minute plans with friends who suddenly are in town or have the evening free or some combination thereof. Because, yay!, but also, ugh.

For much of my life, certainly as long as I have been managing my own time, I have tried to cram and wedge as many things into my life as possible. In high school, I convinced my music teacher to let me leave rehearsals a bit early and my track coach to let me show up at practice a bit late so that I could play in the pit orchestra for the school musical and continue to compete with the track team despite their conflicting schedules. I did it for three years in a row, right through my graduation. And I could never really figure out why I always felt pulled in multiple directions without ever feeling fulfilled or like I was achieving my potential in any of the things I did.

Because here's the thing: the common denominator among every single particle in that jar, or the thing that each particle stands for, is that it has the potential to expand. And no matter what, the expansion of even one of these things means that the rest get pushed and squeezed into ever smaller bits of space until it seems they might never recover or the entire jar just might explode. You finish a long day in the ICU and look down to realize that your right lower leg is swollen and sore, and you know in your heart of hearts that even though it means asking the nanny to stay late and missing your baby's bedtime, you - especially in your postpartum state - need to go rule out a DVT. You buy your first house and as you begin to make the small tweaks you had planned, you discover what a fixer-upper it truly is and how many months of work lie ahead before it is truly inhabitable. You get called into work to cover for a colleague who has lost a loved one or is experiencing a crisis of their own.

And in the same way, the beautiful parts can expand, too. Your normally wiggly little boys decide that on this Sunday morning they are content to lounge in bed with Mom and Dad, tickling, giggling, and nuzzling. Your dad joins you in the other room, ostensibly to help you wrap gifts for your son's birthday, and the two of you have the most honest, heartfelt talk that you've ever shared about your mom's mounting health problems. Your nearly-one-year-old son falls fast asleep in your arms and you just sit in his dark room rocking him, gazing at the curve of his cheeks and the wispy tendrils that curl at the nape of his neck.

A meeting is postponed and you happen to have your laptop and no impending deadlines, so you sit and you think and you write.

This is where the mayonnaise jar falls short. The golf balls and pebbles and grains of sand don't change size, so you can keep adding and adding as long as there is space in the jar. But real life is far more dynamic.

Probably because I work in hospice care and do my best to ease people through the end of life, I spend a lot of time considering what I'd want to do at the end. Recently during my drive home, my mind wandered to the question of what, if I died today, I would regret not having done more of. And immediately answers sprang to mind: Yoga. Reading. Cuddling my boys. Late-night talks with my husband. But these are the things I do so little of lately. The things that always get pushed to the bottom, into the crevices, when everything else expands. And no amount of savvy scheduling or multi-tasking is going to stop that from happening.

I need to make room for these things. Make room for them to expand on the wonderful occasions when they do, and make room to buffer and protect them when the other parts start growing. I've tried for years - decades, if I'm honest - to stuff my jar with as many things as I could jam and pour in, then white-knuckled it to keep it all from exploding out each time any one of them began to expand. And something will always expand.

What all of this boils down to is a bunch of cliches. To be more present. To learn to say no to some things to allow room for others. To prioritize the things that are most important. None of which is earth-shattering. But thinking of my life as the mayonnaise jar into which I have tried to stuff every last particle and drop of hey it would be nice to and well maybe I can make that work has given me a framework that makes it easier for me to begin to change. So I have shaken a few of those less important pebbles out. And, for now at least, I'm keeping the cap on my jar.

We lost our s--t with the stranger who criticized our kid

Genmedmom here.

Hubby and I are not proud of our behavior. As a matter of fact, if anyone at the suburban quick- service restaurant managed to videotape us losing our sh-t, we'll be mortified.

Saturday was Earth Day as well as the March for Science, so we took our kids downtown to meet up with friends for breakfast and then show our support for our planet. Of course it was lovely and inspiring and all, so when we had to cut out early for a birthday party, we were a little bummed. On the other hand, the day was raw and rainy, so we were also a little relieved.

At the train station, a balloon man made a blue balloon sword for Babyboy and a pink poodle for Babygirl. Halfway home, rather predictably, Babyboy's sword popped. He wailed, then pouted, as Babygirl "helpfully" reminded him that HER balloon toy was still like new.

We didn't quite realize how upset he was about the balloon. And also, perhaps, how exhausted from our packed day thus far, dealing with new people at breakfast, trekking all over the downtown area, managing myriad sights and sounds and general chaos, then keeping it together on the train. Though he has autism, he handled it all incredibly well.

So we were probably pushing it when we decided to swing by a takeout salad place for a healthy late lunch just before the birthday party.

The restaurant was pretty crowded, and there were only a few tables open. Babyboy found a small table in one quiet corner, while Babygirl found a bigger table in the middle of the larger sitting room. Both refused to relocate.

Hubby ran to the men's room while I tried to resolve the table situation. Babyboy's table only fit two, while Babygirl's was for four, so, pretty straightforward: "Let's go over there where your sister is, honey, so we can all have a seat."

But Babyboy was done. Just DONE. He had draped himself over the tinier table, hugging it, not budging.

I gently touched his shoulder and leaned down, whispered in his ear: "Honey, we need four seats, or we won't all fit, okay? Let's go to that bigger table, okay?"

He whined: "I want to sit HERE! Why does SHE get to pick where we sit when MY balloon popped and I'm sad? I should pick because I'm SAD. I want to sit HERE."

I tried reasoning, then gentle tugging. While he did release the tabletop and shuffle grudgingly towards the larger space, he did so while whining VERY loudly:

"It's not FAIR! It's not FAIR! Why does SHE get to pick where we sit? Why does SHE get to pick? I'm the one who is sad! MY balloon popped, not HERS!"

Meantime I whispered reassuringly, soothingly: "Okay, okay, I understand, here, you can watch a show on my phone. Want to watch a show? Here, let's pick a show.." I was practically begging, but, to no avail.

The more I whispered/ begged, the more he whined, and loudly. People were watching us, with curiosity and annoyance, and I was acutely aware.

When offering SpongeBob on my iPhone didn't work, I knew we would have to leave, so I announced:

"Okay, this isn't going to work. Let's go home, guys, let's go outside, c'mon. We're leaving, right now." I said this out loud, as much for the other diners' benefit, as I herded our kids out the doors.

The kids were just ahead of me, already in the glass foyer, when I noticed a loud banging and clattering sound.

It was like a fist hammering on a table so hard, that it was making the silverware clatter.

Which is what it was.

An elderly man seated near the open door was bringing his closed fist down heavily on his table, again and again, HARD, so that his food and utensils jumped and rang out with every beat.

Only when I finally looked, did he stop. He then gestured angrily towards Babyboy, raised his finger to his lips, and made an exaggerated, furious, spitting SHHHHHH sound at me.

I froze, eyes locked with this angry old man who didn't seem to speak English.

The kids were already pushing at the outer set of doors.

Only a second passed, but this is what went through my head:

Are you kidding me, asshole?  My kid's autistic and exhausted and fixated on his silly balloon and I cannot do anything about that besides leave. Can't you see that we're leaving? We've only been here about three minutes total and we're LEAVING and you have to pull this shit? 

And then I did was something I don't think I have ever done in my entire life.

I leaned towards him from the doorway, leveled my middle finger right in his face, and said, as clearly and calmly as I could:

"FUCK YOU."

Then I followed my kids into the foyer and out the doors to the parking lot. Babygirl tripped and fell and I lifted her up, pulling Babyboy along with me as I made a beeline for the car.

Meantime, Hubby had just exited the men's room. He had heard Babyboy's whining and then the banging/ clattering ruckus. He had seen the old man pointing at Babyboy and shushing us. Somehow, he didn't catch my reaction, and thought that I had just fled.

So when he passed by that guy's table, he threw out:

"Have a nice day, sir, God bless you, and by the way, FUCK YOU!" and he ran to catch up with us in the parking lot.

In the car, I was shaking, almost crying. Hubby turned to me and shared that he'd given that guy a piece of him mind. I admitted that I had, as well.

We both smirked.

Now, Hubby and I are both well-educated working folks with professional reputations to protect. As such, neither of us uses the F-bomb, or any profanities, very often. And neither of us is in the habit of losing it with compete strangers. But we did both, and if given the chance for a do-over, I'm not sure that we would have done it any differently.

Of course, we didn't do much to advance the cause. Our classless behavior didn't help anyone to understand autism, empathize with struggling parents, or tolerate tantruming children.

I'm not sure if any of that would have even been possible, but we could have acted with more grace. So, we both feel ashamed.

We did end up going to the birthday party, where we shared our story with many very sympathetic parents. People shared their own experiences of child-behavior-shaming in public spaces, and how they reacted. It was therapeutic.

Still, I know for a fact that neither Hubby nor I will ever venture into that takeout restaurant again!

Old Photos

I am typing this on the fourth computer I've used in the past year. When I started a work-from-home job in August, they gave me a nice new laptop just as my old warhorse was dying. When I left that job in November, I sent the nice new laptop back and starting using our old desktop. A few weeks ago I bought myself a refurbished laptop for my new business. I wanted to make sure all the important old stuff migrated from the desktop computer, which we had been using for long-term photo storage, so I upgraded our cloud storage and got everything synced. And the past started flowing onto my new hard drive.

Eve and Grandpa Jim, 2004

Eve and Ga, 2004

The child in those photos is now 17; as I write this she is sprawled on the living room floor watching videos and doing homework and stretching, all at the same time. My father died two years after that photo was taken. My mother, in the late stages of dementia, no longer knows who I am. 

Over the last few days, I have paused from my business and my busy-ness; instead of looking ahead, I've been looking back. Mommabee is not the only one doing a review. I have enjoyed the last six months of doing very little work. I have not cleaned and reorganized the entire house. I have not made scrapbooks of Eve's preschool artwork. I have not trained for a marathon. I have slept well, spent time with friends, done the things I could never do because I was on call, and been the primary parent for the first time since Eve was a toddler. I have written more and sung more and read more than I have in years. Looking back at old photos reminded me that since Eve was born in 2000, we have weathered a great deal of loss, and I worked through all of it. I don't mean I worked through it therapeutically; I mean I kept working. Got up, went to work, did my job, wrote my notes, took call. The last six months have been catch-up time.

I am ready to file away the old photos (happy to know they are safe) and move toward the new ones. There will be Eve's prom photos and dance portraits and candids of her as a lifeguard; there will be snapshots of our garden and our summer vacation (wherever that ends up being) and the college campuses we visit. 

Old photos. New times. Life, as they say, goes on.

Photo credit Amanda Lynch Morris

Me, Sam and Eve at the beach, 2016

Guest post: Two lines

I have become a pee-on-a-stick expert. Ovulation sticks? Done. I have that LH surge targeted with laser precision. Pregnancy tests? I've spent a fortune on negative tests month after month.

Until this morning.

I woke up early to go over my grand rounds talk one more time. I started my normal morning routine, which starts with peeing on a stick, and then moving on to washing my face, brushing teeth, and then glancing at the usually negative test before tossing it in the garbage.

But there were two lines. Two lines! TWO LINES!!!!! I shouted at the fireman to get out of bed and come look. Did he also see 2 lines? "Any line means a positive on a pregnancy test!?" I shouted. "I don't know, it looks faint. You always say I don't know anything about this baby stuff," he replied, sleepily. His thoughts were on the extra 40 minutes of sleep he had left before another 24 hour shift.

I finished getting ready, smoked my presentation, and then took advantage of the freedom of my research rotation to escape the hospital and come back home to reflect. Two lines? I'm pregnant? I'm pregnant.

I'm a pregnant, 4th year orthopedic surgery resident with a husband who works 24-48 hours at a time. Our closest family is 3 hours away and I have no idea how we are going to do this. But there are more pressing, immediate issues to think about. I start a joints rotation in 2 weeks.

This presents a unique issue for mothers(to-be) in medicine. Do I give up my privacy, tell my program that I'm 4 weeks pregnant and I wish to be excused for cementing in all the total knee cases? If I do step out, who will do that part of the case? What if I miscarry? Do I want to have that conversation with a bunch of gray haired old orthopedists? Do I read the literature (again) and tell myself that it will likely be fine, scrub the cases and keep this wonderful miracle to myself until I am confident in my pregnancy? When I put on double lead aprons, will my secret give itself away before I even have a chance to make a decision about how to tell everyone the news?

I will only be the 2nd female resident in my program to have a baby (in addition to 2 former hand fellows), and that was at least 5-6 years ago. Until 2 years ago, the words "maternity leave" did not appear in our vacation policy. My program is considered "female and family friendly", but just because we have a larger number of female residents, and the male residents all have 3-4 kids each, doesn't mean they are ready for this.

What would you do? How did you announce your pregnancy at work?

-Ortho-Mom-to-Be

I am a 29 year old, 4th year orthopedic surgery resident married to a fireman/paramedic. We live in the midwest and, aside from our two 4-legged children, have been trying to conceive for the last 6 months.

a review through the year(s)

I cannot believe it has been almost 4 months since I wrote the post about my miscarriage, 1 year since I left a toxic work environment and dove into health care leadership, 2 years since residency ended, 5 years since becoming a mommy, 12 years since graduating from college, and almost 30 years since I proclaimed that I wanted to become a doctor.

Through it all I have learned so much and I am truly indebted to the colleagues and mentors who have helped me craft this career. I am even more so indebted to my loving husband and family who constantly teach me that my happiness is worth it and at the end of the day, a job is a job, is a job and when you aren’t in your job, the job goes on, the world does not end.

Motherhood changes you. Partnership changes you. Medical training changes you. Motherhood in particular, puts a new perspective on things. And in my opinion, it makes you question things that you had never questioned before. It makes you prioritize in ways that you hadn’t before.

For example, for my whole life I’ve known that I wanted to become a doctor. I never waxed nor waned in that belief. Though it was hard at times, I knew I would achieve that goal and I did. But I also realize that it might not have happened. My heart cries for the countless young medical students who don’t match into residencies. For the countless applicants who go into super extreme debt to attend post-bacc programs or use private loans to finance medical educations in international schools (I know far too many!) and then to not match?!? I can’t fathom that. But that could have been me, could have been any of us. It has happened to some of my friends. But now as a mother as I reflect with other women physicians, so many of us question our decision. In particularly frazzled moments, we say emphatically that it was not worth and we would not do it again and we would discourage our children from pursuing medicine. What was it that shifted our beliefs? Was it aging? Was it pregnancy hormones? We may never know.  

I started residency with a newly crawling baby. I began questioning things that I had learned, that seemed so dichotomized, so absolute because caring for my snuggly little Zo taught me that everything and I mean everything is shades of grey, covered in drops of breastmilk and smeared in shea butter and kisses. There was no more black and white,no more textbook answers to lull me into a false sense of security.

And the changes continued, each moment and each role took on new meaning. Weekends off from work took new meaning. I had a baby to raise and learn and love. I had an amazingly supportive and successful husband to dote on and love. Each moment became more precious because when I was at work, I had to completely be present caring for and keeping alive someone else’s baby. Time at work took on new meaning. Every time things got rough, I would say to myself “this is someone’s baby! This is someone’s baby! Do your freaking best! Love up on this family and this baby! Do the right thing by this baby!” and it worked. I was able to care for countless patients and their families.

I started my first attending job. The one I knew was going to be my dream job. And it wasn’t. From the very beginning. The burn out was palpable among my partners, the check in staff, the medical support staff, the nurses. In my first few weeks, I was warned by various members of the staff to literally “get out” before the patients lured me into staying forever. I didn’t know how to process it. This was my “dream job” at my dream institution, a top 10 children’s health system in a highly desirable area. The one that I was supposed to stay in, rising through the ranks, being a tireless advocate for my patients and their families. But I looked around at the colleagues who had trained me as a medical student and no one was happy.

Everyone was raging against the machine of big-institution medicine without the tools they needed and without the support of the administrators. There were partners who were months behind in charting on the outdated electronic medical record. There were partners who worked hours from home each night and who spent more time charting than seeing patients. There were incompetent team members, difficult to work with management, and mountains of red-tape and bureaucracy at every level and it frustrated us to no end! We were understaffed at every level but the message from the higher ups was “do more, see more patients! You’re not meeting your numbers!” while we providers questioned the safety and quality of fitting in another patient, of overbooking overbooked slots, of opening earlier and closing later. This scenario isn’t unique. I hear countless stories from other physicians in private and academic medicine, from friends working for nonprofits, I could go on. And when you hear it from so many people in so many industries, you realize that we are all workers. We all struggle with the same things, but it is up to us to find our niche, our space where we can deal with the “particular brand of crazy” of an organization.

My mama heart made me extra courageous, extra fierce. I began to network and met a group of other outstanding physicians many of whom were mamas who had experiences just like. They found the strength and courage to craft professional lives that were more in line with their beliefs and their experiences gave me strength and I began to let go of the made up dream as I began to develop a new dream.

If it weren’t for my husband and my family, I never would have had the courage to leave. But I did. I spent countless time and even significant money on legal fees fighting and it’s not even over yet (always, I repeat, always consult with an employment lawyer early when you first begin to worry about retaliation or have safety concerns, just do it! Human Resources works for your employer and unfortunately not really for you). But you know what - MY HAPPINESS IS WORTH IT! I trained too long and too hard to not be valued, to be underappreciated and you did too! We are worth it. We must advocate for ourselves and our happiness as a matter of survival. Physician burnout is on the rise and unfortunately so is physician suicide. Your life is worth it! You should not be miserable in your job! Being a mama made me more courageous. What would I tell Zo if he was going through this? I would tell him find a new job, it’ll be okay! You’re worth it! I know they tell us it’s our calling and although that may be true - a job, is a job, is a job!

This last year in part-time health care leadership coupled with part-time direct pediatric primary care has been a whirlwind. Scary and beautiful, overwhelming and exhilarating. Exhausting and empowering. I have been getting my lean-in on! And the view from my first big girl office is the bomb!

And because I have been courageous enough to sit myself down at the big-kids’ table I realize that we really do have expertise when allow ourselves to do what we are good at. Working with a major managed care organization, I understand why providers are asked to check off certain boxes in our patient assessments and I realize that this information must get back to the providers.  I realize how essential physicians such as myself are in re-envisioning health care.

Everyone has a boss, every organization has a parent organization and auditors to respond to. The system is such that major revision is needed to truly improve outcomes. Though my overall happiness has increased tremendously, the job is still a job. And I don’t think enough physicians, especially those in training, fully grapple with that. You still have people who are burned out; though honestly, much less here in my new office. You still have issues with incompetent people and I had to terminate my first staff member a few months ago. But “this particular brand of crazy” is one that I can deal with and is one I am thriving in. It’s one that my family can deal with.

Thank you for sharing in my self reflection.

Have you done your own personal review lately? If so, please share. What have you learned? How have you changed?

Work Family

I entered the Doctor's Lounge shortly after arriving for work to get coffee and bottled water. It's newly renovated, homier than the old 1950's linoleum version, but still full of mostly white male doctors. Most of whom are excellent at what they do, but my hospital is still not very diverse after ten years of my own practice.

I wave and smile at the ones I know as I am preparing my coffee, and am stopped by a heart transplant doctor as I'm walking out the door. "Oh, yes, my partner told me about an urgent biopsy today. I'm covering."

"It's turned into a postmortem. He died yesterday afternoon."

"Oh my. Oh no. What happened?"

"There was a rare familial genetic disorder, we were about to test him."

He laid out the details.

"I'm the only AP doc here for the rest of the week. Autopsy falls to me. I'll call the gross room right away to give them heads up. Then I'll call Mayo Clinic and get the details of what they need to get the family the information."

"Thank you so much."

I triaged my difficult needles from the day before quickly, ordering immunos to get the diagnosis, then spent an hour on the phone with Mayo learning about what each of three departments needed from us to help them look for the disorder. Skin. Blood in EDTA. Paraffin embedded tissue.

I learned from a partner mid-morning that he was a relative of one of the most prominent employees in our work family. Internally, I doubled over and fell to my knees. Externally, I resolved to work even harder than I already had. Called Mayo again to verify the details. Gathered the schedule of needles from OR, Bronch Lab, and radiology and decided to schedule the autopsy for 11 am to avoid interruption. Called the work family member and told her I had just heard, why was she still here, I was so sorry, and I was praying for her and her family.

A couple of hours later she learned I had done the autopsy. I knew she knew, because we were problem solving an old case with the lead transcriptionist and she put her arm on my shoulder. I sideways hugged her tight, and gestured for her to follow me into my office. I listened to her talk about the shock.  He was young. He has two children heading into prom and graduation. He looked like the picture of healthy life interrupted. I've done a lot of autopsies, but none has ever hit this close to heart. I can usually detach myself clinically, viewing the body as a vessel that the soul has left behind, but during this one I kept thinking that this was a father and a son and a spouse who had left the world prematurely. The emotional connection deepened my already strong commitment to the leagues of tissue I regard daily with the comfort of my detachment from the lives involved.

Luckily a mind-jarring workload kept me from ruminating too hard during the day, but on the way home I lost it, sobbing uncontrollably all the way into my house. The kids noticed, so I enlisted a larger prayer team over dinner. It took me two hours to wind down enough - cleaning and organizing - to finally sit down.

As I was catching up on social media on the couch, I heard my son talking to his friends from downstairs. He was so animated - a girl he liked liked him back and there was something there, not dating - he's in fifth grade - but a connection that wasn't there before, spurred into public with the encouragement of his friends. He excitedly told his sister, then told me as I was tucking him into bed. I wasn't surprised - he has been talking about her for months. A girl who likes the same video games as he does. That's kind of rare, at his age. Mostly boys in that arena.

I told him I remember liking a guy in fifth grade at Montessori. We didn't call it dating back then either, we called it "going together." Which consisted of buying each other gifts at holidays and being totally awkward at school. His name was Clay, and I was Elizabeth, and I had these Liz Claiborne pink sneakers that I thought foretold the relationship. He had brown hair, and eyes so blue that if he caught me looking at him I had to avert mine in order to preserve my senses. Then Summer came, and he went to another school, and that faded as most of those do.

As I tucked Jack in I thought of how strange this world is. One that can yank a father prematurely from his children and throw joy of first love into it on the same day. I texted my work friend and told her I would do anything to help her and her family. Then I sent prayers. What else can you do? There are days I feel so powerless, but I try to remind myself that we are all on a path, and it's our own, and we can't be responsible for other's path, but we can lend the utmost support and love.

On the ropes, it's a balancing act

Finding the balance.  Taking a deep breath.

Changes abound at work these days. Just when I was looking to lean out, the circumstances are urging me to lean in.  Just when I was getting into the new groove, there's a newer groove.  I suppose that keeps things exciting. "But still," as my daughter would say. 

Just when I was learning the ropes, the ropes get entangled with new knots and twists.   Such is academia.

Standing on the platform, I look around.  I like being on even footing.  Do you?  Some prefer the climb.   There are many paths ahead, many directions, some much more challenging, steeper, and uncertain.  What to do when an opportunity that is challenging, steep, and uncertain comes calling?   How to reclaim the balance?  Do I lean in, lean out, or lean in to something else?

It is always the loves of my life in my partner and our kids that keep me grounded, renewed and refreshed. Leaning on each other, for just the right amount of support.

Social media

I have conflicting views on social media.

In order to describe my pro and cons of social media, it would have to reveal my age. I'm 3 weeks away from 32--meaning I was a college freshman in 2003 as I went straight through college, medical school and residency without any gaps.

Facebook was founded February of 2004. I was a college freshman. I remember signing up for it with my college roommate but back then, it was still very much in its early days. There was no photos to post. I don't even remember if there was a wall. I do remember "poking" people. Who knows what that even means?

Even though, it was still around, it really wasn't a huge part of our day to day college life. I believe by the time I started medical school come 2007 that it was when it became bigger and more promiment in our every day lives. I remember getting "friend requests," and thinking "wow, I haven't talked to that person in years!"

As I got older and became a mom, my take on social media has evolved. I do love its convenience. When I was busy with residency, I loved how accessible Facebook was for my relatives as well as my husband's relatives. We both have huge extended families as I still have a lot of family in Korea and he does in Taiwan. The last time we went to either country was before we had little C so it was a great way to share our lives with them. And of course, I would have never been a part of this wonderful MiM community without social media either!

However. as I got older, I find myself, posting less and occasionally going through my friends list and de-friending people that I really haven't spoken to in awhile.

I have a cousin who is 5 years younger than me, a sister in law who is 4 years younger than me and another cousin who is in high school. I look at their social media account and see how I got so lucky. I just missed the era of social media predominance during my childhood as well as my college experience, which I believe is the most vulnerable period in our lives. I believe, at least by grad school, you have a sense of who you are and what you want to be--in my case, I really wanted to be a physician and somehow along that path, I became a mom. It was still definitely a path of self-discovery but by that point, I think what other people posted on social media had less of an effect on me. I knew what I wanted and I was on my way of figuring that out. (Don't worry, I"m still human! It does bother at times too! Like for example, whenever I see photos of a mom postpartum looking like a runway model, it's like how does that even happen??)

However, I see the world of social media through their eyes and it kind of pains me a little. Because I have a little girl and I don't want her to feel this way. They look at Facebook, Instagram and Snapchat and don't realize that these are just snippets of people's lives. They don't realize that nobody posts a bad photo. Nobody shows their bad days. If I spent my weekend at home with my parents in middle school, nobody knew about it and I also didn't know what everyone else was doing. I didn't log onto social media and see some other girls at school doing something fun and exciting. It could have just been a photo but a photo speaks a million words and can be misinterpreted and lead to feelings of loneliness and insecurity.

I see Instagram accounts of people that I know are home but yet, they'll post photos saved up from vacation to make it appear as if they are traveling and leading this exotic, adventurous life. I look at those photos and wonder if they actually enjoyed any time of their vacation if they were so busy, creating such staged, "instagram worthy" photos.

As I'm getting older, I feel like the inevitable is happening. I'm becoming more cautious, more worried and definitely more anxious of what's to come.

As little C gets older, I'm realizing I can't really protect her from everything especially in a world of social media but I can help her deal with its consequences. I'm going to do whatever is in my power to keep her my confident, opinionated, tomboy yet princess dress wearing little girl!

Any thoughts?

X-ray Vision

Who Am I?

So I've been a little - scarce around here lately. My last post was in July, and that was just a link to a piece I had published on Pulse*. My last substantive post was in June, nearly nine months ago. I feel as if I don't have any material.

I still have a kid at home. Writing about her has become more challenging as she's grown older. Eve is 17 now, with her own social media presence and a keen awareness of being talked about. "Mom, you can post that on Facebook if you want to." Her story is her story, and while I have a piece of that story, it's challenging to figure out how to tell my parenting story without invading her privacy.

So I'm still a mother - but am I still "in medicine?" I left my clinical job at the end of July and since then have done a variety of different things, none of which feel much like practicing medicine. For the first time since 1986, my days are not primarily concerned with diagnosis, treatment, and notes. It's - odd. And disorienting.

I've always been determined to have an identity outside of my work, unlike some of the other docs in my family. My grandmother referred to my grandfather as The Doctor, as in "The Doctor won't be home for dinner tonight." My mother didn't do that, but she was The Doctor's Wife first and foremost, and we were The Doctor's Children. I worked fewer hours than they did, although my call still interfered with family life. I took more vacation; my dad took his first week of vacation in 1968. He started practice in 1961. I don't ask Eve's friends to call me Dr. Jay; they mostly call me by my first name. In the end, though, I still defined myself as a doctor first. Everything else is "spare time" - "In her spare time, Dr. Jay hangs out with her husband and daughter and enjoys crossword puzzles and mystery novels."

I guess now my whole life is "spare time." I'm not retired - I still need to contribute financially, and I'm figuring that out - but I know I am done with full-time clinical work. Or even significant part-time clinical work. I'm generally OK with that. I miss talking to patients, and I miss the intellectual challenge. I do not miss having to schedule my life around every third weekend call and I do not miss dragging myself out of bed after being woken up four times over night.

I hope to remain a contributor and figure out what I have to say as we prepare to help Eve launch into college, and launch ourselves into the next part of our life. Most likely, we'll all have to navigate this transition. Perhaps I can start thinking of myself as a trailblazer.

___
*I had another short piece published on Pulse during my MiM hiatus

Documentation

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

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

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

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

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

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

Redefining Dr. Mom - A Review of the First PMG CME Conference

If you're a mother in medicine and you haven't heard about Physician Moms Group, you might be living under a (social media) rock. PMG, which started in 2014 as a Facebook group for exchanging advice and support between women physicians who are moms or moms to be, has morphed into a community of more than 60,000 women with an influential internet presence. Any group of women that can sell out the entire stock of Instant Pots on Amazon in minutes or lobby to get discounts on coveted clothing or other products has some serious clout! As part of the group's continued evolution, founder Hala Sabry, DO and her best friend Dina Seif, MD recently held their first CME Conference in Las Vegas on April 1st, 2017, entitled Redefining Dr. Mom. And I was lucky enough to be able to attend!

Let me start out by saying that this was by far the most interesting and engaging CME activity that I have ever witnessed. There is the tendency at such events to plop down in the back row, pour yourself a large cup of coffee, and whip out your phone to scroll email or social media. Instead, this conference was chock full of useful and relevant information, presented in a dynamic and interactive format. Presentations ranged in topic from recognition and prevention of burnout, to financial planning strategies, to nonclinical paths in medicine. To top it off, there was a female physician entrepreneur panel moderated by ZDogg MD (Hala's friend and local Las Vegan)!

ZDogg in the house!

When I looked around at the other attendees, I was struck by the diversity of women in the room. I saw many ethnicities, shapes, and ages. Some women wore jeans while others were clad in suits. Some had bouffants, others had beach hair. There were bare faces and full makeup. Yet we were all physician mothers, present to discuss what might be lacking in our careers and learn what might enhance our current work-life balance. Each excellent presenter shared a personal experience as part of her talk that represented a watershed moment in her journey, something that had led her to question or change her presumed path in medicine.

Another common thread throughout presentations was the emphasis on identifying core values as a way to assess happiness and drive future direction. The presenters also prompted attendees to think outside of standard paradigms - regarding self-care, business, and leadership or mentoring roles. Included as well were optional organized social events for the two nights surrounding the conference - a spa outing and dinner, plus a dinner and Cirque du Soleil show. Being somewhat of a "local" to Vegas (I travel there frequently in the winter), I also led a small group of PMGers and their families on a hike in the Red Rocks the next morning!

PMG is definitely planning more CMEs for the future, and I would highly recommend attending. Also, if you are not a member and are interested in joining, visit MyPMG.com to supply your own credentials, or have a Facebook friend add you to the closed group.

"Creative Block"

When do you find time to be yourself?   The self you are outside of medicine and parenthood? (Maybe the glimpse of a self you were before medicine and parenthood?)  Outside of being a pathologist and parent I also derive joy from making art.  Well, maybe not immediate joy, but it is a sort of deep satisfaction.  I see making art like I see working out: Sometimes it sucks when I'm doing it, but afterwards I always feel better that I did it.  When I finish a painting and I’m happy with it, I feel the same deep satisfaction and pride that I do when I look at my beautiful little boy.    

But when I say “time” I’m not talking about the hours and minutes.  I have hours and minutes.  My toddler goes to bed at 8 pm every night.  My husband splits the housework and childcare with me.  I go to bed at 11.  That’s almost 3 hours each night that I should technically have to myself.  But I find myself too tired to use it effectively.   I have the time but not the energy to be creative.  I feel like it’s all drained from me by the time our baby is in bed.  And maybe that’s to be expected.  I work full time.  We have an 18 month old.  To be creative you have to have a certain amount of energy.  Those three hours are also the only time I have to get my ADLs done...shopping, taxes, doing the dishes.  Even as I sit here writing this at 9 pm, I’m so so tired.  My eyes hurt.  I’m tempted to throw up my hands, give up.  Make my tea and read a book (sadly sometimes merely Facebook).  I even have a studio and a painting I’m currently working on (sporadically).  But the time I’m in there is often so infrequent that I can’t remember what colors I was using each time I return.  I have completed precisely one piece of art since our son was born.  When we bought our house I picked out the room I would use as a studio.  My husband is proud of me that I do this other thing outside of medicine.  But sometimes I tell him that it’s silly that I have this whole room to myself when I barely use it.  I have had other dry spells in my life that were not related to having a baby.  So maybe having a baby is just an excuse?  Or maybe there is something to this feeling of being spent, dissipated at the end of the day that leaves no room for creativity?  

I haven't written on MiM as much as I planned to either....Sometimes a blank word document is just as terrifying as a blank canvas.  What do other MiMs do to keep themselves creative?   How do you find the energy? 

Last Week

My little family had a tough week last week. In addition to the usual chaos of single-working-mom-with-two-kids life, which includes (but is not limited to) two morning drop offs during the week, ballet, play rehearsal, soccer, swim class, my own personal interviews for a potential promotion at work, and a snow day during the week (oh how I could do a single lengthy post on the chaos of being a doctor mom with two kids on a snow day!), three year old E got sick. And we landed in the hospital.

I should mention that my seven year old daughter, M, has immunity of steel. She had the usual colds, fevers, early childhood sicknesses until roughly 18 months old, and then she’s been rock solid since. I can’t remember a time in 5 years that she’s seen the pediatrician other than for a wellness physical.  

And then there’s E. He’s had an ongoing solidly built relationship with our pediatrician which has landed him in her office so many times we all stopped counting. Sometimes I see her so much (and I like her SO much!) I think I should take her out for coffee or something!  For a while it was bi-weekly, for a new cold, fever, cough.  Between the ages of 6 months and 16 months, this kid was hospitalized three times for respiratory problems.  The frustrating thing was he would get overtaken by a cold which would turn into brochiolitis, land in the hospital with hypoxemia, get treated with oxygen (and time) and get better, but no one could really put a name on it.  It wasn’t asthma. He got tested for CF (oh, that was a harrowing day!), amongst other things, and the pediatricians landed on a diagnosis of “tracheomalacia” and told me he’d grow out of it.  So for 2 solid years, we walked on eggshells with this little guy and his tenuous health.  And, slowly, he seemed to get better and the “colds” got less frequent, and I slowly let go of some of my anxiety about him getting sick.

Last week, he wasn’t himself on Monday and had a low grade temperature. I didn’t think much of it because he wasn’t coughing and thought he’d rest a little on our “bonus” snow day. On the morning after the snow day, he still had a low grade temp so I kept him home from school but I needed to be at work. I was precepting for three residents, two of my colleagues were away on vacation, and there was just absolutely not a single soul (believe me, I racked my brain!) who could precept those residents for me. So, I brought E to work with me -- he was psyched! He sat at my desk, drew pictures, played on the computer, got fawned all over by my colleagues, and enjoyed the bonus graham crackers and apple juice in the ‘supply’ closet! He was really acting fine, even a little energized by being at my office, but a slow, barking cough began to emerge.

We left my office midday and went to the pediatrician (it was a covering doc as our usual pediatrician was out that day! Sigh.) to find he had since spiked a fever, and his room air pulse ox was 92%.  He had a right lower lobe pneumonia [ok, this is the part where I confess I listened to his lungs when he was in my office -- which I try to NEVER do, except I did this time -- and thought I also heard a pneumonia but tried to leave that to his real doctor to decide!]. They gave him nebs in the office (I told them they never work, but they always say it’s worth a try) and his pulse ox remained at 92%.  So, we left with our amoxicillin prescription and a word of caution: “You know what to do. You are a doctor. If he gets worse overnight, don’t even call us. Just go to the ED. If you are worried tomorrow, bring him in again.”

I should have known. It always gets worse.  This kid gets sick fast.  So he got his first dose of amoxicillin, and I waited.  You know that waiting -- the kind of waiting moms do -- where we are so worried, need to be distracted so we don’t obsess, then we second guess our judgement, try to convince ourselves it will be ok, exercise some magical thinking that all will be fine as soon as the antibiotics kick in, and the time can’t pass quick enough.  I put E to bed at 6 pm because he was so tired and miserable, and the next 3 hours were unbearable. He would sleep for 5 minutes, cough uncontrollably, wake up and cry, and then be so tired he’d fall asleep again, and then do the same thing over and over. It went on like this for so long. Did I mention I also was getting my 7 year old fed, showered, ready for bed? Oh yeah, that too!

At 9:30, while holding E in my bed, trying to get him to calm so that he could get some much needed rest, he woke and cried and said “Mama, I need help. I need help.”  So, that’s it.  I sped into action: clothes on, coats, boots, hats, gloves for kids, I woke up M, I put both kids in the car (10 degrees outside!), dropped off M at a friend’s house to sleep over, and drove to the ER.  E’s dad eventually met us there -- another story.

In the ER, E’s room air pulse ox was still 92% but when he fell asleep, he got hypoxemic to the low 80s.  I’m guessing it’s why his sleep was so fitful.  So, we got admitted. And we spent 3 days in the hospital. From the gurney in the ER, I sent emails and texts to my clinic manager, medical director, and colleagues to cancel all my patients and my meetings, and the interviews for the promotion that I’ve been working toward.  The rest of the week was a wash.  In fact, all the stress and chaos of ‘everything else’ just melts away when you have a sick kid. I told myself, “I’ll catch up. It will be ok. Everything else will wait.”  And it did. Time stood still with him in my arms. All I needed was him to get better.

E is fine now. He is back to preschool, and back to his usual self. M had a few days of being bonkers because her routine was off as we figured out how to move all the pieces of the family puzzle while I stayed with E in the hospital (thank goodness for good friends!). But, she was truly a champ during it all. And, we are back to ballet and soccer and swim class and play practice and birthday parties and the crazy of morning school drop off, and I’m back to patients and meetings and interviews. And somehow we are all staying afloat. And we are making sure to do it all with lots of hugs and giggles and a few dance parties mixed in -- the chaos is there, it’s never going away, and we are trying to keep it ‘light’ for now because that’s all this doctor mama can take at the moment.