Bad Habits and how to (attempt) to kick them

When my mother went in to have her diagnostic laparotomy for metastatic disease, my father said that he knew everything was going to be okay because the surgeon had "beautiful, clean, well-kept hands."

Since that day 10 years ago, I have started to take more notice of hands.  As a doctor, the state of a patient's hands, and feet, can suggest underlying disease, hygiene, social situation. Manicured fingers, dirt under nails, dry skin, scabies rashes, diabetic ulcers, clubbed nails of hypoxia.

As I look down at my own hands, though, I'm constantly ashamed.

Confession:
I bite my nails. Not my nails, exactly, and not biting, technically. I pick my cuticles. It's gross, I know. Disgusting, I get it. It's an infection risk, a way for patients' MRSA, fungus, and ESBL infections to get inside. A risk for herpetic whitlow, paronychia. There is an official medical name: Onychophagia.  It looks unkempt. I KNOW.

I've tried getting regular manicures, but that gets a) expensive and b) time consuming. I tried moisturizing, creams, potions, and lotions and gels and ointments. I've read blogs. (link below). This repetitive behavior is SO HARD TO KICK.

Over time, we as individuals develop so many different habits and routines. The way we brush our teeth, which side of the bed we sleep on, which shoe or pant leg goes on first. What we eat for breakfast, which coffee we order, what we reach for when in need of comfort. Take a minute to pay attention to the things that make up your daily routine. We are creatures of habit.

Diet and lifestyle habits and routines are hard to change as well. With all the focus on "new year new you," the explosion of health and fitness "influencers" on Instagram, and the renewed energy that comes with a dedication to a new diet, eating plan, workout regimen, or health motivation, it should be easy. We have so many cheerleaders; however, ingrained habits require a lot of mental energy to change.

So I definitely have a little more compassion for patients when they tell me it is hard to take a new medication, change their eating habits, work out more. I can't seem to do it myself, honestly. (My 15 lbs- 4 years post baby- prove that) The constant reminder of my raw hands is the sign of a continuous struggle.

How do you motivate change? Have you found success with breaking a habit or changing your diet or lifestyle? What resources do you use, or guide your patients to?



Blogs I referenced:

https://www.glamour.com/story/how-to-stop-picking-your-cuticles-tips

Scheduling

The first inkling I had that scheduling was going to be rough as a resident parent started before Toddler was even born.

I still loathe the woman at the front desk at my OB office. Every time I waddled in, I would have the upcoming 3  months schedule in front of me and try to schedule as far out as possible. I was charming, flexible on clinic location, flexible about seeing different providers.  “How about Wednesday the 19th at 8:30 am?” “No? Well how about Thurs the 20th? At 1:20 pm?” “How about (insert particular hour) on (particular day)”. Eventually the receptionist snippily asked me to call the appointment line if it was going to take this long to pick a scheduled date. Note: there was no one else in line behind me. I fumed in the lobby as she clearly carried out a loud non-business call over her headset. Thank goodness for an uncomplicated pregnancy requiring infrequent visits and an office across the street from the hospital I work at.

Well child exams have been even more challenging to schedule as I’ve been trying to coordinate around when my child is actually well. I have the same conversations on the phone. No, Wednesday afternoons don’t regularly work for me, just the random one coming up. We have a great great great pediatrician - which means he’s always booked up. I had scored a rare 4:40 end of the day appt today, but alas - double ear infections and a cranky Toddler = a rescheduled appointment. At least today I’ve figured out how to schedule and reschedule online so I can least minimally annoy other people.

Also I’m getting a little anxious. We (gasp) decided to take a week long vacation this year but due to several medical reasons for my entire family... I’m down to 3.5 days off left before graduation. I used 2 in the last 2 weeks. I keep telling myself that hopefully the absolute worst thing that could happen is I make up a few days at the end of residency (as I already am doing) but still. We rolled the dice today and took Toddler to day care after a tearful sleepless night - but I haven’t gotten called yet and already got a photo of his grinning face so life can’t be too bad.

A nice reminder to myself to not get irritated over people constantly rescheduling with me in clinic. Who knows what they are all juggling. Often I can’t keep track of what I’m all juggling. Which reminds me I have to give tomorrow’s lunch lecture. Keep your fingers crossed as we will likely roll the dice again tomorrow.

Guilt and Determination

Quote of the week:

“Guilt is useless. Determination is important”.

One of my department faculty members is leading a day long seminar of Community Health.

She adds “If you really need guilt, keep it like a cat at home. Pet it every once in awhile, let it know you know it’s there - but when you leave the house, take determination with you.”

I love it. Even before Toddler came into the world, I told myself I would NOT be a guilty mom. I would logically know I was doing the best I could, logically know that I could not be in three places at once. I was going logic myself right out of guilt. Because we all know logic always wins.

I’ve been trying to be mindful when spending time with Toddler - no phones, no distracting screens, just him and me together. It makes me think of this post from Mrs Md PhD which is best characterized by the meme saying I WILL DO ALL THE THINGS WITH MY TODDLER!! (which is definitely due for a revisit if you haven’t seen it in awhile).


However since Toddler currently has the attention span of a small flea and likes to entertain himself a lot, a little too much mindfulness can send me off the deep end. So we’ll play legos together but a little podcast in the background goes a long way. Now that we’ve had a long awaited golden weekend together with minimal leaving-the-house plans, I was able to put that guilt aside for now.

One of my coresidents was feeling guilty lately about working her first week of nights while leaving her baby at home and I told her “you’re a better mom because you’re a doctor, and a better doctor because you’re a mom”. It took me awhile to realize that I really did mean it (at least about myself) and wasn’t just saying it to make her feel better. I appreciate the time I have at home without Toddler, but I also have a small glimspe now into why the nurses I work with who have 4 kids at home come to their busy shifts and sometimes consider it a “break”.

I also think guilt is ingrained into us in medical school. Guilt we didn’t present our patient perfectly. Guilt we missed that lab finding. I was with a second year medical student today, who kept saying “sorry” for things she couldn’t help - like the computer not loading or not having access to charts. It made me remember sitting with a co medical student on our internal medicine rotation watching her beg for an afternoon off for an appointment and constantly apologizing for having to leave. I’ve managed to cut out “I’m sorry” out of my vocabulary if it’s something I can’t help (unless expressing empathy for a patient). My feedback to her was to catch herself when she is going to say “I’m sorry”, see if it’s something she could have actually done anything about, and cut it if she can’t.

I’m sure there are still going to be times I feel guilty, especially if we have another day care drop off melt down tomorrow, but I’m going to do my best to pat Guilt on the head and leave with determination in hand.

Kicks

Looking how to complete the medical equivalent of #squadgoals

As a resident, I rotate through a number of different departments and different hospital sites. This past month (or last month, because I'm late on posting this), I rotated through the trauma service.

On a string of nights, I met another strong, powerful, kick butt mother in medicine. A senior surgery resident on another surgical service, she was not my direct senior; but as we both set up headquarters in the trauma bay, we had the work equivalent of an all night sleepover, q3, for about 2 weeks.

It was so much fun. Being a resident who is also a mom is pretty lonely at times. I'm not free for most brunches, I don't party on weekends, I can't commit to an 8 pm weekly spin class. While I get along with most people on shift,  it has been difficult to connect out of work- with both men an women residents alike.

How do you bridge that gap? Part of me likes having that separation of work life and home life. But  recently, when a resident - who I always laugh with on shift and love working with- got married, it stung that I wasn't invited.  I offered to cover her call, though.

So I will continue to look out for members of the club. Give a head nod to the pregnant resident on the admitting team, look out for the one with pictures of her kids on her phone background. It's nice to be recognized and it's nice to be part of a larger team.

When it's time to get unstuck

Have you been feeling stuck? What are you going to do to get unstuck? Maybe start with your sock drawer? Or start with a vision board for your practice? Or start with a date night with your partner or a girls' night out with your friends. Or start with a breath. Whatever you do, just start!

For the last few years since finishing residency, I have been grappling with many things. After my disappointing first job as an academic pediatrician (my "dream job" I thought), and my foray into private practice I realized that the system of medicine many of us practice in, corporate medicine with the primary goal of seeing enough patients in the day, simply didn't fit with the what fuels my heart.

I spent two years during my American Academy of Pediatrics Leadership Innovation Fostering Education Fellowship researching physician wellness and in particular how systems and practices must incorporate wellness and burn out prevention at all levels. It is not enough to tell physicians to meditate if they are being "strongly encouraged" to see more and more patients, have burgeoning administrative tasks (click this meaningful use button), have mountains of debt, or are in jobs that they hate because of loan forgiveness, have less and less control over their schedules, and less time to make meaningful relationships with their patients. A mindfulness seminar won't cut it. Physicians everywhere are saying enough! It's to much! Record numbers of our colleagues are walking away from medicine or are joining the ranks of the hospitalists and specialists. What happens to our system when there are more hospitals, urgent cares, and intensive care units than quality, sustainable primary care practices? What will continue to happen when emergency rooms and surgical suites continue to be more lucrative than wellness centers and small, high quality private practices? Does it mean people will be allowed to get sicker and sicker? Does it mean that large hospital systems will continue to invest less into primary care and more into expanding their Emergency Rooms? Money talks, right?

This year I will be undertaking some exciting new endeavors. To try to get back to what inspired the premedical student who had all of the time in the world to sit with my patients, to commune with them, to build with them. We see it all around us. Patients who can afford it are flocking to naturopaths and integrative medicine doctors. The overwhelming response is that those providers listen. They have the time. So I have to make the time.

I have been hustling and working, but I still felt stuck. Stuck in fear. Stuck in a laundry list of things to do. Stuck in the what ifs. Stuck. So again, I use the tools that I have and start to research solutions. I have been listening to a lot of podcasts about following your dreams and reading books about decluttering and re-envisioning your life (see the list below). I even watched Marie Kondo's Tidying on Netflix. I saw the piles of clothes folks had and thought "yuck! How could things get so bad?" And then I did this while my boys are away:

(clothes stored in my closet, attic, and drawers - don't judge me until you try it! Very eye-opening!)

It's no wonder I feel stuck. I have been holding on to so much. I still have clothes from my first attending job and from my corporate job that I know I will never wear again. Letting go of them causes so many mixed emotions. Failure. Courage. Pride. Anxiety. Commitment.

It's time to get unstuck. The piles and piles of donations, maternity clothes to pass down, and work clothes to pass on won't unseat themselves. No one is coming to save me. I am saving myself. Starting right here. In this moment, again. And I will do it again and again PRN (as needed for those who don't abbreviate on their prescriptions). One day at a time.


Above references mentioned:

Podcasts:

• Dreams in Drive
• Side Hustle Pro
• Therapy for Black Girls

Books:

• Marie Kondo's "The Life Changing Magic of Tidying Up"
• Dr. Dike Drummond's "Stop Physician Burnout: what to do when working harder isn't working?"

Blogs:

• mnmlist.com
• theafrominimalist.com
• zenhabits.com

Netflix shows:

• Tidying Up with Marie Kondo 

Breaking through the emotional barrier

We have the same birthday, she and I. We were born worlds apart, both geographically and culturally, but on the same day of the same month in the same year. I noticed her birth date, right there on the front page of her daughter’s, my patient’s, medical chart. Her daughter, who should have been a princess. In a family full of men and boys, sons and nephews, the baby was the first girl to be born in over 40 years. The family prepared for her birth, overjoyed, buying frilly dresses and pink bedspreads and dolls. But it was not to be. Mother was stricken with intrapartum hemorrhage and baby was born with anoxic brain injury, doomed to be neurologically devastated.

And that’s not even the worst part.

She tells me that she and her husband sometimes imagine what it would be like if her daughter, now turning one, were born healthy. They can almost hear her say “mama” and “dada”, can almost feel her hugs as she runs, laughing, into their arms. They wonder if she would be crawling now, walking now, what food she would like best, and if her older brother would share his toys with her. They mourn what could have been, what should have been.

That’s not the worst part either.

In their home country, they were told to leave her to die. They were told not to pursue medical care, that God would take care of “the situation.” And that’s when they packed their bags. They ravaged through bureaucratic red tape and procured visas. They left it all, their supportive family, their grand estate, and moved to a small apartment in the United States so they could get medical care for their daughter in the first world. In their home country, they were royalty. And here they work menial jobs to make ends meet. She works at a local supermarket, bagging groceries. One day, she tells me, a customer was checking out groceries with her own daughter, who was particularly rambunctious. The customer was frazzled, stressed, in a rush, and frustrated with her daughter. The customer turned to the woman, this grocery bagger, this almost-but-not-quite-bereaved immigrant mother and said to her, “She’s driving my crazy. Do you want her? Just take her.”

And that was the worst part.

Does she want her? Well, not her exactly, but yes, of course she craves a normal, healthy daughter. What a horrible thing to hear. What a horrible thing to say. It’s not even that the customer was trying to be mean; it’s not human cruelty. It’s the cruelty of the universe, the cosmic unfairness of it all, coupled with human indifference and sarcasm, that combine together to create a vortex of heartbreaking tragedy.

I take care of children like this every day. Children with chronic illness, children with neurologic devastation due to the unfortunate hand that was dealt to them: prematurity, trauma, genetic disease. In order to survive as doctors, there must be an emotional barrier. We can be empathetic, but we cannot get too close emotionally, otherwise we cannot function. But this one hit me hard. Maybe it’s the fact that we have the same birthday. Or maybe it’s because I, too, suffered intrapartum hemorrhage, but because it was expected and planned for, the baby and I did incredibly well. Or maybe it has to do with the fact that I am freshly back from maternity leave after recovering from said complicated delivery and I am physically and emotionally exhausted. This one broke through the emotional barrier and catapulted me from the land of empathy to the state of feeling.

I want to say to her: I feel you. I feel your pain and your heartbreak and you are not alone. Let me bear some of it for you so you can take a breath. Right now, as the discharge papers are being printed and you are collecting your things, let me shoulder some of this pain for you. I don’t say it. Maybe I should but I don’t. I squeeze her hand and wish her well and tell her that her daughter is lucky to have her. I thank her for the opportunity to take care of her daughter, and I say goodbye.

New Year Goals

2018 was intense, harried, and a blur. There were highlights, like our first international trip to Italy in June (amazing, loved every minute, especially hiking through Cinque Terre and going on a timed family scavenger hunt through the streets of Florence), but there were also times that were just so busy that we were just trying to get through the week and not forget anything big (like that First Communion parents' night meeting that I totally forgot).

The busyness was entirely self-inflicted, a combination of too many kid activities, daughter applying to high schools (yes, it's a thing - a very stressful and energy-sucking thing), did I mention too many kid activities? There's three of them and we try to make sure they all get enriching experiences that they are interested in, but it's reached a comic/insane level if I do say so myself. Soccer alone.

Upon reflection during this sedate winter break, I've decided that I'd like to work on some life goals for 2019 for our family and home.

• More time with friends. We once tried to have friends over once a month which was awesome until it petered out. I think this is important for all of us and also important to our house in terms of general upkeep. We are resurrecting Guests of the Month and thinking of our first invites!
• De-cluttering. Our next door neighbors have the same exact house as we do but the mirror image. They had a holiday party which we attended last week and each time I'm in there, I marvel at their lack of clutter. They have NONE. Now I know it's a party and I'm sure they got it party-ready, but they are naturally immaculate (have 2 older kids) and spare. I came home from the party ready to donate 1/3 of the items in our house. We started with the Great Clean Out by having a family organization event of our basement storage room. The storage room has items like Rollerblades circa 1992, a small couch, and 5,395 other items strewn about in no particular order. It's level 2 Hoarders, Buried Alive. All 5 of us were down there, throwing things out, cleaning up, organizing, donating, and it looks amazing! No longer an embarrassment when the plumber needs to go in there! It felt good and didn't take too long. We also unearthed some forgotten treasures like my medical school commencement program and a birthday letter from a college friend. 
• Developing kid grit. Husband and I have decided that at least some of our kids lack grit and tend to give up easily. While watching our two boys, 7 and 10, on an unseasonably beautiful day during this break, I decided we needed to go on a Mom and Sons Run to enjoy the day and get some exercise. After the complaining and realization that I was set about this plan, we all ventured out to do a neighborhood run - just 1 mile! Now, we've all run a mile before- they've all run a 5K - so a mile is nothing right? Well, during that 1 mile, there were 40 stops, crying (someone fell), pushing (in play but still), a side cramp, and so much walking--I had to pause my activity tracker twice until we could continue. It was like the Bad News Bears Go On a Short Run. I told Husband and we decided there would be a repeat Family Run the next day as part of Grit Bootcamp. It was actually pretty fun. The 5 of us ran 1.25 miles with minimal stops and the 7 year old said, "We ran faster, longer, and it wasn't as bad!" We want to teach them they can get through discomfort and to be mentally tough too. More Family Runs to come!
• Mangeable kid activities. I want to include a question mark here since I'm half-hearted about this goal. I think 7 soccer teams was definitely over the top last fall, but I also want them to have time to pursue their interests, develop themselves, etc etc. I guess my goal is to be more conscious of our whole family schedule and to make sure everyone has some down time. Spring means only 4 soccer teams so that's a start! 
• Be more connected to others. Beyond having guests over, I want to reconnect more with friends and make time for that. I want to carve out more time to be connected with my husband. And continue to have great family unit time. I think this means committing to the bullet point above because connecting takes time and time is of short order around here.

Any one else have goals they hope to tackle in 2019? I figure writing them down makes us more accountable so feel free to share in a public declaration. :)

Dinner of Champions/ Freebies From My New Book

Genmedmom here.

Yes, this lovely photo of walnuts, dark chocolate, and red wine against the backdrop of Christmas was my real dinner.

This was several weeks ago. Hubby was traveling. I'd worked a long clinic day, and had just picked the kids up from my mother's. My school-age kids ended up with yogurt, fruit, and cereal, while I ended up with this dinner of champions.

But it's not a bad dinner, from a nutrition standpoint. Actually, I was rather proud of what I'd put together, for cardiovascular reasons.

After all, I've done my research: I've just published a book on this! Healthy Habits for Your Heart is a behavior change focused evidence-based diet and lifestyle book for heart health. I was a bit insane about including the supporting science, so the references section is way larger than the publishers wanted. The first section of the book is all about how our behaviors impact our heart health, and how to approach habit change. Then, for each suggested diet and lifestyle habit, I've included tips to make it stick.

Want a free preview? Here you go! Pasted directly from the book, to you!

I hope folks find it helpful for them and for their patients.

From Chapter 5, Eat For Your Life: Nutrition Habits, here is the lowdown on nuts, chocolate, and wine:

#34: Eat Four Servings of Nuts Per Week
Nuts are good for your heart and your life. Research shows that eating four servings of nuts per week was associated with a significantly lower risk of having coronary heart disease (19 percent) or any type of cardiovascular disease (28 percent). ere was also a significantly lower risk of dying from coronary heart disease (22 percent), cardiovascular disease (22 percent), sudden cardiac death (75 percent), or anything at all (19 percent). e studies looked at tree nuts (which include almonds, walnuts, pistachios, and hazelnuts) as well as peanuts (which are technically a legume but nutritionally similar to tree nuts).

Another study found that for every one serving per week increase in nuts, there was a 10 percent lower risk of having coronary heart disease. is may be due to the fact that nuts are a rich source of healthy oils. Nuts also are great sources of both soluble and insoluble fiber, as well as vitamins and minerals. Nuts are an important part of the classic Mediterranean diet, which we know is a very good diet for heart health. (Allergies are a consideration here. For people who are allergic to nuts, this habit doesn’t apply. As a doctor, I’m going to remind you to update your epinephrine auto-injector and carry it with you at all times!)

What Does One Serving Size of Nuts Look Like?
Per the National Heart, Lung, and Blood Institute (NHLBI):

• 1⁄3 cup nuts (equal to 11⁄2 ounces)
• 2 tablespoons nut butter 

Tips to Make the Habit Stick:

• Regularly stock up on nuts, but keep budget in mind. Nuts are cheaper when bought in larger quantities or ordered online. Shop around for your favorite sources.
  
• Nuts can go rancid. Store them in airtight containers. Glass is ideal.
  
• Make a portion of your favorite nuts a regular go-to snack. Have
  some in your bag or desk at work at all times.
  
• Get in the habit of adding a handful of nuts to your meals, be it
  yogurt, oatmeal, salads, or stir-fries.
  
• Try these recipes: Apple Cinnamon Walnut Overnight Oats; Fill-
  ing Fruit and Nut Bowl with Greek Yogurt; Nutty Tabbouleh Salad (in Appendix A). 
  

#35: Enjoy Two To Three Servings of Dark Chocolate Per Week

Research has consistently shown that people who regularly eat chocolate have lower blood pressure, blood sugars, and less heart disease. Chocolate comes from the toasted seeds of the cacao plant, which is rich in healthy plant chemicals called flavonoids, specifically cocoa flavanols. Cocoa flavanols have beneficial effects on our blood vessels by neutralizing toxins, which helps prevent stiffness and plaque buildup, as well as promoting healing.
The darker the chocolate, the more cocoa flavanols it has. Milk chocolate sometimes has barely any (it can range from 10–50 percent) and also tends to have more unhealthy fat added. For this reason, I recommend only dark chocolate (at least 60 percent cacao, though the darker the better) and only a small amount. One serving is two small squares (about 50–60 grams total), and science suggests that two or three servings per week provide the most benefit.
Do you like chocolate, but not dark chocolate? It is less sweet but definitely much better for you than milk chocolate. e intense cocoa taste is what can help prevent us from overeating this calorie-dense treat. Start with a small amount and build up over time. The less milk chocolate you eat, the more dark chocolate will begin to taste like normal chocolate to you. 

Tips to Make the Habit Stick:

• Add a teaspoon of pure unsweetened cocoa powder to your co ee in the morning for a mocha treat.
  
• Use only dark chocolate chips or chunks (60 percent or higher cacao) in baking and cooking. 
• Try these recipes: Dark Chocolate–Dipped Strawberries; Orange Pistachio Dark Chocolate Bark; Cherry Chocolate Overnight Oats (in Appendix A).
• Use pure unsweetened cocoa powder in your savory cooking as well. Try the Antioxidant Chili recipe in Appendix A.
• If you have a tendency to eat more than a serving (two small squares), consider buying only small amounts at a time or dividing what you buy into serving sizes as soon as you get home. 

#42: Limit Alcohol, Although A Small Amount Daily Can Be Heart-Protective

People who drink a small amount of alcohol every day tend to have lower risk of coronary heart disease when compared to people who don’t drink or to people who drink heavily. Research shows that light drinking can lower the risk of developing heart disease a great deal (between 40 and 70 percent) and also lower the risk of related diseases such as strokes, aortic aneurysms, and peripheral arterial disease. Wine (red wine especially) seems to be the best choice, though the protective e ect is seen with all types of alcohol. e active component in red wine is thought to be an antioxidant plant nutrient called resveratrol, but studies that have isolated this compound and given it to participants as a supplement have not shown any promising results to date. (Of note, that seems to be the case with all supplements.)

But this doesn’t mean it’s advisable to pick up a drinking habit. Alco- hol won’t erase the risk brought on by other factors. Drinking any amount over what’s recommended will actually increase the risk of heart disease by causing high triglycerides (a form of cholesterol), high blood pressure, and weight gain. Alcohol can also be directly toxic to the heart and is asso- ciated with arrhythmias like atrial brillation. Drinking too much—even just a little too much—also increases the risk of cancer (particularly breast cancer), liver disease, and, obviously, alcohol addiction.
For all of these reasons, the American Heart Association recommends that people do not start drinking alcohol as a means to lower their heart disease risk.
For people who can safely drink, and who partake regularly, here is what is recommended:

Men: No more than one to two drinks per day 
Women: No more than one drink per day 

Definition of a Drink: 

• 5 ounces of wine
  
• 12 ounces of beer
  
• 11⁄2 ounces of 80-proof spirits
  
• 1 ounce of 100-proof spirits 

Tips to Make the Habit Stick:

0. Hydrate well before you have any alcohol. If you’re thirsty, you may unintentionally drink too much too quickly.
   
1. Measure out your drink (5 ounces of wine, 12 ounces of beer) and then put the bottle or six-pack away.
   
2. If you’re having mixed drinks, specify how much hard liquor you want and watch the bartender measure. Some bartenders are a lit- tle heavy-handed with the bottle.
   
3. If you’re entertaining, mix up a pitcher of a tempting mocktail and have plenty of healthy and delicious appetizers on hand. It’s good for you and everyone else as well.
   
4. Try the Bubbly Minty Mojito Mocktail recipe in Appendix A.
   

References: 

Research shows that (nuts)... A.J. Mayhew et al.: “A Systematic Review and Meta-analysis of Nut Consumption and Incident Risk of CVD and All-Cause Mortality,” e British Journal of Nutrition 115(2), 28 January 2016, pp. 212–225.
Another study found... Y.Q. Weng et al., “Association Between Nut Consumption and Coronary Heart Disease: A Meta-analysis,” Coronary Artery Disease 27(3), May 2016, pp. 227–232.
Research has consistently... E. Higginbotham and P.R. Taub, “Cardiovascular Bene ts of Dark Chocolate?,” Current Treatment Options in Cardiovascular Medicine 17(12), December 2015, p. 54 and S. Yuan et al., “Chocolate Consumption and Risk of Coronary Heart Disease, Stroke, and Diabetes: A Meta- analysis of Prospective Studies,” Nutrients 9(7), 2017, p. 688
and C.S. Kwok et al., “Habitual Chocolate Consumption and Risk of Cardiovascular Disease among Healthy Men and Women,”
Heart 101(16), August 2015, pp. 1,279–1,287.

Research shows that... and Drinking any amount (alcohol)... S. Bell et al., “Association Between Clinically Recorded Alcohol Consumption and Initial Presentation of 12 Cardiovascular Diseases: Population Based Cohort Study Using Linked Health Records,” e BMJ 356, 22 March 2017, p. j909 and
P.E. Ronksley et al., “Association of Alcohol Consumption with Selected Cardiovascular Disease Outcomes: A Systematic Review and Meta-analysis,” e BMJ 342, 22 February 2011, p. d671.
Alcohol can also... C. Tangney et al., “Cardiac Benefits and Risks
... UpToDate, updated March 2018, https://www.uptodate.com/ contents/cardiovascular-benefits- and-risks-of-moderate-alcohol- consumption.

Exceptionality

I learned a beautiful new word this week - exceptionality

I am on my community health rotation. One of the best parts of being a resident are the off-service rotations, which means less time at the grindstone of patient care after learning after patient care after learning and a little more time to breathe. I got to spend a day with a public school nurse in the metro area school system. I graduated with less than 50 kids in my rural high school graduating class, so touring a public metro school system was eye opening, especially as I toured the schools where the kids were >90% free/reduced lunch. Both as a doctor and as a mother.

The school nurses I met were all so gentle, patient, and kind. I watched at the elementary school as 3 kindergarteners came together for their pre-recess albuterol inhalers and impatiently watched the clock together with their little spacers in place. We talked about the special needs kids there as well. I don't remember the issue we were talking about in particular for one of the kids, but I remember the nurse saying (instead of "part of his disability is...") "Part of his exceptionality is _______". She said it with a knowing smile and a twinkle in her eye despite what I'm sure was a frustrating and time consuming issue for her.

We never really had a schedule. We floated around an elementary school, a middle school, and a high needs school. The nurses were so proud of their schools and their kids and talked non-stop about their goals and wishes and kept pulling me aside to show me other students that had made great strides. One of the middle school nurses was one of the most reflective listeners I'd ever met, and as she told me about the difficult parent interactions she's had, I thought about how much she could teach us as doctors about how to handle difficult patient interactions.

The last school we stopped at was specifically built for high needs cognitively impaired students. We walked into the school nurse's office just as she was calling an ambulance for a child's third seizure of the day. They told me they call 911 approximately once a month. I was additionally interested in this school because I'd never heard of it before 2 weeks ago - when a new teenage patient with significant cognitive delays and no prior records showed up in my office appearing agitated and on the verge of violence. I had a 15 minute appointment with them and wasn't sure what to do. I was referring him to the appropriate specialists but was debating whether I needed to start behavioral medications in the meantime as his grandma had told me he had been on some medication in the past. I had found out through the school system that he was already getting hooked up with basic therapies and they thought they were meeting his school-based needs at that time. Now I was at that school. I met the therapists, the numerous paraprofessionals, and peeked at the kids in wheelchairs and helmets and in all manner of disarrayed behaviors. I saw my teenage guy too. He waved at me across the cafeteria and when I talked to his teacher, I learned he was a "delight" and they had no behavioral concerns - and they spent all day with him. I learned about their functional based classes and even got to sample a cookie from the morning's cookie class.

I won't be in this metro area much longer. As I've said before, I'm looking for jobs - I have had several interviews and don't have a finalized plan yet, but I probably won't be in this community. It gave me professional inspiration to connect with my future school district and learn more about my community wherever I practice, but more importantly I have a new deep and profound appreciation for all teachers, especially for kids with complex medical/social/emotional needs and even more importantly school nurses. Especially the ones that appreciate the exceptionality. And as a mother of one healthy toddler, I appreciate all those that willingly spend their time among hundreds of children and/or teenagers every day.

May this inspire you to appreciate rather than tolerate an "exceptionality" this week. :)

Kicks

Keep your mama friendships guilt free

I have been so blessed to have several amazing groups of girlfriends, most of whom are mamas. I have a handful of dear friends from high school, sorority line and big sisters who have become like family, my college international housemates, my college friends whose spouses have become my husband's friends, beloved friends from our time in family housing at UNC, my Code Brown Crew from UNC Pediatric Residency, the mamas from the parenting group my husband and I started 3 years ago, and my family - I count my mother, mother-in-law, and great aunt as three of my best friends - these women fill my life with advice and love and accept my text messages and incoming calls day or night. I love, love, love them!

I truly believe that it takes a village to raise a family and it takes a tribe of girlfriends to keep a mama sane and thriving. Over time I have come to realize that it is impossible to be everything to someone and as such I have been able to find over time that all of the different qualities my girlfriends have make for some diverse, sound, and priceless advice. I have never been a one-best-friend type of girl even though I wanted to be and instead do much better with a cadre of lady friends. 

As our lives have ebbed and flowed, sometimes the calls are more frequent, sometimes months or even  years go by without communication. But the love is always there. After months of not speaking I have done consults on sick kiddos, talked to family members who had medical questions, done an emergency contraception consult for an adolescent volunteer visiting the United Arab Emirates (it is dangerous in many countries to have unmarried sex). I have walked with friends through infertility, infant loss, miscarriages, marriage challenges, spousal communication issues, school issues, health issues, you name it. 

As my life has become busier I have been doing more lately to immediately send a text when one of them crosses my mind. Just a quick "you ran across my mind, it's been so long, sending you a big ole hug. How are you and the family?!?". Which leads to a flurry of updates before we have to run. And if I really feel compelled and have some alone time in the car, I pick up the phone and call. Some of those impromptu catch up calls have been life changing for me and for the other ladies. 

I have incorporated a saying recently when the inevitable "I am so sorry it's been so long" is uttered. I quickly say something like "Girl!!! Our lives are so busy ain't nobody got time for mama guilt! Call or text me when I run across your mind and I'll do the same for you!" and then we laugh and continue to catch up in the few minutes we have.

So to all of the mamas out there. Call or text your friends when they run across your mind. When you talk, carry on where you need to. If you feel the need to apologize for it being so long, be gentle and forgiving with yourself and stop yourself! Let's minimize the guilt we have in our lives and do what we can when we can unapologetically. If your friend apologizes, tell her you refuse to have any guilt in your relationship when life is already so complicated and you promise to do what you can when you can to stay in touch. Here's to keeping your mama friendships guilt free and full of love! 

How do you keep in touch with your friends? How do you minimize guilt in your relationships? Please comment below!

Interview Season

I hate interviews. I don’t know why I hate them so intensely or get so anxious, but whenever I have a job interview I develop “functional dyspepsia” (or as my mother would call it - a nervous tummy). I’ve started looking for my first real attending job. Someday I’d like to be a residency faculty member, but my university system has zero openings. I got one job interview for a residency faculty at an outside system that met all my criteria - within a couple hours drive from our families, a community that both my husband and I would enjoy living in, and an established residency with good mentoring support. It was a long interview day - beginning at 7:30 in the morning and dinner going past 8 pm that night - and I admittedly wasn’t my best self. It was my sixth week of a stretch with only 6 days off total (2 of which were used for Baby’s first birthday with our family back home), so I was tired. I underestimated how difficult it would be to schedule interviews around a resident’s schedule, and I would have preferred a later date to have recuperated a bit, but this was the only date that lined up for both me and the program.

 I felt like I connected well with the current faculty and really felt like it was a good fit, except for one disappointing part over lunch. I was asked to give a lecture so they could evaluate my teaching style, and I was ready with flashy PowerPoint in hand with a topic I had done research on so I could actually answer a question or two. However, about 15 minutes into the lecture, I realized I was getting warm and lightheaded. The walls started closing in. I realized I was standing locking my legs in a warm suit jacket and hadn’t had much to drink for water. I started talking faster, thinking I could just get through it and no one would notice, but then one of the faculty members stood up and got me a glass of water and I noticed a bead of sweat dripping down my nose, so I finally quit faking it, apologized to the audience, and led the rest of the lecture and discussion from a seat in front of the podium. I was so embarrassed. I have had similar presyncopal vasovagal-y episodes before, but this was the first in front of a large group of people. Hopefully, I’ll get points for finishing regardless of my obvious physiologic distress...

The rest of the day went well but I still won’t hear from them for at least a month. The more I go to other interviews, the more unappealing pumping out RVUs day after day seems to be. I’ve had to stop myself numerous times from emailing the program director “Pick me! I think your program is exactly what I’ve been looking for! We want to live in your town FOREVER!”. But that probably looks bad so I haven’t.  😝 It’s my first choice for a job. I think I’m a decent candidate, but if someone swoops in with experience and/or someone from within their own system is interested, my chances probably aren’t looking too good.

I had another job interview at a community clinic within the past few days. It meets all my non-academic job wish list items except one. I’ve gotten more idealistic rather than less as medical school and residency have gone by, and I was really hoping to work in at least a somewhat underserved community - but this job is in the heart of a beautiful suburb which wasn’t what I was picturing for myself at all. The  more I think about my list of what I want in a job, the more I realize that this is probably a very good fit for me, but  there’s just a small hesitant piece of me that feels like a sell-out. Which is why I’m turning to you all for stories and advice - was there anything you had to sacrifice off your wish list to find a job you were still reasonably happy in?

A Beloved Mentor Falls

I walk by the closed double doors and frosty windows of the ICU. You’re lying in there, intubated. It feels weird to go to work now. I can’t see you or talk to you, don’t know the drips, don’t know the plan... and it’s killing me. I, along with many others, desperately want to express my love. So many feelings are swirling inside:

Guilt... For having a chill workday that day, leaving early to sneak in a pedicure before the evening’s family duties. All the while, you collapsed in the OR. Our colleagues rushed to your side. Emergent intubation. Hours in surgery... A trivial moment for me that was horror for you. It hurts my head and heart to contemplate that this is the case for any two people on Earth at any given moment.

Bitterness... For the memories that have surfaced of my own health crisis. My own rush to the OR and surgery and stay in the ICU. The immediate change to everything in my life, the upset of all routines. The label of a disability, the worries about the future. A dark time that I try to forget but never can. For having the knowledge that you will experience this same bitterness later on... if you’re “lucky.”

Gratitude... For my health now. For the part you played in it. You were the one I went to when I knew something was wrong with me all those years ago. My tears didn’t phase you for a second, and you helped arrange my much-needed absence from training. Others thought I was just performing poorly; they judged and moved on, but you knew what mattered. When I was finally diagnosed, you facilitated my prompt surgery with our most skilled surgeon. The same one who is now taking care of you.

Admiration... For your completely nonjudgmental approach to everything and everyone. I have experienced it myself but never realized it was your M.O. with all people. We all exchange stories quietly in the lounge, then fall silent with sadness and worry. For your goofy sense of humor. For our days in the OR and call nights together during my training; you were the one I felt most comfortable failing or struggling in front of; only now do I realize why.

Anger... For why this had to happen. What higher being would take down such a beloved leader, such a good doctor? At you for not knowing something was wrong inside sooner, so as to maybe prevent this catastrophe. At your family for keeping us from seeing you now. They don’t understand how much we love you, how much doctors bond together in a practice, working in parallel to preserve life and limb. Damn you for not sitting up in your bed right now, pulling that tube out and cracking a joke with a mischievous smile.

I have to write all this here to get it out of my head. Work is not the same without you there. I miss you.

Signs (H/t to Ace of Base)

I believe in signs.

Driving home from getting the kids flu shots, we heard the song "The Sign" by Ace of Base on the radio. Whenever I hear this song, it brings me back to college Spring Break in Cancun. My 13yo knows it well from the movie Pitch Perfect (she is a big fan) so it was a fun song to have on for us. After the song was over, I changed stations only to hear "The Sign" again! Granted, in the DC area, we have a strange preponderance of "old people stations" per my children, but still! What are the chances?

I immediately thought of our priest's winding homily last weekend where he wore a blindfold and held a football (long story) and talked about blindspots and listening for signs.

Okay, this was a sign of some sort that was actually labeled "The Sign." What was I supposed to do?

I decided that it was time to finally extricate myself from one of my extra volunteer commitments that I was not able to fulfill well since it was low on my priority list and that I carried guilt about. It no longer brought me joy. So, later that week, I stepped down from my role. And...deep exhale. It's done! I do feel a tiny bit lighter. I know that I need to pare down my commitments some more, but this was a good start.

Which brings to me to a story of another sign.

So, my daughter's school soccer team is in the playoffs. I was deeply conflicted since their first playoff game was scheduled for the night that I needed to leave for a conference in TX. Couldn't get a later flight than 7:30pm. I had to be in for an important Friday morning meeting. I was so bummed I'd miss her play, and then if they won, I'd then miss their semifinal game on Saturday as well.

When I arrived at the airport garage on Thursday, I joined a huge mass of people waiting for the shuttle to the terminal (apparently they had been there for awhile without service) and checked my phone. My flight was delayed by 2 hours. I looked at the time. 40 minutes until the playoff game started. Really? Could I make it? I did some rapid calculations and decided that I could make the majority of the game. Maybe I could even check-in my luggage now so I can just cruise in later with my TSA precheck!

Hustled back to car. Drove to Hourly Garage. Found a spot. Booked it into terminal. Self-checked bag (thanks Southwest), asked attendant the likelihood that my delayed flight would actually board earlier (answer: very unlikely), booked it back to car, drove the 35 minutes to the high school and got there 6 min into game. There was a big crowd of support for our team there. Many of the girls on the team had painted their faces - such spirit! My daughter was looking great in the goal. She made an amazing save, tipping a ball that was certainly headed in, out of bounds. It was thrilling to watch them play and awesome to be there! (And slightly weird knowing my bags were checked in at the airport and I really needed to catch my flight.) The team was up by 4 goals, it was well into 2nd half, and it was time for me to get back to catch my plane. I jogged out of there, got into my car, and my husband texted me: [daughter] is out. To much accolade. Coach had put in the 2nd goalkeeper with 10 min to go. By the time I got to the airport, I had confirmation that they won!

I sailed to the shuttle, through security, grabbed dinner to go, and got to gate as they were lining up to board. It was intense, slightly crazy, and totally worth it. What's more, the semifinal game on Saturday was canceled due to rain so I missed nothing.

It did all work out. And it did feel entirely meant to be.

Tricks and a Few Unexpected Treats

We went trick-or-treating for fifteen minutes last night. That's right, fifteen minutes.

Let me preface this by specifying that my children are four and a half and two and a half years old. So clearly it was never destined to be a long outing. Last year we made our way up and down most of our street. Walking was still fairly new to Teeny, my little guy, and the whole trick-or-treating concept was new to Bean, my older son (we had lived into a condo building until several months earlier), so progress was slow. As our first Halloween living in our house, it presented a fantastic opportunity to introduce ourselves to the neighbors. While we stood talking to the other adults, Teeny quickly learned that he could continue helping himself to handfuls of candy from their bowls and that, while his parents admonished him, the other adults thought it was adorable and encouraged him to take even more. 

This year, both boys understood and remembered (or at least Bean did) enough about Halloween to spend weeks and months anticipating its arrival and plotting their costumes. Superheroes and Pixar characters are a BIG deal in our house. On any given day, Ben and Teeny will cycle through several different costumes depending on what they are playing, what movie they have watched most recently, or how the stars are aligned. Sometimes they want to match one another exactly and sometimes they don't. Sometimes they want to be superheroes from the same team or characters from the same movie and sometimes they don't. Throughout September and October, they announced their intended Halloween costumes daily. (Well, it was mostly Bean announcing and Teeny chiming in, "Me too!"). Each day's announcement reflected whatever costumes they were wearing at that particular moment.

Wanting to avoid controversy and angst (theirs and my own), I decided to wait until October 31 to elicit a final decision. We own practically all of the suits, whether as true costumes or pajamas, that they could want to wear, so I reasoned that that day they could make a final decision, get dressed, and head out for some trick-or-treating. Early in evening my husband and I compared expectations for the night and agreed that we would likely stick to our street, only venturing further if it were still early and things were going exceedingly well.

What I failed to do, in leaving the final costume determination until the last minute, was the prep work of planning what layers would be worn under or over said costumes and how they would be integrated into the boys' understanding of the night's plans. When I arrived home from work, Bean was wearing his Buzz Lightyear suit and Teeny his Captain America shirt. Both boys indicated that these were the outfits they intended to wear trick-or-treating. There was a minor kerfuffle over the dictum that no further candy would be allowed until after they had eaten dinner, but we got through it and began preparations to leave the house. Teeny made the game-time decision to also dress as Buzz Lightyear, so after a diaper change, my husband put him into his Buzz pajamas. The evening seemed to be progressing smoothly.

But here's the thing: we live in New England. Unless they had been nestled into the thick, furry monkey and lion costumes that they wore two years ago - notably the last time that Mommy got to choose their costumes - there was no way that they were going to leave the house without sweatshirts/fleeces/jackets or some combination of layers. Teeny allowed himself to be wrangled into a jacket, his biggest complaint being that his shirtsleeves were pulled up inside. But Bean was harder to pacify. We tried a fleece underneath his suit; the mock neck bothered him. We tried a jacket, but he grew upset that it covered his suit (even though I pointed out that he didn't have to wear it fully zipped or with the hood up, which he insisted on doing). We moved to a sweatshirt under the suit, but this also failed to pass the comfort test. When I threatened to keep him home while his brother and father went out in quest of candy, he acquiesced and allowed that a specific sweatshirt - obviously not the one that I had suggested - might be tolerable.

With renewed optimism we left our front porch. The neighbors across the street, a middle-aged man and woman with whom the boys are quite friendly, sat on their front steps awaiting trick-or-treaters. But as we approached, the boys suddenly grew shy. A whispered "trick or treat" had to be coaxed from their lips, their hands guided toward the offered candy bowl. "Want go home now," Teeny said, looking up at us with wide, serious eyes.

As we headed down the steps, he changed his mind and we continued on to the house of another neighbor with whom the boys are close. As we crossed the street, we speculated excitedly as to whether her dog might also be in costume. But once again, up on the porch, they withdrew. They muttered "trick-or-treat," accepted some candy, and pulled us on our way.

The same scene played out at one additional house, with each boy clutching one of my legs. This time they both expressed a desire to go home, and we complied. I felt surprised, frustrated, let down - both for myself and for them - and, frankly, confused. They, it seemed, were overtired, overwhelmed, or just not that into this year's Halloween.

Back in our living room, they became different children. With glee, they emptied their plastic jack-o-lantern buckets and surveyed their haul: about five pieces of candy each. Excitedly they requested permission to eat some and then savored - and even shared - their treats. With all of the animation and enthusiasm that had been missing during our short trek, they played with toys and gallivanted around the house. My husband and I offered them the opportunity to go back out to visit a few more houses, but they happily declined. There was no more than the usual amount of fussing when bedtime was announced, and shortly after 8pm they were settled in to sleep.

I also took to my bed. "I'm just done with this day," I said to my husband. "I want to read and go to sleep." Our street had turned quiet so we shut out the porch lights and went to bed. I slept, but did not feel rejuvenated this morning. And I have spent much of the day rehashing yesterday's events.

By lunchtime today, I had settled on my own shortcomings as a mother as the explanation for our failed trick-or-treating expedition. In seeking to avoid controversy, I had failed to provide structure and to set expectations for the boys surrounding their attire and behavior for the evening. They (like their mother) don't always adapt well to sudden changes, and waiting until the last minute to determine a final costume and the associated layers had set them up to be discombobulated. 

But in recounting our evening for a coworker, I heard myself saying, "No, it wasn't great.... Well, actually, it might have been a success." Once we were back at home, they had a grand old time. And they were absolutely thrilled with the few pieces of candy they had collected. They had built up the anticipation of an event but then found themselves in a situation that they actually didn't enjoy. So they voiced their opinions, changed course, and ultimately enjoyed themselves thoroughly.

They, it turns out, had actually been the ones to navigate a rather abrupt change, leaving their mom in the dust struggling to adapt. Perhaps I'm actually the one who should learn from their example.

Who gets to decide if you are too busy?

I talk about my kids. A lot. I mentioned them in my residency application, during my interviews, and share anecdotes at work with my attendings who have kids the same age. We share pictures, school recommendations, fun Sunday activities, etc.  All the attendings with kids, however, are men. My residency program, in a field with a growing feminine presence, is amazingly family friendly, with at least 3 other dads/residents and 1 other mom. It's a fun, sharing atmosphere.

Until it's not. While casually discussing the possibility of becoming chief resident next year (it's not a dedicated year- you still have the same clinical responsibilities just with extra admin ones as well)  one of the attendings, who has a direct role in decision making for the residency,  made an off-hand comment along the lines of "well, you are busy enough, you probably wouldn't want to have anything extra." When I approached him privately after and let him know that I was, in fact, interested and hoped to be considered for chief, he was welcoming and supportive. But the off-hand comment made me think.

Are the biases and expectations and assumptions about what a mothers' role fair game for deciding promotions, responsibilities, career trajectory? Who gets to decide how busy, or not, I want to be, or am? Do I now have to "tone down the mom factor" and work extra hard, just to be considered for the same position as someone without children? Other residents talk about dating, drinking, their dogs, other parts of their outside lives. Do kids not count as an approved extra-curricular activity?

The most frustrating part for me, is that I'll never know. There are a few other amazing residents hoping for the position. If I don't get chosen for the responsibility, will it be because the admin thought the others were better for the job? It's a completely realistic possibility. But what if it's because I have kids and they have assumptions on what I can/want/will handle? Part of me wants to eliminate the possibility of that frustration and uncertainty by denying any interest in the position and just letting it go. But I  have decided I am just going to work harder, smarter, work on being a team player, and keep at it. And maybe share stories a little less.

Have you been in a position where your home life was questioned? Your choices judged? Your responsibilities and commitment challenged?