I went to a concert and it was okay

For Christmas, we gave our 13-year old daughter tickets to a concert for her favorite band. She's played us songs ("Can I play you this song? It is sooooo good! *insert look on my face during song that looks like a shot from The Office when a character smiles uncomfortably into the camera*)

Let's just say that I feel too old to enjoy this kind of young boy band music. 

But nevertheless, we gifted her tickets (#4) for her and her two friends and one very lucky parent chaperone (me). Please note my deep love and devotion for my husband to not even try to do rock-paper-scissors for the pleasure. Because I knew that he might die if he were exposed to that environment. He's more introverted and has somewhat elitist views on music. 

I did establish some expectations with all parties to protect my sanity. Since it would be a school/work night (!), I declared that we would get there early and leave early, like before it ended. There's no way I'd be stuck in concert exit traffic late into the evening by leaving when everyone else did. No. Way.

So, on a recent Thursday night, I drove my daughter and her best friends through 1.5 hours of rush hour traffic to the concert venue.  They were ridiculously excited, playing the band's songs and flipping through a coffee table book of said band the entire time. By the time we got to the garage, they were downright Giddy with excitement. I have to say that seeing them united in Giddiness gave me serious feels.

We walked a couple of blocks towards the arena, realizing that there was a huge parking lot right there and that we unnecessarily parked in a remote garage. Oh well (I followed the signs!). We were almost at the arena when I ran through the exit procedures with the girls. I would leave before them, get the car, then text them to meet up, before the concert ended. 

We made it to our seats, and I noted that the median age of the audience was 14 and 90% female. Parents were on their phones.  At one point, one of the two opening acts gave a shout out to the parents in the audience. That's when you know you're old and at a concert for a much different demographic.

There was a whole lot of screaming that night. Jumping. Glee. I loved seeing my daughter and her friends enjoy the moment so much. That made bearing the screaming and jumping and loud music I didn't care for, bearable. On the plus side, I could go get them food without feeling like I missed anything unlike most of my previous concert experiences. And the music, well, I had very low expectations and it exceeded them. (ears weren't bleeding; I refused to stand though)

After looking at my watch for the 100th time, I decided that it was time for me to make the trek to the remote parking garage ahead of time, trying to project what time the concert might start winding down and how long it would take to get everyone home. I left them there with the concert going strong and, on the way out, took advantage of zero merch lines to buy them all concert shirts as a surprise. Lots of parents out there, sitting in chairs on their phones. 

By the time I came back around with the car, it was at exactly my pre-planned pick-up with them and they were out to meet me within a couple of minutes. The concert was just wrapping up and we made a hasty get away with zero exit traffic! It was a surgical strike! On the way home, the girls basked in their happy exhaustion. 

"That was the best 2 hours of my life!" said one friend.

I dropped each one off at home and presented them with the surprise shirt. They were thrilled! We hugged (more feels). And I felt very good for helping to make that experience happen for them. I might even do it again.

It just looks like that girl has a hook for a hand. Also, that girl stood like the entire time.

Getting down the mountain with Pizza turns.

A few weeks ago we took my kids on their first ski trip. Actually, it was the first time my younger one has ever seen snow!

The first 2 days, the kids were in ski school and my husband and I got to go ski the "fun stuff." We are both pretty advanced skiers so it was great going down the mountain, together, without kids,  like we were dating again. I love anything outdoors and active, so this was the perfect antidote to the recent run of a lot of ED shifts.

But on the last day of our little trip, the kids revolted. They were exhausted from learning this new skill, in this new environment, in a new climate. No one wanted to go to ski school, and the only way we convinced them to get up the mountain was if we promised "family day." So, to the bunny hill we went.

The 4 year old rode the gondola down to town with me after 2 runs, but my 6 yo was still ready to show off her new skills. So she and my husband decided to try to ski down the longest run to the base of the mountain.

The look of sheer disbelief, awe and pride she wore when they walked off the slope 40 minutes later mirrored my own. She had "pizza turned"* the whole way down. Slipped and slid across parts of it, tumbled in others, but she did it. All 3 miles of snowy slope. Some of it way harder than her 2 day total skill level. All of it an entirely new experience.

I felt that way after running my first code. A mix of "what just happened" and "wow, I look like someone who knows what they are doing." Disbelief and gratitude and pride and fear. As this academic year starts to wind down and senior year is approaching, I look forward to having more of those moments. Medicine is humbling. The human body and whatever otherworldly spirit that accompanies it, is capable of incredible, unpredictable, and inspiring things. Our capacity to learn, study, and train in order to impact the course of the life of another person, or use our skills to intervene and directly affect their future, the future of their family, their destiny, is uniquely motivating.

I hope to keep motivating my children to push their limits and challenge themselves. Parenting my children gives me a window to parent myself. Motivate myself. As lifelong learning is a huge tenement of our field, I hope that lesson of small, slow, pizza turns, sticks with me.

* For those who don't ski, "pizza turns" refers to the wedge shape you make with your skis to slow down and control your speed.

Grappling and Grateful

I’m nesting.

No, I’m not pregnant, and I’m not sure when it started exactly, but with the start of residency looming and more free time on my hands right now than I’m used to, l have this strong desire to declutter and reorganize. Thanks in part to a nudge from Mommabee’s recent post on feeling stuck, I dove into Marie Kondo’s Netflix series.

I hoped that I would get some practical tips for decluttering, and I did, but I also found something much more enlightening. It clicked during the 4th episode, when a family of four was working to control the clutter after downsizing from a large house to a 2-bedroom apartment. The crux of the episode was when it became clear that the mother was responsible for essentially all of the “stuff”, both physically, cognitively and emotionally, to the point where her adolescent children and husband would call her throughout the day because they couldn’t find anything. She had taken on the role and implicitly assumed the responsibility while working a full-time job outside the home. I won’t dive into a full analysis of the show (although there’s a good one on the show’s gender dynamics here). The invisible labor of womanhood and motherhood becomes visible.

Suddenly, I saw my impulse to reorganize our home and life in stark clarity. While I’m grateful that my husband is committed to gender equality in our marriage, we’re still fighting generations of inequality and implicit assumptions about men and women’s roles at home and in managing family life. So while some things are straightforward, ie, if I make dinner, he cleans up, and vice versa, other forms of emotional labor are not. Looking back, we can both see the impacts of very unequal emotional labor on each of our mothers. And the “stuff” is just one example. We both moved at least 10 times throughout our childhoods, sometimes internationally, and usually lived in rented housing. While my father was the “packing expert”, my mother managed the bulk of the organizing and cleaning and knowing where everything was, on top of knowing who needed what doctor/dentist/chiropractor appointment or freshly laundered uniform and what we were going to eat for dinner. And I subconsciously still assume that’s my role too. I’ve been able to keep up (mostly) with this invisible work while keeping up in medical school, although it’s gotten a lot harder since my son was born. I’m actually pretty good at managing a lot of this in my head.

But here’s the thing - I know it’s taking energy away from other areas where I want to be excellent, like being really present with my son when I’m with him, and developing into an excellent physician, and building the career that I actually want, rather than just slogging along on a one-size-fits-all career treadmill. I know the other members of my medical-student-mom squad feel it too. We’re constantly exhausted and we’re not even in residency yet. And while decluttering is helpful, it’s not the answer. Delegating is definitely part of the answer, but first I have to list out all of the things that I’m trying to do and then figure out how to delegate them. So keep an eye out for my household organizing/delegating app once I actually figure out how to do all of this. (I'm kidding - this is way beyond the scope of any app.)

No, I put this out there not because I’m expecting someone has a magic answer, but because I’m grappling. And I’m also grateful. I’m grateful for my wonderful mother and mother-in-law, who managed two large, chaotic households with so much love and way more patience than we ever deserved. They fell into bed at the end of every day exhausted for reasons they couldn’t even name. I’m so grateful to them for managing all of our “stuff”, both physical and emotional. And I hope to honor them by finding a way to both love and care for my own little family while letting go of some of those expectations and responsibilities. I hope to honor them by sharing some of the empathy and intuitiveness that I learned from them with my patients and colleagues too. And I’m grateful for the #momsquad that lets me vent without judgement about how hard all of this is, and the husband and toddler who love me just as I am.

Starting Young: A Bad Thing When It Comes to Body Images Issues

The other day, my 3 year old daughter said to me, "I'm feeling fat, so I need to go take a long walk."

Is this the start of myriad negative body image thoughts I will inevitably need to address during her life? Maybe she's just being a word sponge, but I can't believe she said this at her age. Where she learned or heard it, I have no idea. I just want to make sure I don't contribute in any way to it.

I've experienced my share of body image issues like most of us. When you have any unusual feature (in my case, it's being over 6 ft tall), your body becomes a point of commentary. And it can become part of your ego, regardless of whether that feature is considered positive or negative. Fortunately, comments made to me are usually complimentary. The other day, a woman in the gym locker room said to me, "Your legs are absolutely perfect. Amazing." Of note, this woman was herself tall, thin and beautiful. All I could do was laugh. I see my legs (and body, for that matter) as far from perfect - and that's ok.

Men vs. women... Although both sexes are prone to chasing perfection.

"Perfect" is a word we should stop using for many things. None of us can have a truly perfect body, be the perfect parent, the perfect spouse, the perfect doctor. There is no such thing as a perfect home, a perfect job, or a perfect anything. Someone's idea of perfect (in the case of my example, legs) is completely different than another person's vision. Maybe you value strength and thus enjoy the look of muscular legs, while another person desires very thin legs. You can soften the P word by saying "this is perfect for me", but I even have trouble with that. We're never done learning or improving. Why do we spend so much time comparing ourselves to other people and trying to measure up to some sort of perfection endpoint? Endpoints are for fixed mindsets.

Social media, which is a powerful tool for helping us as physicians reach a broad audience with our message, is also a huge conduit for comparison and the pursuit of perfection. And it's frighteningly problematic when it comes to our young girls, who tend to deeply value social inclusion and are very sensitive to shaming. I heard an interview with psychologist Jonathan Haidt, who recently cowrote the book The Coddling of the American Mind. He pointed out an alarming trend of increased depression and suicidality among young girls, which has suspiciously spiked with the ubiquity of social media.

I do love my own body, but I didn't always as a child. I remember wishing to look like "everyone else", to be shorter, smaller, etc. As an aging adult and physician who sees very broken bodies, I appreciate that my body's gotten me through some serious health challenges. I would never trade motherhood for a flat abdomen with no signs of a pregnancy. And I believe in striking a balance between accepting ourselves in the present moment while also trying to make improvements. However, my acceptance only came with age and life experience. I know it'll be difficult to instill these ideas into a young girl's concrete thinking.

What body image issues have you come across with your daughters, and how have you dealt with them? Do you let your girls have social media accounts? I'd love some positive solutions.

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?