Lovely Sam

 

 Photos by the one and only Marcy Hogan.

Scarcity

I live in pretty much perpetual motion.  I am constantly running through the "to do" list in my mind, calculating what I can get done in the next minutes, hours, days.  Some of this is survival for a mother of two and med student.  Shit needs to get done!  And some of this is just a reflection of what I enjoy: a clean home, adventures, outside time, physical activity.  But I think there is a touch of discontent there.  I feel like I am wasting precious time if I am not ticking through my list.  I find it nearly impossible to just sit down and enjoy quiet time chilling with my kids or husband.

I've read a couple of articles recently that have inspired me to reflect on this feverish busyness, and more so, the sense that sometimes overwhelms me that everything is scare.

The Busy Trap
Parenting with Abundance
The Sliver

I notice myself thinking that there just is not enough time to do what needs to be done, that we must be thrifty and not let the bathwater run too long and we must clean our plates and save everything because WHO KNOWS WHEN THE FLOOD MIGHT COME!  Really, this is a crazy way to live, and to parent.  So I am trying to pay more attention to how this vision of scarcity influences me.  I'm also trying little interventions to foster more a sense of abundance and embracing the quiet moment I am in, without rushing off to get something else done: forcing myself to just sit and play trains with Sam or watch Ethan as he plays his videos games; holding my tongue when the words "wasting time" start to bubble up, especially as we get ready to go in the mornings (late as usual); closing the computer screen to just sit on the couch for a while with Jeremy in the evenings.

In fact, I'm going to try that last one right now...

The Complete Physician

In the weeks before the match we took part in a very thoughtful course centered around the idea of the "Complete Physician".  The course involved advanced clinical skills training (advanced CPR, review of emergency management, some basic ICU lectures), lectures and discussions on relevant topics (anti vaccine movement, teaching medical students, emotional resilience in medical practice).  To cap it off, we wrote reflective essays on the experiences that have shaped us in becoming physicians and how we envision ourselves moving toward completeness.  It feels super vulnerable to share my writing here on the interweb, but somehow important too.

Here's my essay:

Respect and Shame

In my third year family medicine clerkship, I saw a working mom of two whose weight and blood pressure had been steadily creeping up over the years.  When I mentioned it, she began weeping.  She felt deep shame for not being able to lose weight.  At the time I empathized with her about how hard it is to lose weight and focused on brainstorming small changes in diet and activity that she might be able to stick with.  But the more I reflect on this encounter, the more layers of complexity that I am able to appreciate, beyond just how hard it is to find time to exercise!  There is the belief that obesity is a moral failing and a mark of sloth and laziness, nothing if not disgusting and shameful, reinforced again and again in potshots taken at obese patients in med school lectures and behind their backs on the wards, and in every facet of media.  Most of the time these messages are so well integrated into the background noise that I don’t even notice them.  With effort, I am trying to notice and to think about how I can do it differently, celebrating “health at any size” and respecting my patients, even when they are out of earshot.  

There is also the issue of shame in general.  Shame does not galvanize us to change.  It paralyzes us, full of ugly thoughts about ourselves.  How could this patient start to change when she already felt that she had failed?  I have felt the hot wave of shame wash over me so many times in my life: every mistake on rounds, every time I lose my temper with my children.  As I go build my practice, I do not want to contribute to shaming my patients.  This seems a particular betrayal when patients offer themselves to us with so much vulnerability and trust, literally undressing in front of us and telling us secrets about their bodies and their lives that they tell no one else.  I want to use that intimacy to help them grow and heal, appreciating the complexity that governs their actions (and mistakes) in the world, not judging them for their shortcomings.  Likewise I am trying to cultivate a respect and generosity for myself, so that thoughts of inadequacy do not get in the way of me growing into a more capable physician.

Patient Autonomy

Parenting my children is one of the most powerful influences on my development as a human being and as a clinician.  I will spare you the details the baptism by fire that parenting my particularly wild child has been, but I will reflect for a moment on both children’s birth stories.

My best friend was the midwife for the birth of my first son at home, one year before I came to medical school.  At the time, everything seemed to go so smoothly from my perspective.  Not a cookie cutter delivery, with my pregnancy approaching 42 weeks, ending in an off and on labor that lasted for 5 days, capped by a full day spent hanging around at 8 cm thanks to an asynclitic presentation, but he came out safe and sound and then I ate the most incredible enchiladas known to man.  No big deal, right?  Looking back with better trained eyes, I see that there were many places where my care could have taken a very different turn, with much more intervention.  But my midwife believed in my ability, in the normalcy of birth, and also understood that I favored a less is more approach.  While it felt like I just cruised along and did it by myself, in reality she was busy “actively managing” my delivery without me really noticing.  She is a role model for me in supporting patients to do the work of giving birth, or getting healthy or parenting their kids or whatever the task at hand is, offering expertise and intervention when necessary, but letting the glory fall to the patient.

Fast forward 4 years to the birth of my second son, which involved different midwives and a transfer to DHMC (eek!).  Being cared for by the very same residents and attendings that I had rotated with with an unnerving experience.  And my skin crawls when I think about the comments I’ve heard about homebirth during my training, and imagine what they had to say about me at the nurses station.  My labor was not too complicated (a little pitocin and we were good to go) but I sure felt like I had stepped onto a train that was clearly not conducted by me.  Despite being a strong advocate of homebirth from the start (indeed, I was born at home) the experience of a hospital birth really helped me to clarify what is so stunning about homebirth.  It is not the soft lighting or familiarity of own’s own home, though that is lovely.  It is the fact that the whole care team is completely centered around the patient and driven fundamentally by the belief that the patient gets to decide what happens to her, that she is in charge of her own body.  This is what I wrote about it at the time:

“What matters most to me is this: Being treated with respect and reverence.  Having providers that are not blinded by protocol and are open to doing things many different ways, whatever way is working for mom and baby.  A real appreciation that intervention may cause harm.  Being able to trust that when intervention is used, it is done so wisely, out of necessity.  Being the most important player in my own care, not some bystander that comes along for the ride.”

As I put my nose to the grindstone of residency, I wonder how I will keep my eyes open to the question of patient autonomy.  Will I just charge ahead with the algorithms that I have memorized, or will I be able to see and adapt to the unique person in front of me?  Will I take the time to counsel my patients about risk, instead of just prescribing a particular intervention?  Will I ask them what they actually want?

Choosing Family Medicine

I am going into family medicine in part because I think it is a specialty that really values knowing patients well and will help me to develop the patient centeredness, with a focus on respect and autonomy, and the deep relationships that I think are so important.  But my motivation in choosing family medicine is about more than my own enjoyment and what I think I can gain from training in this particular field; it is about social justice and societal need.

In third year, I was asked again and again: “What do you like?”  I could answer that question easily.  I loved inpatient medicine which is so interesting, with so much depth and acuity.  I loved outpatient too, the pace, the ability to form relationships over time, being the first contact for undifferentiated patients.  I liked variety more than one narrow specialty.  I’d rather talk to my patients than do things to them.

It wasn’t until the dust of third year settled and I had some time to reflect that I noticed what questions hadn’t been asked:  “Where are you needed?” and “How can you best serve your community?”  I do not think anyone should be forced into a specialty that they do not enjoy, but the need for primary care docs and the huge inequalities in medical care are undeniable.  If students are not given an opportunity to think about these issues in the context of specialty choice, if no one asks them to think about what patients and communities need in addition to what the student enjoys, how can we hope to meet that need?  We need some help to see the larger context that we fit into.

After deciding on primary care, I struggled over internal medicine vs. family medicine.  I ultimately felt that the breadth of family medicine would put me in a better position to meet the needs of an underserved community.  Need an ultrasound, a joint injection, a biopsy, a visit for yourself and your kids at the same time?  No problem!  Again, it was less a question of what I like (although I do like procedures and variety) but rather a question of societal need.

Another factor for me in residency choice that surprised me was prestige.  I don’t think of myself as someone who is swayed by prestige.  I take pride in being from a working class family.  My mom never went to college and my dad worked two jobs throughout my childhood.  But it sure felt like I was giving something up when I chose family medicine.   At first it was difficult for me to name my hesitation.  I wasn’t sure why FM looked so unsexy, why I was clinging to the ivory tower, what made the idea of training in internal medicine at some Ivy League program so appealing.  But I have clearly been subject to the influence of training at an elite academic medical center, which is driven by specialties and pitches itself as the pinnacle of care.  I have come to associate certain specialities and training at certain institutions with super smartness, high achievement, garnering respect and reverence everywhere you go.  To step away from that, to give up an imagined prestigious career to train in a community program and take care of poor people’s everyday complaints, requires letting go of some measure of prestige and social status.  I have had to be honest with myself about this rather embarrassing desire of mine to be any Ivy League superstar.  But I hope that seeing this for what it is (the siren’s song of prestige) will help me in letting that go.  Because ultimately, my most dearly held values do not put my own glorious career over taking great care of patients who need it most.  When I think about what is most important to me, service overshadows status.  

Seeing Clearly

One of the abilities that I think distinguishes an expert from a novice is the ability to see what is in front of you.  I remember that it took months of living abroad before I could reliably distinguish tea house from corner store from pharmacy.  With a different language and script, different architecture and unfamiliar products, I had to work hard to appreciate what I was looking at.  My husband is a gifted observer.  After a movie, I look forward to him explaining to me what we just saw.  It amazes me that he can see so much: the unusual long shot, the jump cut in this scene, the absence of music in that scene, the blue lighting, the allegory in the plotline.   It is like we are watching completely different things.

This applies to clinical medicine too.  Being able to recognize the physical findings, to hear the script in the story is key to diagnosis.  I remember the first time that I actually noticed that the patient I was interviewing was pausing for breath after every few words: an important clinical sign that I had certainly seen before but never really noticed.  It is this ability to see and hear more clearly, with finer granulation, that I strive to cultivate in my career.  Not just in my direct observations of the patient but also in my ability to appreciate the interpersonal interactions, the systems of care, the larger social and global forces at play.  My values are pretty clear (service, respect, autonomy, excellent clinical skills, joy, taking time to play with my kids), but I think my work is to look more closely at how my actions align with those values in everyday clinical practice.

This is my vision of myself as a complete physician: looking closely at my practice and probing for the deeper meaning and significance.  Getting better and better at actually seeing what is in front of me, and as I see the implications of my actions more clearly, taking steps to align my practice with my values to provide the best care possible.    

The Magic Madison Match

Last Friday I matched for residency at the University of Wisconsin Family Medicine program! We are delighted to be going back to such a wonderful and supportive community in our old, familiar Madison.

 During the residency interview process I poured over every pro and con of the programs I visited: community vs. academic program, number of residents, number of OB deliveries ( I prefer less), emphasis on care for the underserved (I prefer more), frequency of interpreted visits, pediatric volume, location, reputation, presence of residents in other specialties, open vs. closed ICU, etc, etc.  In the end, what seemed most important was being in an affordable city full of friends, with good schools for Ethan, rugby for Jeremy and a program that really takes care of its residents.  Madison wins on all counts.

Match Day was wildly emotional with anxiety, excitement, relief, joy, disappointment all in one busy afternoon.  We left the kids with a babysitter.  (Great call! Not dragging my kids to everything I want to do is my new mature mommy move.)  After some silly med student video skits, mingling, and laughing nervously, the Match Day ceremony proper began.  At Dartmouth this involves being called one by one to the front of a very large crowd, receiving an envelope containing your secret match information, and (if you are brave/extroverted/swayed by peer pressure) you open it up and announce your match via microphone to everyone and their mother.  I was almost the last one called and got so distracted by all the excitement around everyone else's match that I almost forgot to be nervous about the contents of my own mysterious envelope!

 I admit to feeling a little out of place and lonesome on Match Day, as I added a year to medical school and thus I don't know this class of graduating students very well.  I felt a little like I was crashing their party.  Also, there were tons of super elite Ivy League matches, and I felt (in the true Wisconsin sense of the word) different for choosing Family Medicine training at a public, midwestern school. A bunch of folks didn't know if they should be happy or sad for me!  Fortunately I have a small but solid crew of excellent colleagues going into Family Medicine and I had my family and some good friends there to back me up.  Jeremy was all smiles after we matched.

Now it's on to house hunting, packing, cleaning, purging, and trying to squeeze in as much New England goodness as we can before the move in June.