With your head held high

I heard a phrase today that I will remember for a lifetime. It has given me inspiration in my struggle to achieve a perfect balance between parenting and working GUILT-FREE.

Grand Rounds today was given by a very accomplished woman (and Mom). Faculty at Harvard Medical School. She's affected national policy and changed the course of a major public health issue. What struck me was her introduction. One of the first comments was that one of her first employers, while reluctant to hire her only part-time, soon realized that even her part-time work, amounted to a dozen others working full time. (I nodded when I heard this because I often feel I'm efficient and use this rationale to justify my part-time work as well.

Her introduction was 15 minutes long as her introducer took us through her career path and mentioned all her accomplishments along the way. When finally at the end, we were all anxious to get on with the show, the introducer continued, "I can't end an introduction about this remarkable woman without telling you about her family. She has 3 amazing children who are all incredible human beings. They are all adults now and have all gone on to college. Until all 3 children went to college, she worked part-time. And the remarkable thing about her, is that every day that she left work early, she did so with her head held high. She made it clear to those around her that raising her family was as important as her work."

I love that last line - I often feel like I have to sneak out the back door when I leave early to be with the kids. Today I decided that I need to hold my head up high more often at work. I am a confident woman in the many hats I wear at work, but when it comes to leaving early, I am quiet, almost sneaky, hold my breath and only relax when I'm finally home with the kids...it doesn't need to be like that. I felt an enormous amount of pride and excitement to hear this woman's introduction today. It was a clear articulation of the woman I want to be. Proud to be both Mom and Doctor. That's the introduction I want to earn 15 years from now.

The brutal nanny hunt

Tomorrow morning my nanny starts and this is not something I take for granted.

I had a nanny for almost five years, she now wants to only work part-time so three months ago, I went about looking for a replacement. Yes, amazingly, it has taken me three months to find a nanny.

There are so many things about this search that were painful. Amazingly, despite the slump in the economy, experienced and affordable nannies are hard to come by.

In our area, the cost is crazy - most nannies value themselves on their hourly rate, feeling that they are entitled to at least $15/hour. Well, that's fine except that they also want all the benefits of being on salary - like vacation, sick leave, personal days, health benefits etc...for my husband who runs his own company, this drives him crazy because because we are paying more per hour than his (more formally educated) office manager and this 'hourly' rate that nannies use doesn't include the 'true' cost to us - the real baseline is $17/hour since we have to pay social security and unemployment on top....(painful since these are all AFTER tax dollars).

The second most painful thing was finding the right person. I hired one lady who I thought was perfect, and she didn't show up for work the first day because of something 'personal'.

Then I hired another lady who was cheaper, a little less experience but willing to work longer days and she just had no instincts about caring for a baby (mine is now 10 months). Plus, she was missing her own two kids while working long days so that didn't last but a week.

Third, I hired a 25year old student who was taking classes on the weekend. I was really excited about her because she was young, energetic and would live with us so we would have the flexibility of having her babysit in the evening. So we moved all 3 of our kids into one room to accommodate her (yes, I really thought I could manage with all 3 in one room...). The second day she was watching TV, on email while my baby was sitting under the table. The next day my Mom came to check in on them and she was barefoot in the garage, trying to adjust the stroller while she had the baby PROPPED UP on a box...ultimately she confessed that she had no time to babysit and we both agreed it was not a good fit.

The fourth lady seemed amazing on the phone but it turned out she had NO filter. When she came over for the first time, she expressed many opinions including inappropriate commentary about my kids in front of them. She also only provided references from five years prior and didn't show up to her second day on trial because she thought it would be ok....when I called her to tell her she didn't get the job she really let her words sneak out of her mind and I was reassured that I made the right decision.

Finally, we found our current nanny who has been with one family for the last 8 years- she's wonderful. We found her from a teacher at the preschool.

I must have interviewed over 30 ladies on the phone and brought 20 ladies home over the last few months. I bought subscriptions to all the nanny websites and as good as their services are, the nanny I loved came from a personal reference...which in the final analysis is really the best way to find a caregiver.

For anyone who's interested, Here are the sites I used:

enannysource.com - good listings, good sample documents to use

care.com - utlimately the best site I found, I got a lot of responses from this site and found the spectrum of young and mature

sittercity.com - found most of them to be quite young and a lot of people who just want part time work

sulekha.com - the indian classified ads, people willing to work for good rates, good hours but most want cash

Others include: dcurbanmom.com; whitehousenannies.com

I would be happy to share many more pearls from the nanny hunt for anyone who's interested. For now, I'm just enjoying all the free time I have!

Are we over-snacking our kids?

I came across this great article in the New York Times about snacking. It's ironic timing for me as yesterday when I went grocery shopping, I was scouring the cookie/cracker isle for packaged, semi-processed, almost-healthy snacks I could grab along to the kids' activities. (Of course, I ended up with so many boxes there's no room for them in my pantry).

Anyhow, this article talks about the culture in American society that we now expect that there will be snacks for kids and adults at EVERY activity that kids do - regardless of duration. That instead of coming home and going outside to play, kids now come home and seek to satisfy their cravings. And because so few of these snacks are home-made, this must be contributing to the declining health of our youngsters.

I can speak for myself that as an internist, I worry a lot about the obesity epidemic in this country, especially among children. Yet when it comes to my kids, I don't think much about the QUANTITY of snacks, but I try to get the 4 food groups into the day, try to make sure there's at least one vegetable on the table at dinner and try to avoid purchasing processed foods from the grocery store. I think about the quality of snacks but I really don't' think much about the number of snacks. In fact, I'll be the first to confess that I use snacks as a way to get the kids into the car, out of the house, avoid tantrums ... really it's my most frequent bribe because I considered it relatively harmless.

I'm not sure I'll change my parenting style but this article has definitely made me think about it!

Things kids love to do with their Mothers...

As we make resolutions for the new year, I'm sure we will all be thinking about how we can be better parent, spend quality time with our kids and nurture healthy relationships in the family. I came across this wonderful article http://tinyurl.com/ybf43go with a list of the top ten things students around the world said they remembered and loved most about their mothers. It was reassuring to see that despite my craving to make ambitious plans for the year, it's the simple things they love. I thought I would share...

1. Come into my bedroom at night, tuck me in and sing me a song. Also tell me stories about when you were little.
2. Give me hugs and kisses
and sit and talk with me privately.
3. Spend quality time just with me, not with my brothers and sisters around.
4. Give me nutritious food so I can grow up healthy.
5. At dinner talk about what we could do together on the weekend.
6. At night talk to me about about anything; love, school, family etc.
7. Let me play outside a lot.
8. Cuddle under a blanket and watch our favorite TV show together.
9. Discipline me. It makes me feel like you care.
10. Leave special messages in my desk or lunch bag.

Private vs. Public School

My oldest daughter is 5 years old and her birthday is in December so she missed the cut-off to go to kindergarten this year. At first, I was disappointed that she would be 'left behind' for the year, but I soon realized this meant an extra year to be with her and one more year for her to be a kid.

Meanwhile, one of my goals this year was to understand the education system. I grew up in Canada where almost everyone I knew went to public schools. The school system from elementary, to junior high to high school, even including the universities in Canada are all about the same quality. There isn't the same diversity in quality of schools as there is in the US. Since moving here, I have heard all about 'magnet schools', the 'gifted track', and schools with 'bad test scores'. Until recently, I found all of these terms quite intimidating and insisted that I would blindly send my kids to public schools because I didn't want to complicate life. Trying to keep life simple is an over-arching goal I am striving for. Sometimes in contradiction, I have also been trying to make educated decisions, particularly those that affect my children.

Well...in the name of getting 'educated' about the school system, I now find myself drowning in the debate of whether to send my kids to public or private school. I have researched dozens of schools online, called at least a dozen and visited a handful of schools in the area. This search has taken hours of my time and at the end of it all, I have a host of new emotions - irritated, excited, frustrated, inspired, and very, very confused.

Here are some of the highlights of my search:
- Some schools you can triage over the phone. I called one school, which is a Montessori school, and explained that I was looking for a school for my 5 year old. The lady who answered spent the next few minutes explaining why my child was now past the ability to learn in Montessori style and why all other preschools were inadequate. Montessori was the better way to learn she said but it was too late for my daughter....thanks.

- My husband and I went to one of the elite private schools in the area and spent one hour on what I thought was a tour and what turned out to be an interview. We were amazed by the grounds and the facility but not so inspired by the way the lady was sizing us up the whole time. This was early on in the process, I didn't realize that they were vetting us as well and I knew we really blew it when my husband asked after the schools finances - she answered "I'll have the development team get back to you on that...." as she rolled her eyes. Knowing that it would cost us at least 1 Million dollars if we sent all 3 of our kids to her school, I thought this was a very reasonable question...but clearly she wasn't impressed.

Here's what we've decided. While the public school system in our area is generally speaking one of the best in the country, our particular school has one of the lowest scores in the county so we won't be sending our children there. If we move in the next few years (which we might) then we will gladly reconsider as there are many advantages to the public school system.

In the meantime, I will try to send my daughter to a private school. I say 'try' because unfortunately she needs to take an IQ test. Unfortunately, because these tests are not good at predicting future cognitive ability - they only test a child's current skills which means that 70% of future gifted children would be missed when tested at the age of 5...(this fact is courtesy of Nurture Shock - a book I HIGHLY recommend).

So if she passes the IQ test, behaves well on her trial 'day at the school' and the administrators like our application, then she will go to a private school that is affordable (more than Catholic, less than the elite), on the smaller side in numbers and not a Montessori :).

We would like to send her there for at least kindergarten, maybe Grade 1 and then we'll have to see...I'm not convinced that long-term private school is the right path - there are social, financial and academic implications that I still need to think through.

Would love to hear any other thoughts on this debate that I'm sure many have considered.

How I Spent My Maternity Leave

I am winding down from an extended maternity leave. I decided after having my third kid in April of this year that it was time to take some time off from being doctor, and focus on just being Mom. I am now in my 7th month and I have had a wonderful time. It's amazing how fast time has flown. I found a list yesterday that I made before I had my baby, of all the things I wanted to do in my time off. Fortunately, I have done most things on the list - the last thing on the list is to make a scrap-book for the kids, which I'm not sure will get done.

I spent most of my time being Mom - doing activities with the kids, thinking about their diets, their sleeping habits, organizing their toys and arranging play dates (most of which I could barely find time for in my juggling act prior to leave).

Over and above being Mom, I seemed to have gone through various phases during my leave:

The first couple months I spent in a post-partum state. Sleepy, emotionally labile, sensitive about my weight and just trying to establish new coping mechanisms with three kids. Fortunately, that phase seemed to go by quickly.

The next two months, while my baby was temporarily sleeping through the night, I spent most of my time on me - I worked out every morning, read a book, started a global health blog, established a presence on twitter, got involved in some volunteer work...yes, a busy couple of months.

The next phase was in the fall, flu season started and the baby stopped sleeping through the night. I spent at least one month again sleepy and this time driving to doctor's appointments or vaccine appointments all of which seemed to be inefficiently staggered.

Last month, I focused on doing research on schools (since my eldest will start kindergarten next academic year). I'm trying to determine my answer to public vs, private school and get to know the options in my area. I had been meaning to do this for the last year and I finally made this a priority.

Finally, in the home stretch, I am now interviewing for a full-time nanny. I've met at least a dozen ladies from all walks of life and have yet to find the right match. This process has taken much more time that I anticipated and after spending the last 7 months with my little one, I'm much more attached than I expected.

After deliberately neglecting my medical journals for the last few months, it's now time to dust them off and get reaquainted with the medical world. I'm nervous about all that I must have forgotten and all the patient follow-up that always follows me home. Yet, I'm excited to start being a doctor again - having spent so much time on myself, it will be nice to focus on my patients.

Admitting I need help

I recently let me my nanny of four years go, just after having my third kid - yes, I know it sounds crazy but I was having an identity crisis. I decided to take an extended leave from work to enjoy being 'mom' and I was sure that with the older kids (4 yrs and 2yrs) being in school half days that I could manage without help. I've always thought that I can do more than what's normal, in fact, now that I think about it, I think I define myself by being able to go 'above and beyond the call of duty'. Well, sadly I was wrong. I struggled through two months of life with the three kids and found myself tired, disorganized, snapping at my kids, craving time with my husband and over-using my Mom for help.

I've finally come around to the conclusion that it's precisely because I want to be a great Mom that I need help at home.

The challenge is not just finding one, but also managing one. I had a nanny for four years and despite my ability to manage difficult patients on an internal medicine ward, challenging residents in a large academic program and three kids with all different needs (well 4 kids if you count my husband), I find that it is the most challenging to manage my nanny. I realize now it has a lot to do with mother's guilt. I just do not want to see my nanny as an employee, a housekeeper or a babysitter. I want to see her as an extension of myself so that I can say to myself, that my kids are in good hands. For a long time I had a problem with the thought that the same person who would look after my kids would clean my bathrooms - so for a long time, I didn't ask my nanny to do anything but look after the kids. But this meant that when I would come home from work, I would do all the housework while she continued to play with the kids - something is wrong with that picture!
So as I now look for a new nanny, I have come to terms with the fact that firstly, I need help and second, that I need someone who will look after my kids AND my house. I met a family today visiting from Pakistan. The Mom had 3 kids exactly the same age as mine and she said she doesn't know how I do it - because where she lives, there is so much help - for the house and for the kids. She said, where she lives, it's easy to have three kids! After meeting her and after a long few months without help, I now can comfortably say that I need help with both my kids AND my home.

When EBM is not enough...

I recently had my third child (he's 7 weeks today) and he's a boy - which is a new experience since my two others are girls. Among the various new challenges (which include changing diapers - I've managed to get sprayed on more than one occasion) one unanticipated challenge is what to do with the vaccination schedule? Since my 2 older children are girls, I didn't really worry about autism - but now that I have a son, I find others are asking what I will do?

Well, I started to answer this question with my EBM skills - I looked up the evidence to support any change in the normal practice and of course, there is no good evidence right now. However, now that I have engaged my many Mom friends on this topic, I have heard many, many anecdotes of parents who are sure that a known case of autisum was related to the vaccines given all at once.

Next week, my little one is schedule to get 5 vaccines at once - 4 injected and 1 oral. With all due respect to EBM, while there's no good evidence to support any interventions, I've decided to give the vaccines over 2 visits, probably 1-2 weeks apart. I figure there's little to lose and possibly something to gain? At the very least I wont' have to sit there and watch him scream 4 times - on the other hand, I'll have to take a crying baby home on 2 different days...

Any thoughts on this issue?

The Challenge of Being Pregnant, Mom and Doctor...

It's interesting being a Mom, doctor and pregnant. I often have to choose which hat I'm going to wear to respectfully endure a situation.

Here's an example - my husband's grandmother (Ma) is visiting. She has a very strong personality. I love her and I'm absolutely thrilled that she is visiting, especially for my children. I'm pregnant and have now revealed that I will be having the boy who will carry the family name. (I'd like to believe this is an irrelevant point but given the generation gap, I'm pretty sure it contributes). Very soon after she arrived, Ma gave me a stern lecture about carrying my kids. I have a 2-year old and a 4 year-old. Neither 'have' to be carried but you all know how it is....sometimes they just want 'up' and sometimes you just want to carry them down the stairs because it's SO much faster. I said very little but she had a lot to say. "You're the doctor, you should know that if you carry too much weight, the baby will come out."

I should give more background - back in the day when she was in her 30's and 40's she was a midwife. She continues..."I saw many women who lost their babies because of placenta problems and stress on the body. You must not carry the children! Learn to say know and ask for help"

This is easier said than done. My husband is currently travelling for two weeks, I'm alone with the kids and it's virtually impossible to avoid carrying them for one reason or another. So I continue to carry them, only with the additional voice of guilt from Ma playing in my mind.

On the one hand, I want to respect her experience in life, she's lived many more years than I have. But the doctor in my mind is saying "nowadays, we have ultrasounds so I know where my placenta is and I'm really only putting my own back at risk which is a calculated risk in the moment!"

Perhaps if I didn't know better, I would be more worried about the baby, I'd ask more for help, or arrange for hired help and life would be easier? I can't decide if my medical knowledge is a blessing or a curse.

I've tried to respectfully tell Ma using few words that the baby is not at risk when I carry the kids but she still glares at me when she sees me holding my 2-year old even for a minute...Putting on my Mom-hat, I respectully put my daughter down and look around for help.

Round 3

I am a Mom of 2 kids and now soon to be 3....yes, I know it's crazy but despite the tough balancing act, my children are the best thing that has happened to me so we have decided to add one more.

It's been very interesting sharing the news of my pregnancy with colleagues, family and friends. The response I get is different for this third pregnancy.

With my first pregnancy, people were generally very excited for me. I was embarking into the world of parenting and people congratulated the decision and celebrated the novelty with me. I got lots of advice on how to manage the pregnancy and what to savour BEFORE the kids come.

With my second pregnancy, people seemed to react as though it was the natural next step. It was more a 'matter of fact' and parents with multiple children shared parenting advice on how to cope with the extra chaos.

With the third pregnancy, I find that the reactions depend on personal situations:

Those who are not yet married, or married without children, think I'm crazy to go for a third (they just can't relate);

Those with three children of their own celebrate the news and reassure me that life will just get better;

Those with two children (young and old) all recount to me how they came to the decision NOT to have a third, as if my news has made them revisit their decision;

And those with only one child feel the need to explain why they haven't yet had a second!

Ironically, even my husband has found the same trend in responses.

Regardless, we are absolutely thrilled and praying for a healthy pregnancy and baby and eager to hear any advice on going from 2 to 3!

Happy Thanksgiving!

First day of school

Tomorrow is my 2 year-old's first day of school. We're all excited, fortunately this includes her. As I was watching her today, she looked so little to be going to school. I wondered if I will look back on this phase of life and feel content that we started her in school so young (which is largely because of my interest in working) or if I will regret this decision and wish to have spent more time with her while she was young. Hindsight is 20/20 and I have terrible foresight so I really struggle with this.

My father-in-law once told me (regarding parenting) to remember that we know better than them. (he said this as I was struggling to force antibiotics down)...but I often recall this phrase. I know that my 2yr old will enjoy and benefit from the socialization and learning she will get at school. And most days I'm sure that even if I was home I would want her to go to school for her sake...but then I'm not entirely sure I'm being objective.

I guess for now, I'll enjoy the moment, her excitement to go to school and hope that when I pick her up tomorrow she has a smile on her face because it will surely make it harder if she's not happy.

Enjoy the moment

Having spent a few weeks off with my kids this month I feel renewed.

It has been an interesting time - My kids are 3yrs and 22mos so not quite independent, rather being with them is quite tiring. And while I still have to escort my 3 year old to her room several times a night, and my 22-month old has started having night-terrors...I feel ironically refreshed and rested.

It's because spending time with the kids requires me to be in the moment. They require my attention physically and emotionally.

Throughout my work day, I am usually multi-processing. Driving to and from work I am carefully planning how to use my time effeciently. While in a room with a patient, I am busy trying to cram their agenda in with mine while simultaneously typing their note. In between patients I'm usually checking labs while keeping a window open for my two email accounts...my usual routine is hardly restfull.

I'm not sure I need to do so much multi-processing, but from the time I spent this month at home with the kids, I am reminded of how important it is to enjoy and stay in the moment. I also feel blessed to have children to share these moments with.

I want to be a homer...

My daughter is 3 years old and in preschool. The class is split into those who go home after lunch "homers" and those that take a nap after lunch, "nappers". She started there when she was 2 and has always been a 'napper'.

We just came back from vacation, I was tucking her in bed and wanted to remind her that tomorrow was a school day. She says to me " Mommy, I don't mind going to school but what I really want is to be a 'homer'. " My heart sank. I try my best to make her wishes come true. I take days off when there's a field trip. I rush home when she says 'come early'. I dawdle in the mornings when she's feeling lazy...but being a homer...there's no way I can pick her up at 1pm...(I have clinic every afternoon). My mind flirts with ideas of switching - maybe I could work fewer days, maybe I should just work mornings and go completely part-time!

I might even consider any of the above options if it would be the end of the guilt. The reality is there will likely always be requests that I can't fulfill...the answer I think lies in my ability to get through the moment, listen to a pep talk from my spouse and hopefully see the big picture in the morning.

...for now, my 3 year old with remain a napper. Maybe I'll take an afternoon off next week and surprise her.

Love my job?...depends when you ask

This work-family balance is very tenuous. It's Sunday night and after a relaxing, fun-filled weekend with the kids I am dreading going to work tomorrow. I will miss them. Not to mention, I just sat down at my computer to 'check in' and am reminded that I have a ton of email to respond to, a ton of projects to keep moving forward and a busy week ahead. So as I sit here desperately trying to organize my life before the craziness of the week, I have fleeting thoughts of what it would be like if I didn't have to do all this, if I didn't work and if I could just kick my feet up and watch a little TV or read a book...(what I am convinced 'normal' people do).

...and yet I know that at around 2pm tomorrow when I"m in the thick of it at work, intellectually engaged, stimulated and satisfied after helping a few patients, I will feel content to be working and perhaps even excited about some of the projects with the residents. I will walk to my car tomorrow evening thinking about how happy I am with the balance in my life and how I would be intellectually bored if I didn't have my work.

...and then I will go home, play with the girls, cuddle them to sleep and wish again that I didn't have to wake up so early in the morning to go to work.