Mind the gap ~ by Jay

The gap between posts, that is.

School starts next week, which means this week we have 1) filled out multiple forms with the same information 2) discovered that our daughter will not have the teacher she really wanted and will not be in the same class as either of her two best pals 3) chosen not to fight the don't-wear-your-school-clothes-before-school-starts battle 4) refused to buy more new clothes that were requested because the old new ones have already been worn and are therefore not actually new 5) realized that she still has to write something about six books on a form we must have put in the recycling at some point last June.

Plus she signed up for two dance classes and she wants to take piano lessons, which means I need to figure out how to get her to and from said lessons once I find a teacher, and did I mention I'm working full-time again? which means that Sam and I had to renegotiate the drop-off and pick-up balance. Plus she needs new ballet shoes and tap shoes, plus some sort of leotard but we don't know yet if it will be the black leotard/pink tights or black/black or pink/pink.

Plus it's about to be Rosh Hashanah. Which means I have to learn the Torah portion I'm chanting and write something about how my home is a Jewish home (I'm sorely tempted to say "because we're Jewish and we live there" but I think more is expected of me) and I am chanting Kol Nidre again this year and have to rehearse with the accompanist(s?) next week.

This is Elul, the month before Rosh Hashanah, a time when Jews are supposed to reflect on the past year, ask forgiveness from those they have offended, and prepare for the season of teshuvah, (renewal and repentance). Yes, it's something like a searching spiritual inventory. The irony of modern life: I am commanded to be reflective during the month when I barely have time to sleep.

First do no harm ~by Jay

"Any other pregnancies?"

Such a simple question. She was cuddling her five-week-old, happily describing how much help she had from her ten-year-old daughter. I could tell as soon as I asked that the answer wasn't so simple. I could tell from the look on her face, from the hesitation as she answered me. I have learned to identify the body language of loss. I made sure I wasn't clicking my pen, or tapping my foot, or in any other way expressing impatience. I waited quietly, openly, and after a minute she said "Well, I had an abortion a few years ago. And I pray every day to God to forgive me".

I'm used to that, to women who believe the messages that they have failed themselves and their God by making this most difficult of choices. I'm used to hearing about the grief and guilt and the tears that show up every year on the day the baby would have been born. And no, this doesn't happen to every woman who has an abortion and no, it's not "post-abortion syndrome". It's the logical result of a traumatic experience brought on, at its root, by a cult of motherhood and femininity that serves the patriarchy by demonizing women. I hate it - I am sickened by it - but I'm used to it. It was her next comment that stopped me cold:

"My last doctor told me I shouldn't tell anyone that, even a doctor. He said I should say I had a miscarriage. But I didn't, and I figured you need to know the difference. And you're a doctor. Doctors aren't supposed to judge people".

He told her what? That she'd done something so shameful, so awful, that she couldn't even include it in her medical history? That she should forget about it, pretend it never happened? Protect herself from being judged by other idiots like him? And no, we're not supposed to do that.

First, do no harm. Sure, "do no harm" means "don't prescribe the wrong medicine" and "don't use patient's suffering for your own ends". But it also means we need to watch our own biases, and our judgments. We can wound with our words as surely as with a scalpel.

It's bad enough that contraception isn't generally covered by insurance and that women who live in poverty often can't access preventive gynecological or prenatal care. It's bad enough that women are assaulted with the dual messages of our culture: be sexual, be "hot", be available, but if you prepare for sex you're a slut, and if you have sex you should be prepared to "suffer the consequences" by having a child you can't afford. It's bad enough that women can't afford to have children because mothers earn less, and are often still responsible for so much of the child care that they can't work full-time. It's bad enough that we have a president who continues to promote abstinence-only sex education despite good evidence that these programs don't work. But I hold my colleagues to a higher standard. We're supposed to put our patients above everything else.

First, do no harm.

And she told two friends.... ~by Jay

I've looked all over for a video clip of that old shampoo commercial, the one with multiplying pictures of someone (Farrah Fawcett?) and the voiceover "She told two friends, and they told two friends, and so on..." That's what my little corner of the blogosphere* feels like to me right now.

See, I met Orange because we both love crossword puzzles (although I'm a rank amateur compared to her) and I read her crossword blog. And then I read her personal blog, and she suggested I read some other blogs, like this one and this one and this one. And THEN she said "so why aren't you blogging?". (And she will tell me if I screwed up that punctuation, which I think I did.)

Before I met Orange, I already knew Mary through our participation in a listserve. It's a great community, but the list doesn't really tolerate political discussion, and I was getting pretty frustrated having to censor my political opinions. And then she started blogging here. I was just looking for an excuse to blog, I think, trying to find some way around my cold feet and my noisy internal critic. I decided I could do it if I blogged with Mary, so she kindly set up this blog. And I've been at it ever since.

And then Megan, who was reading Mary's blog, found about TwoWomen, and now Megan has a blog, too. Go, Megan!

So maybe it's "she told one friend, and so on and so on". But it's still pretty cool. All these interconnections and weaving back and forth. I'm not at all sure I buy the idea that men communicate to create a hierarchy and women to create a web (vide Deborah Tannen), but I like following bits of silk to other people's personal spaces. My virtual community is deepening and blending and becoming part of my face-to-face life (and, Orange, we will meet. I promise). (There's that nasty punctuation thing again.) It's as if I put on my 3-D glasses and these friendships have acquired another dimension. Life is richer. Even if I don't rinse and repeat.

* wouldn't you think that "blogosphere" would be in the Firefox spellcheck dictionary? For that matter, wouldn't you think "spellcheck" would be?

What's in a name? ~by Jay

I know you'll all be astonished to hear that I kept my name when Sam I were married. Shocked, right? My mother was. Shocked, I mean. And upset. See, she'd been telling me for years that the reason I don't have a middle name is that I'd just drop it when I was married, so why bother? She was convinced I kept my name just for spite.

Eventually, she figured out that I'm the third generation Dr. Jay, and I didn't want to lose that. Besides, I figured the whole name-changing thing was done with - over, finished, relic of a bygone patriarchal era. I was married in the modern age, and what woman would change her name? It was, after all, 1984. We were all going to keep our names. The patriarchy was dying.

Right.

And no, this has not confused the children (who all call me Daughter's Mom anyway). It did not prevent us from getting a mortgage. It did not make it difficult for me to see Sam when he was having a medical procedure. But we still have to explain it - and answer all those questions - over and over and over again.

I did reconsider once, about five years into this social experiment we call a marriage. We were moving from Blue State to Red State for Sam to do a post-doc. I was going to be working part-time and we were only there for a year; I knew our entire social life would be centered around the college where Sam was teaching. So I told him I thought I'd use his name. Then we went to open a bank account. It was a small town and we had nice, personal service from a very young man, who was happy to welcome us to the area and had nice things to say about the college. He helped us pick out the account we wanted, and then asked for our ID. And then it started:

"Aren't you married?" Yes, we are. "Oh, you must be newlyweds." Um, no, we've been married five years. "But your ID has different names." Well, yes, because we have different names. "Well", looking at me, "this account has to have your legal name on it. Your legal name is Jones".

Nothing being told I have to do something to make me refuse to do it. I explained that my last name was my legal name and I intended to use it. He said he couldn't open a joint account with two different last names for a married couple. I told him he most certainly could. He excused himself to ask one of the VPs, and she (yes, I was delighted it was she) apparently set him straight. He came back with his tail between his legs, and I kept my name. Sorry, Mom.

Lucky lady ~by Jay

"Aren't you lucky! He helps around the house!"

Yup. He helps. Because picking up his laundry, cooking his meals, paying his bills, and raising his child is by rights my job. Of course, my laundry and bills and meals are my job, too. Along with the playdates and the grocery shopping and scheduling babysitters. But he helps! Wow!

"You must have trained him well".

That's it. Exactly. I held a chocolate chip cookie in front of his nose, and every time he washed a dish or put away a T-shirt I gave him the cookie, patted him on the head and said "good husband! Good boy!" until he wagged his, um, tail.

"I don't how he can work and be ritual chair for the synagogue and still manage to come to PTA meetings and do the school drop-off and pick-up".

Gosh, I wonder if it's the same way I manage to work, be president of the synagogue, volunteer for a national professional organization and teach one night a month, and still do as many school drop-offs and pick-ups as he does. Oh, no, I don't go to PTA meetings, it's true - because they are always scheduled when I have evening office hours. Which means, of course, that I "must really miss being involved in your child's life". Right, because I never see her and have no idea what's she's doing, since I've already betrayed her by allowing her to be raised by strangers. Bad mommy. No cookie for you.

"You make more money than he does and it doesn't bother him? He's really supportive".

Gosh, and I would have said I was the one doing the supporting the year he was unemployed, and the years he was in graduate school earning less than $10,000 per. But Sam was really open to sharing my salary, and bravely accepted the fact that he didn't have to take an adjunct teaching job in South Nowhere just to pay the rent. He was incredibly understanding when I gave up my job and friends and moved across the country so he could take the job he finally did get. Yup, it's amazing he could put aside his male ego enough to tolerate all that.

If Sam were writing this, he'd rant about the people who think he's "babysitting" when he takes care of his own child. He'd tell you that men who can't be left alone with their infants should be ashamed of their incompetence. He'd repeat the story about our first post-adoption visit with the social worker, the one who asked him what parts of parenting he didn't participate in. He always says that at first he didn't even understand the question, and then he got angry at the suggestion that he wouldn't be a full part of parenting our child. And he's sincere about all of it. He accepts housework as part of his responsibility, just like it's part of mine, and he loves to cook as much as he enjoys building fences. He'd also point out the flip side of this assumption - that he's somehow less a man because he "helps".

But all of that serious talk might make male privilege visible. It might make women actually think that they don't have to do all the housework, that their male partners could participate and the world wouldn't come to an end. And we can't have that. No making the patriarchy uncomfortable; wouldn't be prudent. Besides, I have to go set the table now. Sam made dinner, and emptied the dishwasher, and fed the dogs while I was writing this. And he went to the grocery store this afternoon so I could stay home and watch the baseball game. I am lucky; he's kind and generous and he's a damn good cook. But don't tell me he's helping.

What I didn't say ~ by Jay

What he said: "Leaving already?" ("He" is one of my practice partners, a man about my age who see patients 36 hours a week as opposed to the 24 I schedule, and who is unable to keep up with his paperwork despite more dedicated help from staff than I have.)

This was about 1:00 PM today, and I was indeed leaving the office. He was sort-of kidding - you know, the way people talk when they have some emotion about something but don't want to cop to it.

What I said: "I saw my patients"(the two who cancelled and the one who didn't show up were balanced out by the three people I squeezed in for urgent visits). "I wrote my notes" (using my computer templates). "I answered my messages and I authorized my refills and I reviewed my lab reports" (which I can do more rapidly than he can because I keep up-to-date med lists and my charts are in chronological order). And I left.

What I didn't say: "I'm now going to the grocery store and the post office to run household errands, and then I'll take the cake and ice cream over to someone's house for the surprise birthday party for Sam tonight, and then I'll pick my daughter up and take her home so she can make Daddy a card, and then I'll pick up the prayerbooks and kiddush supplies for the family service that precedes the pot luck that includes the birthday party, and then I'll take my daughter over to the potluck and hope Sam remembers he's supposed to bring the pizza that will be our contribution. All you have to do today - all you ever have to do - is work. The same work that I do before I go home and do all the other stuff.

"You get big extra Daddy points for showing up for soccer games, but you don't have to wash the uniforms and pack the snack bag first. Your food appears, and your laundry is washed, and your kids get from place to place, and you don't have to do any of it. And yes, I can keep up with my paperwork. Sure, I read and write faster than most people - but I also keep my charts organized and set up systems so I can find what I need, and I learned how to use my time with patients more effectively so I can run my office hours on time, and I don't order unnecessary tests that I then would have to review and respond to. I work damn hard to make it look as if I don't work as hard you do".

And yes, I do have a husband who "helps". Look for a rant about that idea coming soon.

Girl Talk ~ by Jay

It was one of those it's-a-small-world moments. We were visiting my grandparents in Florida, having dessert with a man who was a professor emeritus. It turned out that his successor, the man he'd hired and mentored to be chair of the department, was Sam's sister-in-law's father. So we talked about the family, and what they were doing, and we told him that Traci, whom he'd last seen when she was 12, had graduated from college with a degree in physics and was in graduate school. Her sister? Finishing a degree in computer science, headed for a job at NASA. At the time I was in residency. My grandmother looked at me and said "Girl talk must have a whole new meaning for your generation".

I was never very good at girl talk. As a kid I had few friends, and I don't remember what we talked about. The only place I was with groups of girls was summer camp, and I hated summer camp. Those girls spoke a language I didn't understand and they weren't interested in books or music or writing poetry. They sure weren't interested in a 12-year-old who brought "Winds of War" with her to read during the summer.

High school was better, socially, but most of my friends were male and we hung out in mixed groups, watching TV and listening to music and going to the city for concerts and museums. College wasn't much different except we got to stay up all night and drink while we talked about books and music and politics. Nerd life. I loved it. There were girls who hung out in all-girl groups and had fancier clothes, and nail polish. There were women who wore rattier jeans and hung out in the women's center. I avoided both groups.

When I started med school, I figured life would be the same: mostly male friends, a few women in the group. I didn't join the student chapter of the American Medical Women's Association. And for the first two years that's how it was - academic and social life not that much different from college. The first inkling of change for me was our Introduction to Clinical Medicine course at the end of second year, when the one woman instructor took the women aside and explained to us that we'd need to figure out how to keep our money and ID somewhere other than a purse, because when we started our clinical rotations we wouldn't be able to carry purses. And of course women's clothing aren't designed to hold a wallet in the pocket, like men's. She showed us her solution to this problem and advised us to come up with our own. That was my first clue that my experience as a doc was going to be different than Bob's or Joe's.

Third year was a shock in so many ways. In the first month, I dropped my "I'm not a feminist, I'm just for equal rights" stance. By fourth year I was actively seeking the company of women for the first time in my life, and I wanted to learn from the experiences of the female residents and the very few female attendings I met. I chose my residency because the program supported women and paid attention to work/life balance - a radical idea in 1986, especially in internal medicine. Almost all my friends in residency were women.

Life is different for my generation. Traci and I don't talk about physics or medicine, but we do share the experience of being women in a largely male profession. When I meet other women docs, there's an immediate recognition, an understanding that we've had the same strain of white coat syndrome. Most of my female colleagues can tell the same kinds of stories I'll share in my next few posts. We could call it consciousness-raising, or patriarchy-blaming, but my grandmother would call it girl talk.

Unexpected cheerleaders ~ by Jay

I didn't expect to see cheerleaders at the mall. It's back-to-school time, sure, but I was still surprised to find a whole squad of young women in pleated skirts and jumper blouses, white sneakers and ponytails equally perky, entertaining the crowd at the local department store. Well, "crowd" is probably overstating it: there were four or five moms with video cameras and one entranced seven-year-old girl. The spellbound kid was mine.

My daughter wants to be a cheerleader. The only thing she likes about color war at camp is that she gets to learn cheers and we can't stop her. She has secret tutoring sessions with her friends who are cheerleaders - or maybe apprentice cheerleaders - at the local programs. She loves the clothes, the moves, the camaraderie, the rhymes, and the sense of belonging.

I hate cheerleading. I hate the idea that it's the girl's job to cheer for the boy's team. I hate the emphasis on looks and body type. (Yes, I know that college cheerleading squads include men, and I know what college students in general think about male cheerleaders.) I especially dislike the hypersexualized adult cheerleaders for professional teams. A culture that values cheerleading devalues all other forms of achievement for women. A culture that values cheerleading sends the message that women's lives reach a peak at age 21 and it's all downhill from there. Sam doesn't much like football and doesn't much like looking at the cheerleaders, and he has a deepening awareness of male privilege and feminist thought; we are a united front.

So we didn't let our daughter sign up for cheerleading in preschool, and we let the principal know that we thought it was an inappropriate choice as an afterschool activity. We don't watch anything on TV that involves cheerleaders, since major league baseball is still the realm of the wacky mascot and not the scantily clad teenager. By the time cheerleading becomes an extracurricular option for our daughter in middle school, I suspect she'll be getting ready for pointe class and will be more interested in summer ballet academies than cheerleading camps - but if she asks, we'll still say no. And I still let her watch the cheerleaders yesterday, much to Sam's astonishment.

I want my daughter to be proud of her brains and her coordination and her strength as well as her looks. I want her to be a feminist, but it has to be her own choice. I want to wholeheartedly support her interests and I want to let her do her bliss - but not if her bliss is being a cheerleader. So I try to strike a careful balance, to let her know that her parents make different choices than many other families and to teach her why, as much as she can understand. I want her to know that even though she can't look forward to playing for the Yankees, she can do almost anything else she wants. I don't want to make cheerleading, or Barbie, or Hillary Duff, into forbidden fruit that will taste all the sweeter when she does get to it. I can't shut her off from popular culture and I can't always be there when she encounters it. What I really want, I realize, is that she will recognize misogyny and work to change the patriarchal system without actually being injured by it. That's not going to happen, so all I can wish for is that she'll come to me - or someone else she loves and trusts - when the injury occurs. For the moment, all I can do is watch the cheerleaders with her and hope she learns something from me.

Hannah ~ by Jay

I promised another story in the series of patient vignettes. I want to tell you about Hannah.

I've known Hannah and Tom for six years. I've watched her care for him as he's become progressively disabled both physically and psychiatrically. Unlike many of my patients, Tom has insurance that actually covers his psychiatric care, but his illness has worsened despite medications, hospitalizations and ongoing therapy. He is now struggling with other problems brought on by the psychiatric meds, as well as by the three packs of cigarettes he smokes each day. I'd seen Tom twice recently and I was concerned by his increased agitation and anger. He cursed about Hannah, using language I'd never heard from him, and demanded that I prescribe Viagra. After the first visit I called his psychiatrist. I called four times, and finally spoke with a covering physician, who agreed to make sure Tom was seen that week. I considered trying to commit him involuntarily, but our state has very restrictive rules about that and he didn't directly threaten Hannah. He wasn't suicidal. And on his second visit he seemed calmer and more coherent, although still resentful of Hannah's attempts to help him.

Then Hannah came in last week, bruised and scratched and in tears. Four days after his last visit with me, Tom attacked her with his fists and a pair of scissors. He broke her nose. Now he was in the medical ward of the county prison, and she had also been arrested for fighting him off. She was trying to figure out how to make sure he still got medical care when he was released. She has a court order to avoid contact with him, but knows he can't be alone. She was told to go to a shelter, because there's no way to force him to stay out of their house.

I felt as if I'd watched a speeding train crash into Hannah and done nothing to stop it. Should I have committed him? Should I have at least tried? Would it have mattered? In general, I don't think it's a good idea to increase the power of the state to control people's medical care. There's a long, ugly American history to wrestle with. We've put people away for life because they didn't fit some social norm; we've allowed men of color to suffer for decades with a curable illness; we've forcibly sterilized women. And even for well-insured patients like Tom, decent psychiatric care is hard to access, at least around here. I wish I'd had a good psychiatric home care program to refer him to, or intensive outpatient therapy, or even inpatient care that wasn't so horrifying. I wish my colleagues in psychiatry had enough support for their work; if they did, they would be more open to collaborating.

It turns out Tom's deterioration was likely due to a medication the neurologist started, and that I didn't know he was taking. Why didn't I know? The neurologist never sent me a letter. Tom didn't remember what he was taking, and because he was so angry at Hannah he refused to allow her to come to his most recent visits with me.

What I find most troubling about Hannah's situation, though, is that she's still responsible for Tom's care, even after he attacked her. And that she's convinced this is her fault. My experience with men who've been attacked is that they are angry and full of blame. Women are far more likely to blame themselves. And why? Not because they're neurotic, but because they've accurately interpreted the messages they've received from childhood, the messages that are all around us. Women who are raped were "asking for it". Many religious traditions teach that even the sight of a woman is enough to drive a man beyond reason, so it's our responsibility to cover ourselves, to hide our hair, and to stay out of daily life to protect men. Popular culture celebrates a brand of aggressive, antisocial masculinity that is defined by the absence of emotion, the absence of caring, so that all the caring and emotive functions in relationships - in society - must fall to women. If it's the woman's job to manage the relationship, then it's also her fault if the relationship is so bad he ends up hitting her.

Before this attack, Tom and Hannah's relationship wasn't overtly abusive. He was dependent on her but appreciative of what she did; he often said "if it weren't for Hannah I'd be dead", and he's right. Unlike Sheila's husband, he didn't belittle her or criticize her - not until a medication made him crazy. But now she can't keep herself safe without putting him at risk, and the system is set up so that the one who is attacked is the one who has to take all the action, who has to leave the house, who has to choose her safety over the rest of her life. The legal system punishes women for the actions of men. And those women are presumed by the medical system to be not worth saving.

There's another post to write about the ways in which my profession has supported lousy care in the name of "physician autonomy"; if we had a universal electronic medical record similar to the ones in Scandinavian countries, I would have known that Tom's meds had been changed right before his behavior worsened. But even without that, if we took the experiences of women seriously and held men accountable for their own actions, Hannah would be home with support instead of hanging off the edge of a cliff, by herself.

Misogyny before breakfast by Jay

You'll have to wait for the next story of my series illustrating how the patriarchy plays out in the lives of my patients, because I was distracted by this morning's comics section. And by "distracted", I mean "horrified". Here's the second page of comics as it appears in our local paper. To be fair, I should tell you that the final comic on this page was "Doonesbury", which was not misogynistic but not funny enough to make me feel better, either.

First: The Wizard of Id

Because God forbid women ever get power. If "Wizard of Id" were ever remotely connected to the real world I'd be tempted to think this was a commentary on the presidential race, but since it's not, I won't.

Next: Shoe

Women must continue to radiate youth and sexual allure to men. Older women are ugly and repellent, and therefore should be ashamed to exist. And at least should have the good sense to remember to simper, because simpering is so attractive.

On to Hagar the Horrible
Because it's so much better to be behind the throne than to actually be powerful in the real world (see "Wizard of Id", at top). Honi is young and nubile now, so she can exert her power as women should - by using sex - but someday she'll be transformed into her mother (see "Shoe", ibid) and be reduced to violence, since no man should have to work with women on an equal level.

The last straw was Baby Blues:


And, finally, the real world can continue to ignore and demean women because after all, women never do anything, they just talk. A lot. About nothing at all.

Wow, a whole post about sexism in the comics and I didn't even have to mention "Cathy" or the execrable "Girls and Sports".

Blogging means never having to say you're sorry ~ by Jay

So I won't. Even though it's been weeks since I last posted and you all (those of you who are left, anyway) were thinking I'd given up entirely on this project. But I'm back now. OK, I have Gloria Gaynor in my head, courtesy of my daughter, who learned "I Will Survive" as part of color war. Don't ask me how they connected disco and color war.

Gloria's not a bad segue into this series of posts. The three women you'll meet are survivors, but none of them showed Gloria's energy or self-confidence in their visits with me last week. Each visit left me shaken by the tragedy of the woman's particular circumstance, and by the larger implications.

Sheila came in for her first visit, referred by her gynecologist because she's tired. She works full-time, has a child and is also a painter. Yes, she's tired, but she can manage her symptoms - except for her husband. He says there's something wrong with her energy level. He says that she should be able to do more, that she shouldn't need time to recover from her work day before interacting with her family, that her meditation and studio time are unacceptable. And she's worried about how he's interacting with their son. Sheila is already taking an antidepressant, which is helping her a little, but she wakes most nights feeling panicked and terrified, not sure if she's dreaming of childhood horrors or adult tragedies. I couldn't escape the feeling, as I listened to her, that she was taking medicine for her husband's problem.

The family systems folks talk about the "designated patient", the family member who is identified as pathological and is, in effect, scapegoated for the ills of everyone else. But it's not just Sheila; women are the designated patient for society in general. We're supposed to contribute economically, be nurturing to everyone in our lives, find the perfect level of involvement with our kids, and be sexually alluring and available to boot, and we're supposed to do it joyfully and without any assistance of any kind from "anti-family" government programs - or even assistance from other family members.

Sheila doesn't see herself as a victim, not any more, not since she escaped her father's abuse and her mother's blame. But she also can't yet voice her own truth, even to herself; she feels compelled to meet her husband's expectations. Her inability to do it all isn't a disease, but I wrote her prescription for it, anyway.