The kinder choice: Antibiotics editon

Believe me, I know how to put a kid in a headlock. When my oldest was 3, a positive rapid strep test sent me to the pharmacy to pick up amoxicillin. This was going to be easy, I thought. It tastes decent, the volume is small enough, and it’s only twice a day. My daughter was a precocious sort, easily engaged and reasoned with. But twice a day, for ten days, we would have a conversation that went something like this:

Me: It’s time for your medicine. We can do this the easy way or the hard way. The easy way is you take your medicine and then get a spoonful of ice cream. The hard way is we put you in a headlock and force it down.

Her: Hard way.

Me: Are you sure? You didn’t really like the hard way last time.

Her: I’m sure. Hard way.

So, twice a day for ten days, my husband and/or I would put my daughter in a headlock and force the syringe of pink bubble gum-flavored antibiotic into her mouth. We would hold and she would squirm and cry and scream, and somewhere after 2 cc’s or so she would yell – Stop! I’m ready for the easy way! And then she would calmly drink the rest and have a spoonful of ice cream. We did this 20 times.

Fast-forward 6 years.  My son is 3 and now he has strep. But he’s … different. He doesn’t understand the easy/hard conversation the way his sister did. His tantrums are louder, and longer. He does not recover from them as easily, and they can ruin his entire day. My son is not officially on “the spectrum”; there’s no label to why is he how he is. We are still in the process of figuring out how his (different) (amazing) (beautiful) brain works. The journey is both frustrating and heartwarming, and there is so much unknown. But one thing is clear: the headlock isn’t working.

I text my pediatrician and ask if she will administer intramuscular bicillin. She agrees, but doesn’t have it in the office. I call around and find a compounding pharmacy 45 minutes away that has it in stock. She calls in the prescription, my husband drives out with all the kids to pick it up (I am in the hospital on service of course), and then drives back to the pediatrician, who gives my son the shot. He cries a little, and we’re done.

As a pediatric hospitalist, I spend a lot of time teaching residents about prescribing antibiotics. We talk about cultures and sensitivities, about side effect profiles. We talk about mg/kg, a lot. The residents all know that liquid clindamycin tastes gross and that augmentin ES causes less diarrhea than the original. But one thing many of them still don’t understand is why any parent in their right mind would subject their poor innocent child to an injection (a shot!) when the same medication can be given orally. What I try to teach them, to illustrate to them, is that sometimes it’s actually the kinder choice.

It’s not the right call for every kid every time. For my son, I am confident that we made the right choice, the kinder choice. But every child is different. I encourage my residents to think creatively about their patients, to use the biopsychosocial model to help guide their management decisions, to be flexible in their thought processes and to always, always show compassion.

The great thing about kids, though, is that they grow. My daughter who had strep when she was 3? Well, she’s 9 now, and she just had strep again along with her little brother. And she squirted her own amoxicillin into her mouth every time, no ice cream required.

My ideal medical practice - I opened up shop!

House call doctor tools of the trade. I have since gotten another rolling bag.

Over the last few years I have slowly been inching toward establishing my own practice. And this January, I did it, I incorporated my practice, Healthy Home Pediatrics! It is a house call based concierge, or direct primary care, practice serving Washington, DC and the surrounding Maryland and Virginia areas.

In my first blog post as a new business owner, I wrote:

It feels so good to work hard for my own vision. For the last 5 years I have worked extremely hard for visions that were established by hospital administrators or the organizations that I worked for. Too often, these visions fell short of what I knew my colleagues and I were truly capable of and far short of what patients really wanted and needed.

During times like this, when I am venturing into the unknown, I often go back to one of my all time favorite books, The Alchemist, by Paulo Coelho. I have read this book countless times. In it, Coelho shares the story of a young shepherd boy who leaves home and goes in search of his dreams. Along the way he is tested and experiences both profound joy and deep disappointments. One of my favorite sections of the book shares a conversation with the boy, his heart, and the alchemist:

“People are afraid to pursue their most important dreams, because they feel that they don’t deserve them, or that they’ll be unable to achieve them. We, their hearts, become fearful just thinking of loved ones who go away forever, or of moments that could have been good but weren’t, or of treasures that might have been found but were forever hidden in the sands. Because, when these things happen, we suffer terribly.”

“My heart is afraid that it will have to suffer,” the boy told the alchemist one night as they looked up at the moonless sky.

“Tell your heart that the fear of suffering is worse than the suffering itself. And that no heart has ever suffered when it goes in search of its dreams, because every second of the search is a second’s encounter with God and with eternity.”

“Every second of the search is an encounter with God,” the boy told his heart. “When I have been truly searching for my treasure, every day has been luminous, because I’ve known that every hour was a part of the dream that I would find it. When I have been truly searching for my treasure, I’ve discovered things along the way that I never would have seen had I not had the courage to try things that seemed impossible for a shepherd to achieve.”

This is my dream. To practice medicine in the way that feels good to my heart, in a way that I know will help families and my community. To be unhindered by traditional systems such as hospital systems and clinic administrators. To collaborate directly with my patients and their families. To build sustainable relationships with families that help prevent disease and suffering. To be there for my patients when they need me.

Many thanks to KC and others for encouraging me and supporting me. A gentle nudge from her is what prompted this post. Even though it is scary, sharing such a personal detailed account on MiM, I want to share this new phase of my life because I have already received countless messages from colleagues, friends and family saying how much my business has inspired them to pursue their own dreams. I want to take you all on this new path with me. Let me know if there are particular topics about entrepreneurship and balancing work and life that you would like me to write about.

Thanks Mothers in Medicine for inspiring me!

Please follow my journey on social media:

https://www.facebook.com/pedsdrj

https://www.instagram.com/pedsdrj/

https://twitter.com/pedsdrj

What my toddler is teaching me about growth

In the last couple of weeks, my son has been learning to identify colors. Mama and Dada are bursting with pride that he's so verbal and learning new things so quickly (he's not quite two years old). For the first few days, he would try to identify a color and be right maybe ten percent of the time. When we'd gently correct him, his little brow would furrow for a fraction of a second, and then he'd try again. He's been persistent, and now a few weeks in, he names the colors of the flowers and the cars that we see walking around our neighborhood. And he's so excited when he gets it - just bursting with pride that he's learned something new.

I have a lot to learn from my son. He is curious and eager to learn, and he doesn't give up when he struggles. He's not embarrassed to admit that he doesn't know something, and why should he be? It's all new to him, and he's learning so much! He's having fun, even when he doesn't know the answer.

In just 7 short weeks, I'll be a brand new intern, and I will struggle. I will be wrong often. I will try my best and still fall short. Obviously, the stakes are drastically different for me than they are for him. But if I can approach the next phase of my training with half of my son's enthusiasm, joy and persistence in learning, I think I'll be ok. 

The critical first decade

I was at a conference a few weeks ago for rising chief residents. Hilariously, my husband (who had a few days off from work) decided to take advantage of the free hotel room and come with me, bringing out 20 month old. They had a lot of fun during the day, until he got a febrile URI and became a clingy mess. (Of course, then I felt guilty being wined and dined with the program leadership while he sat in the hotel room with a sick kid, but what else is new in Mom-land?)

But this isn't about that.

During the first day, the keynote speaker gave an address about carving a career path for yourself in academia -- life "after" chief year. He talked about the historic ideal of the "triple threat," where you succeed in teaching, research, and clinical time, essentially having a contract that allows you to spend 1/3 of your time in each area, adding up to a full time job. He reminded us, not so gently, that no one ever succeeds at all of these things, not as effectively as they could if they focused on one or two areas, and encouraged us to pick one or two when envisioning our future career.

And then he described the trajectory of a career in academic medicine: "The first decade is focused on establishing yourself, making a name for you and the research or clinical area you want to be known for. The second decade is to deepen that commitment to "your thing" -- publishing extensively, traveling, teaching, and speaking. By the third decade, you're known -- being asked to contribute chapters to books, leading courses with medical students, innovating as a clinic director. The fourth decade is a time to relax, to live in the space you've carved for yourself - and if you're lucky enough to have a 5th decade, you're an emeritus, enjoying the learning and not doing very much."

And as I sat in the audience, surrounded by future chief residents, I thought about how ~50% of us are women, and women who, most likely, will only be fertile during that first decade of our careers. What does that mean for the "most critical" decade of our work, to also recognize the very real demands that daycare and illness and doctor's appointments and soccer and pickups and dropoffs have?

Years ago, I once told a mentor that I thought that, realistically, this 10 years of my career would likely be my least productive, by publishing standards. I have a small child, I was planning on having multiple others. He was totally blown away, immediately shook his head, said there's no way that would be true, that he knew me and my work ethic, that lots of women "succeed despite kids." I left that meeting embarrassed, thinking that perhaps I shouldn't admit what I knew to be true - my partner works, too, and our lives have to adjust to the very real presence of our child.

This lecture was fresh on my mind when we returned from the conference and my husband went back to work. They've had some staffing turnover among the employees, and a new boss has been hired. Two leaders who currently work part-time (for various family reasons) were instructed that they would be welcome to sign a contract for next year in their current positions, but would not be able to work part-time - leadership requires a full time commitment. If they wanted part-time they could do a similar role, but without "a seat at the leadership table." This discussion among the staff at his job has been burning my brain ever since he told me - that two of the women (and, not-coincidentally, the only two mothers) on their leadership team were told that their commitment wasn't enough, that their desire to work part-time wasn't enough, that the hours they put in at night after their kids go to bed, and on the weekends, and in-between the other parts of their lives wasn't enough. I was in tears as he explained it to me, and I don't even know this women well - they work in another department.

I remember this keynote speaker, and I imagine the first decade of these women's careers. I suppose they didn't establish themselves, their credibility, their niche as clearly or as well as their male colleagues - that when it comes down to it, their skills are dispensable. The New York Times had a great article about this very topic yesterday - in short, that in heterosexual couples with children, employed mothers get the short end of the proverbial stick - faced with the demands of parenting and the ever-increasing demands of the work force, they end up forced to cut somewhere. For these women at my husband's workplace (and, realistically, for future me) - they cut back a bit at work. But working 25% less doesn't mean making 25% less, or being valued 25% less -- it means making 200% less, being valued 200% less.

I'd love to know reflections on your first decade at work, post-residency and fellowship and training. How did you carve out a niche for yourself? Or is that overrated in the first place? And what does it look like to parent when work is "greedy"?

Saturday AM coffee

The golden weekend begins

I wake up at 7:30 before my alarm. Approx 10 seconds of quiet uninterrupted bliss ensues when I realize I’m the only one awake. I can’t wait to make Saturday morning coffee. Then Dog demands to go outside.

While dog is outside, I read the last few page stories of the mystery I’ve been working on. Toddler fusses. I think “only ten pages to go” and Toddler falls miraculously back asleep and I finish my book.

Toddler fusses again. No coffee yet. Upstairs I find Toddler covered in poo including pieces in hair and hands. Apparently letting him eat that much pizza last night was a mistake. Toddler is protesting in the tub but much much cleaner 5 minutes later. I peek out in the hall for backup, turns out Husband heard the commotion and closed the bedroom door for a little longer sleep in. Hmph.

Toddler is dried out of bath. I sit him downstairs with yogurt and all is forgiven instantly. He smears his yogurt-covered hands through his recently bathed hair as I rinse the poo off of sheets, his pajamas, my pajamas and throw in the wash. Coffeemaker is finally started. I sit down with my own yogurt, which Toddler immediately realizes is different from his own and demands some. We share a little more yogurt.

Toddler gets spot cleaned, and I finally pour my cup of coffee.

It’s a beautiful day. Toddler loves being outside. Dog, coats, boots are collected and I spill a little of my precious “mom juice” on the floor. (“Mom juice” is my explanation to Toddler for coffee, wine, diet Mountain Dew, etc.). Clean floor. I go out thinking I might sit outside a sip some coffee, watch the commotion and listen to the radio. Coffee is a little colder but still tolerable. Spill some coffee on my old white worn fleece

I drag my chair to the sunny corner of the backyard, before realizing I have nowhere to put my coffee down. Coffee sits on little mud pile.Toddler decides he wants to rock with me on the chair, then by himself.  The ball is thrown to dog. Sip. Throw. Sip. Throw. Toddler gets stuck in his plastic car. Extract Toddler. Sip. Run around yard with Toddler and Dog. Sip slightly warm coffee.

Sneak inside to top off cup with warm coffee and grab Kleenex for Toddler.

Back inside. Laundry gets  done, clothes are packed and bathroom gets cleaned. Toddler finds the Swiffer cloths very interesting.. Now off to our parents for a weekend away.

I think I need another cup of coffee.

I can’t wait until I start my attending primary care clinic job this fall (yay!) and this becomes more of a typical than atypical Saturday (minus the poo).

Kicks

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.