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?

Mom wisdom: spacing of kids?

Hello mom-asphere,

I'm curious to get people's opinions/advice on spacing of kiddos. My husband and I have been talking about how close in age we'd like to have kids (and, since we're foster parents, we have more say in this than most people do!), and I've of two minds -- I see a lot of benefits to having them be able to be friends and playmates for each other, very close in age, but I also think there are practical perks to having a 3-4 year old who can entertain themselves (albeit briefly) while you're busy with a newborn.

Professionally, I'm also curious - does it seem to make more sense to have 3-4 unproductive years, professionally, rather than draw it out for 7-8 years of really small kids, when probably publishing/etc is more challenging?

What worked for you?

I Am Kristie Reynolds

A little snippet of a recent email

At work, I go by Dawn Baker MD, MS. But at home, I’m sometimes known as Kristie Reynolds.

I don’t mean to give away my husband’s “Wizard of Oz”-type work secret here, but I will elaborate for the sake of this post. I highly doubt any of his clients are reading anyway. He has his own law firm, and a while ago he came up with the idea of creating a dummy admin email address for sending unpleasant or mundane emails, like reminding clients to pay their bills. It preserves the professional air of his one-man law firm and also allows him to not be “the bad guy” when it comes to collections or deadlines. It’s genius, actually. The admin’s name that he fabricated is Kristie Reynolds.

Well, Kristie has also started ordering (and apparently picking up) coffee beans for our espresso machine, and facilitating document exchange, and she recently became the voice for the firm’s voicemail greeting. Her duties have grown to the point where sometimes she is now required to perform these transactions in person. Guess who gets to be her?

It’s got me thinking about all the other roles we take on in our lives. Besides “Doctor” and “Kristie”, I’m also “Moo” - my husband’s longtime term of endearment for me. Of course, I’m now also “Mommy” - a name I’ll never get tired of answering to. And while these personas don’t have particular names, I’ve also been known at home as a cleaning lady, a driver, and a short-order cook. To my parents, I'm Daughter and Doctor; yet, they still rarely take my advice. Lately, I'm working more on blogger/entrepreneur as well, trying to grow and expand my personal blog (which means I'd better write more)!

Who are you outside of work? What are you known as besides "Doctor"?

“Pumped” in JAMA

I was at our block education the other day when one of my male co residents asked me, “Did you read the JAMA reflection piece from Sept 11?” (answer to this is always no, my JAMA sits on my kitchen table where it’s main purpose in life is to be an excellent spider squisher). When I said I hadn’t, he took his issue out of his backpack and gave it to me.

If you haven’t seen it, the article is called Pumped by Dr. Charlotte Grinberg. (Article here). It is a fantastic reflection on pumping during intern year and like most reflections on pumping I identified with it so much. I almost cried when *spoiler alert* her freezer broke and she lost her stash. And cheered at the final couple of paragraphs.

I am so happy to see this in JAMA. My coresident told me - “I read it and thought of you guys”. I’d lately been fielding comments like “I wish I got a twenty minute break in my clinic schedule!” so it was great to hear something more affirming. I suppose my male coresidents are less likely to be reading blog posts on mothersinmedicine.com so I’m hopeful this will bring more discussion and more advocacy to pumping residents among the non pumpers among us.

Re: my own pumping journey - baby is 11 months and we have almost made it to a full year of exclusive breast milk due to the combination of ridiculous pumping sessions, learning to advocate for myself, a lot a lot of luck, and a pretty supportive work environment. Cant wait to celebrate his one year journey by temporarily retiring the Spectra. 

Lift Those Weights, Ladies (and Let Your Patients Know!)

Genmedmom here.

I am officially closer to 50 than 40, and it shows.

If I didn't hear it all the time from my patients, I would be complaining: "I'm exercising the same and eating the same, but I'm gaining weight... around my middle!"

Yup, it's that middle-age middle-gain. Horrified that this was happening to me, despite having lost fifty pounds after two AMA pregnancies and religiously maintaining a healthy diet and exercise routine for years, I decided to fight back.

How do Type A M.D.s fight back? The evidence, baby. I hit the books big-time. My reading and research into this area have led to a newfound passion: Lifestyle Medicine. Everything from my personal life to my primary care practice to my writing has been impacted. I've even got a book coming out in December.

Back to the battle of the bulge. I learned all about sarcopenia, a well-known physiologic phenomenon of age. We simply lose muscle mass as we get older-- and women basically hemorrhage muscle mass around menopause. As we all know, muscle burns calories just by existing. When we lose muscle, our metabolism plummets, and we gain fat. Hence, that perimenopausal pudge.

This process, left unchecked, can lead to sarcopenic obesity: high adiposity coupled with low muscle mass, which is often associated with a deceivingly normal body mass index. 

There's more to it, of course. Sarcopenia is bad for so many reasons. As one Cambridge University Press research review points out, "Sarcopenia, the age-associated loss of skeletal muscle, is a major concern in ageing populations and has been associated with metabolic impairment, cardiovascular disease risk factors, physical disability and mortality." 

I was thrilled to see this topic covered in wonderful detail by Jane Brody, writer for the New York Times, in this and this article. She provides a wonderful review of the literature and expert opinion, along with some good suggestions. As she correctly points out, "few practicing physicians alert their older patients to this condition and tell them how to slow or reverse what is otherwise an inevitable decline that can seriously impair their physical and emotional well-being and ability to carry out the tasks of daily life." It may be that few practicing physicians are fully aware of how big a deal this is. I wasn't!

A review in the Journal of Family Practice describes sarcopenia as a known major cause of debility and frailty, but highlights that it can be effectively prevented or treated with a healthy high-protein diet and resistance training. 

And it's true: when we gain muscle, our metabolism increases. The more muscle we gain, the more fat we lose (and we can even tolerate a little dietary indiscretion). There's endless benefits to toning that muscle: a stronger core prevents back pain and protects against back injuries. Increased strength prevents falls and protects from injuries if falls occur. Strength and mobility promotes the ability to manage ADLs and extends independent living. 

For all of these reasons, I've taken up a simple resistance training regimen. I have zero time to be consulting personal trainers (who here can make any appointments and keep them? Not me) so I created my own plan, including a few key pilates moves I learned over the years, and alot of basic exercises using a pair of five-pound barbells I've had since literally 2005. That's it. Sometimes I'm on a yoga mat, sometimes on my daughter's rug (it's the softest one in the house). This routine takes me all of ten minutes, but has yielded visible results in four weeks. 

On the days that I have no time, I at least drop and do ten planky-pushups, meaning I hold the plank position between pushups, and aim for ten. I sometimes do this right before bed, and typically, this move leads to a few other basic yoga stretches that really help ease me into sleep. 

When I counsel women my age, I usually advise that they seek the advice of a trainer. Some women are former athletes and know their way around the weight room, and need only be educated, and then they're off and running. For elderly folks, especially those with prior injuries or who are really very frail, I recommend the official guidance of a physical therapist, with specific goals like "increased core strengthening and balance exercises for falls prevention". 

I know there's physical therapists and physiatrists and orthopedic surgeons in this audience, and I welcome your input. What advice do you provide to patients around sarcopenia and sarcopenic obesity? What training regimen do you follow? Any tips appreciated! 



Photo by Cyril Saulnier on Unsplash

Residents Who Pump

How to succeed with pumping as a resident:

I am an intern in a busy internal medicine program. I try to pump several times a day. At first, it was very challenging for me to balance pumping and being an intern. I hope I can shed some light on how it can be done and let other moms know that that I once struggled with it too. It is part of who I am now, but it took a lot of commitment and preservence. I know not all mothers choose to pump and not all mothers can pump, and that’s great too! This is how I do it. I will first say that I have an incredibly supportive residency program. I hope that is the case for all mommas wanting to pump.

1. Make it known that you have to pump. Be upfront about it with the chief residents, senior residents and your co-interns. This way, people don’t wonder where you are. You’d be surprised how many people are supportive of your need to pump. And impressed!

2. Plan your day accordingly. I would make sure to get a session in before rounds, during lunch conference and once or twice in the pm depending on the length of the work day. It requires a lot of planning but think ahead! There have been times when rounds starts earlier than expected, but some time pumping is better than no time!

3. Have a system. Efficiency is key. A handsfree clip on bra helps! A tote bag with a cooler and ice pack helps! Find what works best for you.

4. Have a safe space. A designated pumping room with an outlet, sink, chair, table is what you need. Find a way to get the environment you need. If your facility does not have a lactation or expression room, they really should! It is required by law. Check out mamava.com if you want to help your hospital get a pumping pod.

5. Support at home. My husband helps out so much with washing my pumping bottles and preparing our baby’s bottles for daycare every night. I couldn’t do it without him.

6. Prioritize pumping. There will be times you think you’re too busy to pump. Do it anyways. Figure out a way. You’d be surprised how you can squeeze it in the workday. You’ll be so glad you did it.

7. Try your best not to skip sessions because it can mess up your supply, cause engorgement and even mastitis. This may not be true for everyone, but it was true for me. After I got mastitis from missing pumping sessions, I knew I had to be more diligent about pumping every 3-4 hours.

8. Massage/squeeze during pumping! This helps prevent clogged ducts and really increases the flow.

9. Drink lots of water and carry snacks. You have to be well hydrated and well fed for a good milk supply. Also rest is key! Good rest is hard for an intern but the more rested you are the better the milk supply!

10. Be so proud of yourself. It is a huge accomplishment to be able to pump and be an intern! Some days you’ll have a bigger supply than other days but keep going! You’re a rockstar for doing this and your healthy baby will thank you!

11. Nights can be particularly hard but doable. When I was working nights, I was so exhausted, mainly because I was unable to sleep more than a few hours during the days because I was still pumping every 3 hours. It was very hard, no other way to say it. I even got mastitis then. I was fortunately allowed 2 sick days so I could heal from my mastitis. In addition to taking antibiotics, my trusted lactation consultant advised me to just keep on pumping even if the output is low and as soon as I recover, the milk supply will pick back up. And she was right!

If you’re also a pumping resident, please comment and let me know your experience!

The myth (?) of flexibility

I had a job interview last week, in an odd surprising way, with the medical director of a local system of FQHC medical clinics in our town. It was surprising in that I was on a rotation providing medical care to homeless patients out in a park, working with one of the doctors in their practice (who, interestingly, is actually on staff as their street medicine attending, which is pretty cool!) -- and this attending came up to me, and asked if I wanted a job in their clinic system,

What did I say? "Oh, goodness, that's so kind of you. Umm."

Sometimes, I hear myself fulfilling a female stereotype and I want to punch myself in the metaphorical nuts.

Once I collect myself and act like maybe I deserve having a job, given that I'm a pretty good resident, a rising chief, and would actually be a great fit for their clinic, we make an appointment to discuss it in a meeting in his office later that week.

I agonize over what to wear. Is this a job interview? I'm also caring for homeless patients in the park that morning - it's 95F and 90% humidity. I wear a silk shirt, and by lunchtime, it's slick with sweat and stuck to my back. My curly hair is an untamed frizz ball, and I have to bike 4 miles to the clinic where his office is located. Suffice it to say, I look great.

We had a lovely conversation about what I think I could do for their practice (Adolescent methadone clinic! Expand their home visit program!), but when he asked what was important to me, all I could think about was flexibility.

Being a resident is one of the least flexible jobs I can imagine (though I've never been in the military, which is likely even more rigid). Your schedule is given out to you a year in advance, it's incredibly difficult to get out of shifts for your own illness (or your children's many illnesses), you don't get to choose your own vacations (which is hard for those of us whose partners are teachers, or with kids in school), and when you're there, you need to be 100% all of the time (which breastfeeding mom hasn't been paged for an urgent need while pumping?).

I dream sometimes about a job where I could work full time, but with flexibility - in fact, I've drawn inspiration from some of the schedules of writers on this blog, who have Tues/Thurs afternoons off (I could volunteer at preschool! I could go to the dentist!) or do fun volunteer work on Mondays all day, or get to (gasp) do some research working from home. I want to be productive, I want to be part of a million different things (I wouldn't be Med-Peds if I could make up my mind!), and I want to work full-time, but I'd like some agency over what that looks like.

To this, the medical director responded, "Well, we're open to being flexible. Lots of young mothers want to work part-time."

I'm frustrated that we live in a society where wanting to work ~50 hours/week is seen as wanting to work part time, or that not wanting to drive in during the middle of the night as an interventionalist means you aren't committed to medicine, or that if you have children you can't be a productive educator and researcher. And I'm frustrated that wanting to work part-time is a thing "young mothers" want - working part time sounds amazing, sometimes, and I have no judgment for moms that do it -- but couldn't dads be interested in that too?

I just want to not always be the first to drop my son at daycare and the last to pick him up. Is that inconsistent with being committed to working full time?

Bipolar

There is a patient that has been on my mind this year.

I was fired as her doctor.

I have had two patients fire me. The first was a sweet little old lady with mild cognitive impairment that wasn’t too cognitively impaired to realize I was moving in on her drivers license and switched to another clinic. She sent me a card though letting me know she switched clinics, wishing me the best and left me a teddy bear for my baby. The second one was much tougher. It was definitely the toughest initial OB visit I’ve ever had. I was in there over an hour. She was a mom with 9 kids at home and a partner who was controlling and emotionally abusive. She was late onset to prenatal care and came in maxing out the anxiety and depressive scales in the office. She was basically the sole caretaker of her kids, and worried constantly about things like if she passed out in the tub, who would take care of her kids? We talked a lot and luckily I had a no show following her. I thought we were developing a good rapport when she told me she had worked for 3 days straight without sleeping at a huge event downtown. On further discussion, I found she screened positive for possible bipolar disorder. I patted myself on the back for being a good primary care doc and sent her to psychiatry for further evaluation.

She missed her psychiatry appointment, but occasionally made it back to see me.

We left a lot of our appointments frustrated - most of her problems were so complex I wanted to refer her out multiple times, but she had trouble with transportation to our specialists and finding someone to watch the kids at those times, so they never happened. Every time she came into the office and we tried to fix one problem, three more would pop up. She was taking illicit prescription medications for chronic back pain and smoking marijuana, and was frustrated I wouldn’t prescribe her buprenorphine without a referral (our clinic wasn’t doing buprenorphine at the time) and I was frustrated she wouldn’t consider psychiatric medications for her fear of harming her baby, yet continued to smoke cigarettes, marijuana, and use the pain pills. She was frustrated at me because all I could offer was Tylenol and more referrals.

I bent over backwards for her. Our OB coordinator pulled strings so we could have 40 minute appointments together - which is something I have never done for any other patient. When she wouldn’t go to specialists, I would call them on the phone for recommendations. I was prepared to put her on lithium at one point with the guidance of a perinatal psychiatrist over the phone.

She fired me because she didn’t think I was doing anything for her chronic pain, and because I was always kicking her partner out of the room to ask if she was safe. She told our OB coordinator she didn’t care who delivered her baby as long as it wasn’t me. I found out later that she delivered at a different hospital system, and as far as our OB coordinator knew everything went well.

I was her doctor before I had my baby. Since then, I think of her every once in a while when I am overwhelmed by working and taking care of one little peanut with a supportive partner in the house. I think about our discussions of her working days on end without sleep - although that might go along  with a diagnosis of bipolar disorder, I also wonder if I was pathologizing her motherhood and what she had to do to support her family. I think about her inability to make appointments and her worries about what would happen to her children if she was gone. I think about what it must be like to have to choose to stay with a nasty partner who will provide at least some financial stability and a house for all your children versus turning to a system that will assuredly break your family apart in an attempt to provide safety and security.

I think of her often, and wish her the best.

Kicks

Recovery

After recovering from the the good kind of pain at the end of November last year, I developed the plain-old kind of pain that is in no way good: an intense, searing pain of a likely cervical radiculopathy that prompted me to go to the ER one fine December Saturday after leading a children's Nativity re-enactment rehearsal. My neurological symptoms were getting increasingly worse, as was the pain, despite stopping running completely for weeks, sparing my right side from any kind of lifting or serious use, taking around-the-clock high dose NSAIDs, and even wearing a lovely soft cervical collar for a week (fantastic way to garner sympathy and/or jokes from colleagues).

The ER physician assigned to me was an older man who showed absolutely zero empathy, compassion, or patience. You know when you can feel someone's impatience with your history-sharing, who just wants you to get to it? I told him I was a physician - not sure whether his bedside manner was because of that fact or in spite of it. I had plain films done showing cervical degenerative changes (I had never felt quite so old) and his plan for me was a) switch to naproxen from ibuprofen; b) reassurance that it would get better (delivered by someone without a compassionate approach, this felt tin-hollow); c) follow-up with PCP the next week. This felt like a wholly inadequate plan to me. I suggested a medrol dose pack which he agreed to.

The medrol dose pack was a temporary godsend. It worked within a day to drastically improve my pain. It was amazing! I felt almost normal again. Once the pack was done, though, the pain returned, in some ways worsened. Dealing with this pain - chronic, unclear end date - was humbling and deeply frustrating.

I have always thought of myself as a physically strong person. This has been part of my self-identity. On the playground, I used to win arm wrestling matches against boys. In high school, I was a cheerleader "base" and held girls' feet on my shoulders and bench-pressed them until my arms were extended. (If I did that now, I'm sure multiple discs would herniate simultaneously. Actually, maybe that's why my neck imaging looks the way it does.) This injury, occurring after no single traumatic moment upended that self-image. For awhile, during the worst of it, I cringed as my seven year old came in for a hug from my right side.

After a lot of physical therapy and time (probably most important), the pain lost its hard edge and now has settled to a stiffness and soreness that I don't always notice. A couple of months ago, I started running gingerly again, and a couple of weekends ago, I ran my first race in almost a year. It felt like it usually feels constitutionally-speaking: horrible during, fantastic afterwards, and I'm ready for the next one.

I'm grateful to be mostly recovered. I have new appreciation for those with chronic pain. And most importantly, I'm running again and feeling like myself.