On The Road Again ~ by Jay

Tomorrow I'm taking my daughter and driving an hour to get on a train to travel another five hours to get to a city where a dear friend lives with her family. Sam has all sorts of fun stuff planned that involves driving around odd places in neighboring states looking for trains, plus dear friend has a cat so it's a Sam-proof household. My friend knows about the blog but I anticipate far too much time spent schmoozing and wrangling kids to have any time blogging.

My daughter has laid out her clothes for me to pack and has started to pack her bag for the train.

I'm a good organizer. I put the tiny things in the tiny pockets, the small things in the small pockets, the big things in the big pockets and the humongous things in the humongous pockets. Except Bear. Bear won't fit, so we'll need an extra bag, Mommy.

She will have the use of my iPod during the train trip, now that I finally figured out how to delete the videos from the iPod without deleting them from iTunes. She's also packed four books ("big chapter books, Mommy"), her Nintendo DS, a sketchbook and a collection of CDs "in case we want to dance when I get there".

OK, it's time to pack my own clothes, sort through the stack my daughter left, charge the iPod and iPhone and find a set of earphones for each of us. Here's hoping those of you in the US have a good holiday weekend and stay safe from Gustav, and that we all find a few moments of true peace in the days to come.

Kneejerk Response ~ by Jay

I am trying to change my default response to my daughter from "no" to "let me think about it". It seems that no matter what she asks, my mouth says "no" before she even finishes the question.

Mommy, can I......?

No.

I was just going to ask if I could go clean up my room.

What sane mother would say "no" to that?

Me, especially at the end of a long day when I'm thinking about all the stuff left to do rather than actually listening.

Sigh.

Working through cranky ~ by Tigermom

Just so you know, at baseline I am a happy person. I see the world from a glass half full perspective. We all have our health and each other and all that.

But, boy, was I feeling cranky this morning.

Issues cropped up all around me. Everyone expecting me to rescue them. My patients did not. But my family did. Looking back, it had been brewing for a day or two.

The Tigercubs are in a camp this week that does not provide transportation. So I drive them every day and pick them up every afternoon. This is a big deal for me. We live in a walkable community and for the few activities the kids do in the summer there is bus transportation. So adding in the drive changes the timing of all of my obligations and makes me growl.

Tigerdad had really wanted the cubs to attend this particular program this week. I had told him if you want it, then do all the arranging yourself because, as mama from The Elmo Wallpapers often says, "Stick a fork in me, I am done." And he did. He registered them, got them the supplies they needed, and took us all on a practice trip over the weekend to see where it is.

Then Sunday night rolls around. "Oh, I have to be at work by 8 AM tomorrow morning, " says Tigerdad. "Oookay." knowing that means, "Tag, I am it." So I haul everyone out to camp, including the cub who is not in camp this week. On the way home that afternoon, there is a chorus of, "My feet hurt. My sneakers are pinching me." So off to the shoe store to get new sneaks for these growaholics. All the while under a time crunch since I had left the non camping cub home with a relative who had other things to do.

Monday night I spent with Friend's sick husband learning his evening medication routine since his doctor is on a MONTH LONG vacation and no one else wants to do neighbor's meds. Truly a monkey could do it, but no one non-medical feels comfortable and it take - 3 hours a night! Doctor did dig up a great medical student to administer the meds for the first half of the vacation, but, "Tag, I am it," again for the second half starting Saturday. Grrr....

Glass half full. Glass half full. Glass half full, I keep as my mantra. There but for the grace of, oh you know.

Tuesday I take the kids and get to work just on time. But barely. Patient sessions go well and I feel more in my element. Easing back into a routine. But we go to bed late what with the Democratic convention on TV and baseball after that. I really do better on a full night's sleep.

All I want to do is exercise some of the rising stress out of my system so I plan to ride my bike to work this morning. So last night I casually ask Tigerdad, "So can you take the kids into camp tomorrow?" "I have an 8 AM meeting tomorrow. Sorry." Grrr....

This morning I told him I really had wanted to work out. "You could have gotten up earlier this morning to work out before taking them to camp." Double Grrr....

So work today is better. I had a half a cup of coffee when I came in. I am back into a routine I feel comfortable with, but missing the other two docs who are still on vacation.

I want to plan my own days!!!

How Do You Keep Those Plates In the Air? ~ by Jay

There's a very cool new blog up called WoLFi TaLEs. AztecRose is a PhD student who is using this blog as a resource for her dissertation work on work/life family balance. She calls this "interconnectivity", and she has some fascinating ideas.

I've been holding onto her recent post full of questions, waiting for time to answer it fully - which says something in itself about balance. Tonight I have no charts to write and no baseball game to listen to, and my daughter is playing Webkinz for her precious half-hour while Sam makes our dinner, so I'll get started.

What choices have you made in your life to work towards work, life, family balance? Do you feel you have been able to make ‘real’ or ‘genuine’ choices?

Eight months after my daughter was born, I left a job that I hated. This year - eight years later - I am making about 80% of what I was earning the year before she was born. The story I tell is that I left that job because of my daughter, but the truth is that her birth gave me permission to do what I wanted and needed to do. I couldn't leave a prestigious, high-paying position because I didn't like it, but I could leave because it didn't work for my family. What really didn't work for my family was that I was miserable.

Since then, I have mostly worked part-time, a real choice that I have the privilege to make because I work in a profession that pays very well, even for part-time work, and because I have a partner who is also employed at a well-paying job, and because I have family who have helped us with unforeseen expenses. So yes, these are real choices, but I am well aware that they are not available to most people.

What constraints have made it difficult for you to reconcile work, life, & family responsibilities?

I remain the primary earner in our family. I'm currently working full-time, with half my time in primary care and half in hospice. The primary care work pays about 75% of my salary. I'd like to work part-time but it is the hospice work that I find most appealing, and I can't cut back any further on my primary care practice without reducing my income.

On a smaller scale, there are the daily irritants that make everything much harder. I want my daughter to feel that I am available to her and interested in her life. That's a challenge when her school schedules family programs in the middle of the workday with only a week's notice. And I want to be part of her growing interactions with popular culture, so I'd like to spend more time with her than I can in my current work situation. I blame the patriarchy - really. Popular culture is sexist and misogynist and sexualized and I don't want to leave her alone with other, less feminist, adults any more than I have to.

What support structures (govt, workplace, family etc) do you think are important in achieving balance or interconnectivity?

Flexible work schedules. Being allowed to use sick time when a child or family member is sick (not allowed at my previous job, allowed with a wink at my current position). Valuing, supporting, licensing and appreciating good day care. Universal health care. You know, the usual.

What conflicting feelings, values or attitudes have you experienced in regards to childrearing from the workplace vs the home?

From me or from other people? I work in an office where 99% of the support staff is female and 50% of the physicians are male. The women on our staff are constantly dealing with child care or family care issues: who's picking up the kids? who's doing their homework? what will happen if I have to work late? how will I manage if my mother-in-law is sick and can't watch the baby? The male physicians both have stay-at-home wives. They don't have any child-care issues of their own, and are unsympathetic to the staff's concerns. I don't have the same level of stress about child care, because I can afford full-time care and I have a partner who has flexible hours and works close to home. I feel caught in the middle - neither fish nor fowl. And, as I've said before, I also hear my husband being extravagantly praised for doing essentially the same thing I do.

In what way is work life family balance a gender equality issue for you?

In every way. Family work isn't valued because women do it. Women do the majority of family work because it isn't valued. Men are socialized to feel more responsible to their bosses than to their families. Women hold on to control in the home to make up for lack of control and power outside the home. Family life itself has become feminized and thus devalued, and work life has remained masculinized at the same time that masculinity has been bulked up like Stallone on steroids. I'm a woman in a traditionally male profession with a husband who defies many social expectations of masculinity, and we've managed to do a better job than most with the balancing act, but we were trangressive before our daughter was born.

Research by Galtry & Callister (2005) suggest shorter leaves are better for gender equality while longer leaves are better for child health and development. How do you feel about this?

It reminds me of the studies on physician work hours. Bear with me here - this will make sense. (This is entirely US-centric, for which I apologize in advance, but it's the story I know.)

When my father was an intern, he worked 48 hours on, 12 off. For a full year. He had one week of vacation and my mother says she finally woke him up after three days. It was brutal, inhumane, dehumanizing - and Dad always said it was the best educational experience of his life. That kind of work went on for years. Eventually the trainees began to complain, and finally someone noticed that exhausted doctors weren't very good doctors. A woman named Libby Zion died because an overworked, undersupervised resident made a mistake. So a number of states started regulating physician work hours. This meant that instead of having one doctor see a patient for most of the patient's hospital stay, there could be four or five in shifts, with handoffs every 8 to 12 hours. With each handoff, the docs try to transmit important information, but inevitably something is lost in translation.

Turns out that working in shifts like that is better for doctors, but not necessarily good for patients. Continuity counts for hospital care. The more often a patient is handed off, the longer they stay in the hospital and the more likely they are to have duplicate procedures or other unnecessary tests. It's very difficult to strike a balance between physician health and wellbeing and patient wellbeing. We're still trying to get it right.

So it makes sense to me that having one person be the primary parent would be good for the child: more stability, more continuity, fewer handoffs. It also makes sense that having one parent - most often the mother - stop out of work for long stretches will work against gender equity. I wonder about third paths, especially about supporting families to help their children grow and develop in health. If we had better education about child development, better support for learning to parent, better health care, maybe it wouldn't matter so much who the primary caretaker was. Yes, I know that's heresy - the primacy of the mother! The bonding! Parents know best! The family is all! Feh. I think kids can thrive in any number of settings with any number of people as long as they know what to expect and they're safe and loved.

Thanks to AztecRose for the very interesting questions! Lots to chew on. I know it's a long post and I'm grateful to those of you who made it through. I look forward to hearing your thoughts, or reading your own posts.

Helpaholism revisited ~by Tigermom

I have just returned from my August vacation, I am a psychiatrist after all. And I feel refreshed and rejuvenated, happy, and typically anxious about getting slammed this week in the office.

Yet, I visited the ER twice during my 10 days away.

I am fine. But my host during vacation needed two ER visits while I was there and a third the day after I left. I went with my host for both visits, first time in an ambulance and the second time in my own car. It was immediately clear to me both times that the medical issues needed an ER evaluation.

But something felt fundamentally different to me about helping my host compared to how I feel helping my neighbor's husband.

I care deeply about both people. My host is a beloved relative; my neighbor a beloved friend.

Their medical situations were quite different. My relative first had a traumatic injury, fixed in a straightforward way, then an infection, also fixed in a straightforward way despite taking a few days and the last two ER visits to correctly diagnose. My neighbor has an unremitting degenerative illness.

Their support systems differ. My relative has, if I do say so myself, a small but reliable and committed coterie of supports. My neighbor has lots of relatives, but they do not swoop in to help using the neighbors in a supporting role. Instead he has a devoted, but over stretched, wife who coordinates the friends and neighbors and manages the relatives to help in the circumscribed ways that work best to capture their help.

My own support systems differed in these two situations. With my relative ill, I had Tigerdad to look after the Tigercubs so I had no worries about child care coverage. When I help my neighbor it is in addition to the delicate house of cards balancing work and child care.

I am so sorry my relative had any medical mishaps at all. But I would not have been anywhere else but by her side helping her navigate the system and keeping her company.

And the experience made me see health in my impulses to help others, not helpaholism.

Dreams ~ by Jay

I have one question left to answer from Anna:

Do you remember any of your childhood dreams? (actual dreams, not aspirations...) although, sure, why not - do you remember any childhood aspirations? (OK, I have two questions left to answer.)

Yes, I remember at least one of my childhood dreams. At the time I know I remembered the whole dream - or at least a lot of it - very clearly, which was unusual for me, but many of the details have faded. I was maybe 10, possibly younger. In the dream I was running away from someone - someone I knew, but I don't remember who it was - and I found myself on a narrow ledge at the edge of a cliff, with a chain-link fence on one side and a sheer drop on the other. As I type this, the terror is coming back into my body. I can feel myself edging along that cliff, feel the fence digging into my back and the rocks slipping under my feet.

This was not a recurring dream, thank God, and I don't remember any specific reason for it at the time. I do remember feeling scared about it for days afterward, and even a little afraid to go to sleep for a while. And I don't want to think about what it means. That's a rock I don't want to turn over right now.

Aspirations? Well, when I was four, I had a visiting nurse's outfit that I wore for Halloween. There was a little cap and cape and red plastic nurse's bag with a stethoscope. I loved that outfit. I read every book I could find about nurses, especially Sue Barton and Cherry Ames. Both Sue and Cherry worked as visiting nurses. I first heard of Lillian Wald and the Henry Street Settlement House from a Sue Barton book. I was the child of a medical family, and I was a girl, so of course I wanted to be a nurse. And I wanted to start right away. Dad suggested I wait until I was 14 and sign up then to be a candy striper, so I did.

I spent six months delivering flowers and pushing wheelchairs around, and then they offered a few us the chance to train to be volunteer nurse's aides. We learned how to make beds, how to crank them up and down (yes, hand cranks), how to assist in bathing and turning patients and how to fold towels just the right way to fit on the linen carts. Once we finished, we were given caps - pink and white versions of the caps I'd read about in those books - and assigned to a specific floor. I worked on 4-T for three years, at least every other Sunday for four hours. I did all the things I'd been trained to do but then they figured out that I was capable of answering phones and filling out paperwork, I became the de facto ward clerk/secretary. And somewhere in the first few months, I met someone new to the community: a young woman OB/gyn doc who was just starting her practice.

By that time, my experience with infected wounds and dirty bedpans had removed any sense of glamour I'd retained from Sue and Cherry, but I loved the hospital. I felt at home there, and I enjoyed being part of an institution full of people with a shared, noble purpose. I'd also realized that when nurses advanced in their careers, they left patient care and moved into administration, and even at 14 I knew I didn't want to be an administrator. I wanted to take care of patients, and I wanted to be in charge. Once I realized that was possible, I decided to go to medical school.

Ten years later I was a second-year med student, struggling through pathology and bacteriology and acutely aware that I'd been admitted to med school - to only one school - because my father was on faculty there. I began to wonder if I really belonged there, or I was just following my programming. That kept me up nights for a while, until we started our physical diagnosis class. We went to real hospitals and talked with real patients and began to learn real medicine - and I was reminded of how at home I felt. And I was good at that part, the talking to patients part. I realized that it didn't really matter how I got there or why it worked for me. It only mattered that I was where I wanted to be, learning how to do the only thing I'd ever really wanted to do. Sure, I got lucky - but the real luck wasn't getting into med school. The really lucky thing is that I get to wake up each morning and go to a job that still challenges me and intrigues me and calls on all my skills, and that I'm good at what I do. I get to make a difference in the lives of other people, have fun doing it, and get paid. How great is that?

The Three Billy Goats Gruff ~ by Jay

Mama asks about trolls.

Do you ever receive nasty, probably anonymous, comments on your blog? Are you tempted to answer them, or is it easy for you to ignore them? Can you tell I am struggling with this?

Just this morning, I deleted a comment calling me a "Satanic 12-step blogger". That one wasn't anonymous. I wasn't tempted to answer that one, because it was so off-the-wall. Can't the troll tell the difference between a six-pointed star and a pentagram?

I am tempted to answer them and it's not easy to ignore them (I do get anonymous ones as well). I put my real self into these posts, even though my real name isn't on the blog. I know this is true for Mama as well. And it hurts when someone calls my real self nasty names. I'm still the kid who hated recess.

When I guest-blogged at Feministe, I felt more of a responsibility to post negative and even nasty comments, because the comment threads there take on a life of their own. Deleting obnoxious comments seemed somehow unfair. It wasn't really my space, after all; I was just borrowing their soapbox. Even so, after a while on the mental health thread I stopped posting the comments of one guy who was patronizing and repetitive.

I just re-read that post and the comment thread, and I was kind of astonished at the tone of my own comments. Sure, it's a different blog and sure, I was being accused of saying stuff I hadn't said, but I was pretty flippant and very snide. I don't particularly like being flippant and snide, although I'm really good at it. That kind of exchange raises my heart rate and makes me feel keyed up, alert and ready to sally forth. My responses speed up, and I am far more likely to say something I'll regret. I lose all my empathy and instead of connecting with people, I use my considerable language skills to pound them into the ground. When I'm in that state I can't be deliberate or thoughtful. I act and speak as if I don't care about people. I become someone I don't want to be.

So there's the best reason I can think of to avoid engaging with trolls: I fall off the bridge and become a troll myself. I'd rather be a calm, centered billy goat.

I Didn't Know That Was an Option ~ by Jay

From a radio commercial in heavy rotation:

Ask us about term life insurance that guarantees your money back, even if you don't die.

My Favorite Place ~ by Jay

Anna asked more questions in response to my invitation (and you can still ask me questions, too, if you want - it's over there).

What's your favorite place in your house? in your neighborhood?

Mary had a group writing assignment almost a year ago asking us about our happy place, and I neatly avoided answering the question by writing this. Anna gives me no such metaphorical out, and I find this hard to answer.

The place I spend the most time is probably this seat at the dining room table. This is my place when we eat together and my spot with my computer. But it's not my favorite place. It's not cozy or comfortable, and I can always see something I should be cleaning up. Currently: two day's worth of newspapers in front of me; a tote bag and straw hat at the other end of the table along with rolls of gimp and something large made out of cardboard; my daughter's lunch box on the counter waiting to be emptied; the dishes in the sink in the kitchen (it's one big room with a dividing breakfast bar). I love the backyard on the rare day that is not too hot, not too cold, not too buggy and not raining, but it's not my favorite, either.

My favorite place is the big blue comfy chair in our bedroom. It's a nice place to sit and read, or watch TV, or talk on the phone. If I had one of those Levenger laptop tables, I'd never leave that chair.

My favorite place in the neighborhood is my house. I do love our neighborhood (not so much our neighbors, unfortunately). We're in a city but this area is all residential, single houses and twins built mostly between 1920 and 1960. Every house is different, and there are big trees arching over the street and real sidewalks with real people walking real dogs. It's generally quiet but close to most everything we need. I love pulling into our driveway and looking at the nicely landscaped front yard and the bay windows, knowing someone I love is waiting inside.

Flashbacks ~ by Jay

cross-posted from Modern Mitzvot
1972 Olympics.


1972 Olympics.


I was 12. Sitting in our familiar, cozy den, not feeling so safe anymore. Listening to my mother say, over and over, “This is what it means to be a Jew. Don’t you ever forget. This is what it means”.
I haven’t forgotten. Every time Michael Phelps swam and someone said “1972 Olympics”, I saw that picture. My heart beat faster, and I started to sweat. Lately I’ve been waking up at night feeling anxious.
Don’t you ever forget.
For my mother I suspect that this is all it means to be a Jew. It’s not all it means to me. Judaism is my culture, my heritage, and my spiritual practice. Being Jewish brings me joy and helps me find meaning. I say the kaddish and I am healed. I sing ancient melodies and I find peace. Love, community, acceptance, wisdom - and under all of that is the fear. The fear of what my mother watched in newsreels in 1945, what I watched at age 12.

Don’t you ever forget.
My sister-in-law hasn’t been on a plane since 9/11. She called me in early October that year, asking what precautions we were taking. Were we stockpiling antibiotics? Did we think it was a good idea to get gas masks? I said we were going on with life pretty much as we had before. She was amazed. How can you do that? Isn’t it awful not to feel safe? My sister-in-law is not Jewish. Safe? I drop my daughter off every day at a building with the word JEWISH on the side. Safe? The year my daughter was born they found an unexploded Molotov cocktail in the playground of that JCC. Safe? I’m Jewish. I’m my mother’s daughter. I haven’t felt safe since that day in 1972.
Don’t you ever forget.
I will continue to voice my dissent with Israeli policies and struggle with my place in the fight for Palestine, as TGD eloquently describes. I will continue to flinch at coded (and not-so-coded) anti-Semitism in those movements. And, as she says, why should we call for Israel to be eliminated when we don’t call for the US to vanish? Both built nations on landgrabs from other people. But under the logic, under the rational language, under the calm I work to keep in my voice, I still feel the fear.
Don’t you ever forget.

Wish I'd Said That, Again ~ by Jay

This time it was bluemilk, who said

What happens when the most productive work on the planet isn’t recognised? What happens when this work, the work of rearing the next generation of productive workers is mythologised into ”mothers are angels in training”? This is what happens. Any success you achieve goes uncelebrated as work, because this work, while done with love, is really just ’nurturing’, an innate biological function of your gender, a generosity and a purity that came with your ovaries. And any failures you experience, rather than being related to the complexity of the work or the precariousness of your status as an invisible worker, are instead nothing short of your own moral failure.

That's it, precisely. What mothers do is simply what we are destined to do, what we should be doing. No credit, no money, no personal security for just being women. But if we don't fulfill that duty - or if we are perceived as doing it wrong - we are personal failures.

The Adoption Story ~ by Jay

Ariane asks about adoption.

I wonder what your feelings are about the origin of the adopted child. My mother carried a surrogate child for my father's sister, so I watched that adoptive process. I don't believe that an adopted kid has more issues than any other, just different ones. I was an accident, and caused my parents to marry. I find myself wondering whether it is really any more traumatic to be adopted into a loving family than to have other dodgy pasts. What do you think? Is an adopted kid in the middle of the "kid experience" spectrum? Do you think international adoption is substantially worse?

Is international adoption worse? Worse than what? Domestic adoption in the US isn't always picking up a newborn baby at the hospital. We have a number of friends who've adopted through the state foster care system, and their kids have been abused or neglected and then often shuffled around. That can be at least as damaging as institutional care.

We chose domestic adoption because it suited us. I wanted a newborn, and I find international travel very difficult physically. Jet lag makes me sick, and I couldn't deal with the idea of feeling sick and exhausted and at the mercy of some agency worker in a country where I couldn't even read a street sign, and then poof! becoming the mother of a baby or toddler. I found it easier to deal with meeting and maybe having a relationship with the woman who gave birth to my child. There's no judgment attached to it for me. This worked for us; adopting from another country works for other people.

I think kids use their own experiences to do the developmental work they have to do. So a kid who is testing her readiness to start separating from her parents will fantasize about having another family. Bio kids fantasize that they're really adopted; adopted kids fantasize that their birth parents come and take them away to their "real" home. Same issue, different articulation.

That sounds confident. I can even quote a source - "Talking With Young Children About Adoption" - one of the first books I read after my daughter was born. Sure, it's in the book - but I chose the book for the same reason I hold onto this idea 8 years later: I need to believe it. I need to believe that my daughter isn't damaged. I need to feel certain that her history isn't a time bomb, ready to explode with adolescent rage. So far it's been OK. We've been honest with our daughter. She asks us questions from time to time and seems content with the answers. But she's not the kind of kid who tells us everything she's thinking, and I don't know, really, how she feels about being adopted.

I don't think adoption is damaging. I think secrets are damaging. I think kids need to know as much as possible about who they are and how they came to be in their families. It's a challenge to keep our answers at the right level, but she deserves to know her own story, and eventually to tell it herself. I think kids need to know they're loved, unconditionally, whether they are "accidents" like Ariane or long-awaited first children like me or adopted kids like my daughter. The greatest gift my parents gave me was their love. Even when I broke the rules, they loved me. Even when they were angry with me, they loved me. I can't imagine life without that unconditional love, and I hope my daughter has that from us.

I have met adult adoptees who are happy, confident people, secure in their relationships with their parents and seemingly unmarked by their history. I have friends who have helped their now grown kids search for their birthparents, and friends who have relationships with their child's birth family, and friends who have closed adoptions and want to keep it that way. I know women who have placed children for adoption and who live in fear of that phone call because they never told the men they subsequently married about their first child. We all have our own stories, and I have to believe that my daughter's story will have a happy ending.

How I Became an Internist, or Here Comes the Patriarchy Again ~ by Jay

Anna responded to my questions post with several interesting inquiries. Since that's the only response I've had so far (not too late! hop on over and add yours!) I'll take one at a time.

Anna asks how did you pick your medical field? did you consider others?

Well, shortly after my wedding, when I was in my third year of medical school and starting to consider residencies, my grandfather (the retired internist) asked what I was planning to do. Hadn't decided yet, I replied, but strongly considering internal medicine. "Nonsense", said he. "You can be a radiologist, a psychiatrist, an anesthesiologist or a dermatologist. If you have to be an internist, you can be an allergist". What do all these fields have in common? "They will allow you to fulfill your primary responsibility as a wife and mother". My mother, to her credit, burst out laughing. She may have thrown a napkin at him, too.

Then there was the anesthesiologist I met during my surgery rotation, who asked me why my husband was allowing me to become an internist. And the classmate who told me that the residency I'd chosen was perfect for women because "they understand if you don't take medicine seriously".

Sorry, I seem to have been distracted. Where was I? Oh, yes. I was getting to the irony.

The irony is that I chose my specialty because I was married to Sam. I really wanted to be a family doc. But I also wanted to actually live with my husband, after years of being apart, and he was in graduate school in an area without any good family practice residencies. And he was hoping for an academic career in a field with maybe two or three tenure-track jobs a year, so we would have to go where he could get a job. Family docs are portable but practicing family medicine is very different in a major urban center than in a rural area. I didn't want to find myself somewhere where family docs were second-class citizens, and I was destined to be the trailing spouse.

It wasn't all about Sam. I'm a third-generation internist. It wasn't just Dad; both of my grandfathers were board-certified before 1942, which is pretty remarkable considering that the exam was first offered in 1936. When I mentioned my interest in family medicine, my father wrinkled his nose and said "You don't want to do that. You'd have to do well-baby exams." And I also considered psychiatry, but my family didn't think psychiatrists were real doctors (sorry, Tigermom) and I had no exposure to psychiatrists doing actual therapy; treating profoundly disabled schizophrenic patients didn't appeal to me. Internal medicine was the obvious and easy path, and I took it. Sam and I never discussed it. I never considered asking him to modify his plans in any way for mine. We both assumed I would go wherever he went. After all, I was more portable. Or so we assumed.

I laughed when I read this in that article about shared parenting in the Times:

{The researcher cited} two actual couples, one in which he is a college professor and she is a physician and one in which she is a college professor and he is a physician. In either case, Deutsch says “both the husband and wife claimed the man’s job was less flexible."

I suspect if Sam had been the doc and I the academic, I would still have ended up as the trailing spouse. That was my expectation, as well as everyone else's. So I compromised and did what I had to do.

I'm an excellent internist, but I've never felt like I belong. Internal medicine prides itself on being cognitive, rational, dispassionate. I'm a smart doctor and a damned good diagnostician, but my heart lies in the affective, in the world of stories and emotions and relationships. I don't get excited about finding the zebra, the rare disease that eludes diagnosis. It's much more satisfying when a patient looks in my eyes and says "I always feel better after I see you, because I know you really listen to me".

Now, nearly 20 years after I finished residency, I am planning to take another Board exam. In October, I will take the certification exam for a subspeciality in Hospice and Palliative Care. I'm still practicing primary care - I haven't given it up yet - but I'm now spending 50% of my time doing hospice work. I've finally found a specialty where my values are shared and my skills - all my skills - are appreciated. It wasn't the most direct path, but I know I'm in the right place.

Got Questions? ~ by Jay

Mary's invitation to questions wasn't really a meme, but I found it fascinating, and I'm enjoying her answers.

So in classic Jay-imitates-Mary fashion, I'm doing what she did! Ask away in comments and I'll answer. Adoption, Judaism, relationships, feminism - if you want to know what I think, I'll tell you.

I have some of the same exceptions as Mary - I won't answer questions that compromise my anonymity - and one other: I can't give you medical advice. But general medical questions are fair game. I'll demonstrate the difference:

What do you think about the use of hormone replacement therapy to treat osteoporosis? = a question I can answer.

Should I take estrogen for my osteoporosis? = a question I can't answer.

Brilliante! ~ by Jay

The wonderful bluemilk makes us blush. She's nominated us for the Brilliante Blog Award. Or she's just given it to us. Either way, we get to post it here and marvel at the way it kind of winks at us.




See what I mean?

We are honored. Bluemilk posted the rules:

1. Put the logo on your blog.
2. Add a link to the person who awarded it to you.
3. Nominate at least 7 other blogs.
4. Add links to these blogs on your blog.
5. Leave a message for your nominee on their blog.

I can think of more than 7 other blogs I'd nominate but many of them don't do memes or awards, so I'll pick two, which happen to be blogs of entirely awesome women that I am lucky enough to know in my 3-D life as well as over the interwebs.

Anna at forty-two roads, who can make amazing things from cardboard, fabric and oil paint while she's being mom to a toddler and writing a dissertation and dealing with a husband who is doing two residencies simultaneously.

Delaine at dkzody's weblog. Delaine was one of my first-ever online friends, back on CompuServe about 14 years ago (Delaine? When was that?) and her blog is just like her, except without the red hair. Smart, idealistic without being unrealistic, full of enthusiasm for California and San Francisco and her family and her students.

Check 'em out, and tell them Jay sent you.

Jews and Booze ~ by Jay

My grandfather had a theory about addiction. He believed that addiction was a sign of a less-evolved civilization, and that as a culture matured, the incidence of addiction dropped. This explained, to his satisfaction at least, why there were no Jewish alcoholics. I asked him once about Chinese opium addicts. He was not pleased.

I wonder what he would think of Lisa Miller's article in Newsweek describing what she claims is a "growing problem of alcohol abuse in {Orthodox} communities" which is fueled in part by kiddush clubs. Kiddush clubs, apparently, are gatherings of men in the social hall during or after Shabbat services, and some are serving "fine single-malt whiskey with a sumptuous smorgasbord". Miller quotes a rabbi, who says "It's not only drinking, it's idealized drinking, which is a very, very bad message for the kids."

Idealized drinking? Anyone have any idea what that is?

Here's my favorite part of the article:

The truth is, though, that Jews don't drink—much. Historically, Jews have not had alcohol problems to the extent as some other religious groups—only 11 percent of Jewish men have problems with alcohol abuse and dependence, compared with 28 percent of non-Jewish men. Researchers aren't sure why, but point to a possible combination of factors. It could be that Jews, who for generations have lived as guests in a host country, feel pressure to be "on our best behavior," as Katz puts it. It could be that rigorous religious observance inoculates people against drunkenness—shown to be true across religions.

The prevalence numbers she quotes don't match any studies I can find in the literature. She's combining abuse and dependence, and that 11% prevalence rate is lower than any accepted prevalence rate for alcohol abuse. The prevalence of addiction or dependence varies from 10% to 20%, depending on the study approach and population, and the prevalence of abuse is higher and even more variable. Drug and alcohol abuse may vary among ethnic and religious groups, but there is no evidence that "rigorous religious observance inoculates people against drunkenness". In fact, religious observance that forbids alcohol use tends to inoculate people against moderate drinking. The average per capita consumption of alcohol in heavily Southern Baptist counties in the American South is the same as in the Northeast, but the distribution is bimodal: people either don't drink at all or they drink to excess.

I can't find a single reputable study that confirms that Jews drink less than non-Jews. I can't check Miller's sources because she doesn't provide them. Perhaps my grandfather is speaking to her from beyond the grave. Far as I can tell, it's "shown to be true" because she says it is.

Miller goes on to suggest that the lower incidence of alcoholism in Jews is due to the prevalence of "a gene, also common in Asians, which can protect against alcohol abuse." I presume she's talking about the genes that code for two enzymes, alcohol dehydrogenase and aldehyde dehydrogenase. These enzymes have a wide variation in their efficiency; people with the less efficient isoenzymes have a flushing reaction to alcohol similar to the symptoms of drinking while on Antabuse. Some early studies suggest that this variant may inhibit abusive drinking, but there's no evidence it prevents addiction to other substances. And even if this is all true - that there's an enzyme that "protects" against alcoholism - which Jewish gene pool is she referring to? The Ashkenazim? Sephardim? Jews from the Indian subcontinent? Or does she presume that all Orthodox Jews share a distinct gene pool, which is now being diluted by intermarriage, hence the sudden shonda of drunken Jews?

As my grandmother would say, feh.

Miller gave us a triple threat: bad science, lousy journalism and persistent religious stereotypes. Let's hear it for Newsweek.
_____
what other picture would you expect on a post about Jews and addiction?

Medical System Out of Control ~by Tigermom

My rant actually describes a medical systems problem that resolved itself relatively well and only after one hour of phone calls and wrangling on a summer's Friday afternoon near 5 o'clock, but geez...

Patient is stable on a dose of conventional medication, but unconventional dosing.

Patient needs a refill.

Caveat?

Patient is staying Far Away From Home and Spouse needs to get the medication refilled before Spouse joins Patient Far Away From Home.

The question? To refill at local pharmacy or mail order pharmacy? Local pharmacy will be faster, but mail order pharmacy will be loads cheaper, but the medication might not arrive on time.

I tell Spouse to give local pharmacy a call and see if they will refill it if Spouse pays out of pocket. I take relevant information from Spouse in case I need to call mail order pharmacy for a prior authorization. Remember I am out of network so I never have insurance information on me and it's Friday afternoon anyway and I am not in the office.

Nope. Local pharmacy won't do it.

So Spouse calls me back with the phone number of the prior authorization department. Go Spouse!

I call Prior Authorizations and Someone Nice answers after a 5 second hold time. Yup, 5 seconds. I thank the Nice Person for the prompt answering of the phone. It takes 20 minutes what with their computer system and taking lots of information from me about my patient and about me, but Nice Person gets the authorization for the conventional medication at the unusual dose and it is good for the next ... 10 years!

I ask if I can just call the actual prescriptions in instead of the patient mailing them in and Nice Person says sure, I will transfer you, but here is the number just in case you get disconnected.

I, predictably, do get disconnected, but have the direct number and call and get another Nice Person in 5 seconds who transfers me to another Nice Person in 5 seconds.

That Nice Person takes all the information about the prescription to be called in and all the information about the patient and some more information about me and I ask her if the order can be expedited and Nice Person says there is already a note in the computer to that effect and the order will get mailed out on Tuesday. WOW.

I call Spouse with the follow up and wish Spouse good luck with the script and tell Spouse to please call the me with any further issue even through the on call doctor since I am going on vacation in 2 days.

A disaster was probably averted with lots of cooperation and people taking responsibility and being nice in the process.

Total time spent by doctor, un-reimbursed on a Friday afternoon? One hour.

Mood swings experienced by Spouse? From panic to relaxed.

Priceless.

Things I Could Do Without, Technology Edition ~ by Jay

Spellcheckers that don't speak medicine and therefore want to change "prn"* to "porn".

____
*"prn" is an abbreviation for "pro re nata" or "as the thing requires". It's how we say "as needed" on a prescription, or in an Email to a nurse. Who would have at least gotten a laugh out of it, had it been changed automatically.

And one small footnote for my medical readers: back in the old days of my residency I was the first doc in our hospital to use tPA, and dictated an urgent discharge summary on the patient in question. The transcriptionist dutifully used the medical dictionary available and returned to me a document stating that we had infused 100 mg of treponema pallidum antigen. I changed that, too.

Late ~ by Jay

I hate being late. I don't like staying up late. I like to start on time (or early) and finish on time (or early). I like dinner at 6:30 with most of the work of the day done and a couple of hours to relax afterwards, and bed at 11:00.

Lately I've been getting dinner at 8:30 followed by dishes/laundry/charts/cleaning/billpaying and bed at midnight. Today I was on time for my first meeting, 10 minutes late for the next one, 30 minutes late for the home visit after the second meeting, and didn't even get home until nearly 6:00. My daughter arrived home from her playdate at 7:00 and Sam and I were just sitting down to dinner, but I had to call into a conference call and I'm just reheating my dinner now. And I still haven't written my notes from the four home visits I did (and was late for) this afternoon.

Anyone know how to tesser? Or have one of those handy little gadgets Hermione used to take extra classes at Hogwarts?

How Many Women? ~ by Jay

You may have noticed that there are actually three women blogging at Two Women Blogging. We loved having Tigermom here so much that we've invited her to stay. And yet we haven't changed the name of the blog. So we're really Two Women Blogging At Any Given Time. Or something.

They've Got To Be Taught ~ by Jay

To conform to gender stereotypes, and you've got to start early. REALLY early.



Yes, it's a pacifier.

My Browser Cache Says I'm David Bowie ~ by Jay

Likelihood of you being FEMALE is 51%
Likelihood of you being MALE is 49%

Site	Male-Female Ratio
amazon.com	0.9
flickr.com	1.15
nytimes.com	1.13
snopes.com	0.74
honda.com	1.2
switchboard.com	0.85
consumerreports.org	1.08
pandora.com	0.9
hyundaiusa.com	1.08
kia.com	1.02

See the explanation here.

via.

(and yes, I'm shopping for a new car to replace the minivan. Suggestions welcome.)

Because You Need To Know My Ringtone ~ by Jay

I just spent about 30 minutes purchasing tracks from the iTunes store and making ringtones. My very first custom ringtones. And of course they're hopelessly square, because that's just who I am.

When Sam calls me, my phone will play Pachelbel's Canon in D, a piano arrangement similar to the one that served as the processional at our wedding.

My default ringtone is now "Home", by Karla Bonoff.

Home sings me of sweet things
Why life there has its own wings
To fly over the mountain
Though I'm standing still...

And when I want to, I can change it to "The Water is Wide", sung by Cat Edgerton (because iTunes doesn't have the Karla Bonoff version available for ringtones). Also a line about flying

The water is wide
I can't cross over
And neither have
I wings to fly...

Let's not read anything into this. Whatever interpretations you have (I'm looking at you, Tigermom!) you may keep to yourselves. I'm just playing with my toy.

Me! Me! Meme! ~ by Jay

Mary has a needs meme on her blog. Wherever Mary goes in meme-land, I am sure to follow.

So I plugged "Jay needs" into Google, and here are the first ten results.

1) Jay-Z needs to fire his stylist Donald Trump style! From here I went to look at pictures of Jay-Z to see what was so wrong with his style. Maybe the secret message is that I need style. Hmm.

2) Sounds like that va-jay-jay needs to be baptized. Monday, August 27th at Lauriol Plaza restaurant: "I know many Catholic girls who have very Pagan vaginas." From a site called "Eavesdrop DC". Sam and I love to eavesdrop in restaurants, but we've never heard anything this awesome. Is baptizing a vagina anything like douching?

3) Jan 18, 2006 ... Go to Google and search on your name followed by the word "needs" (for example, I searched on "Jay needs"). Then take the first ten entries...From a blog called Woolsrake. This meme has been around a looong time. I feel behind the times.

4) Jul 16, 2008 ... Jay-Z has at least one super-producer onboard for his next LP, and according to said super-producer, that's all Hova needs. ... back to Jay-Z. Does he really make LPs? Now I feel un-hip AND behind the times.

5) Apr 13, 2007 ... Jay Z needs to keep his girlfriend in the studio working with music where we all luv her and off THE BIG SCREEN where she can not act at all Ah, we've struck patriarchy. Because of course Jay-Z controls Beyonce, and she must do what he says.

6) MTV | Topic | Default ContentDetail | Jay is such a creep. I can't see Tils with someone like that. I think he's jealous of Bo. Bo is hotter, more caring, ... Is "The Real World" still airing? Should I care? Should I try dating Bo? After all, he's hot. And caring.

7) If you are looking for a cruel joke, refer to the article I wrote 370 days ago (A.P.B. - Jay Needs Snow) to see the same thing happened last year Some sort of online magazine version of Groundhog Day? It's been pretty dang hot here lately. Jay doesn't need snow but Jay sure does need a tall, sweet iced coffee.

8) Jay needs to shit and is stuck in traffic. This is a YouTube video link. And no, I didn't watch it. And I refuse to discuss any way in which it applies to me.

9) Jay needs a home where he is the only child or the other siblings are male. ... Jay needs more information on filter strips and how effective they would be...From a site called jaysembryopigfarm. Um, what?

10) Jay-Z Needs An Intern. Rapper searching for motivated youth to help out with the New Jersey Nets for the summer. by IGN Music Our rapper-mogul again. Done with the intern thing, thanks.

This was my second try. The first time I did my real first name, just for funsies, and I came up with one sports story about a women's track meet and nine porn sites. Saved from porn by a hip-hop entrepreneur.

Jay needs to blame the patriarchy.

Tales of a Help-aholic ~by Tigermom

When can you tell if you have gone from being a socially acceptable helper to running right over the edge?

Let's look at the facts:

I come from a long line of helpers.
I do it for a living.
And now I do it in my free time.

I meet all the CAGE criteria. That's medical for:

I have been trying to Cut down.
Others are getting Annoyed about it.
I feel Guilty about the time not spent elsewhere.
And yes, I have an Eye opener in the mornings.

Huh?

Friend's husband got re-hospitalized. I validate her experiences and prepare her for what the medical team might be thinking and might do to treat husband. I know a great doctor at that hospital so I get Friend the contact information. Tigerdad wishes I would focus on family and not answer the phone. I check my email first thing in the AM and last thing at night to see what's what.

I know that while Friend's situation inconveniences me, what it does to her own family and sanity is beyond any inconvenience to me. Plus, I have valuable resources. And what are they worth if not to share with a Friend?

But do I help to get a rush? Do I get high from being needed? Do I regret it in the morning?

Can I stop anytime I want?

Things I Could Do Without, Sports Scheduling Edition ~ by Jay

It's the heart of baseball season, and the Yankees are in a pennant race (OK, barely, but they're in it). Tomorrow they start a series in Texas, and every game they play is crucial. So what's playing on our local radio tomorrow evening?

Football.

Preseason football.

In August. The very first preseason game.

Ah, to live in New York again, where they have enough radio stations (and enough sense) not to pre-empt a meaningful baseball game for an empty exercise in sweat and profit.

Conversations With My Daughter ~ by Jay

Mommy, why do you touch me all the time?

Because you're my kid, and I love you. I like hugging you and touching your hair.

I don't like it.

OK.

I don't want you to touch me unless I say it's OK.

Well, you get to decide who can touch you and when. I'll try, but it will be hard, because I really like reaching out to hug you.

I'll be nice about it, Mommy.

Can I hug you?

Not now. Check with me later.

Autonomy, Paternalism, and Colleagues Gone Wild ~ by Jay

crossposted from Modern Mitzvot

Angie asked me to write about that strange story from New Jersey - the one where a surgeon placed a temporary tattoo on the abdomen of a young woman, without her knowledge or consent, while she was anesthetized for back surgery. I'd read other blog posts on the topic but I just read the story itself for the first time, and was kind of stunned to realize that the surgeon admits he did it.

Kirshner does not deny placing the tattoo - and has left washable marks on patients before to improve their spirits, his lawyer, Robert Agre of Haddonfield, said last night. He said none has complained.

To improve their spirits? He actually said that? The article goes on to say that the surgeon is offended by being sued because of the implication that his actions were "prurient". He's offended? Wow. Just, wow.

I agree with everything Brown Shoes said: this is troubling because it is sexist, and also because it raises a deep concern about the actions of doctors who can't distinguish between their own desires and their professional obligations. And I also agree with PhysioProf about the culture of arrogance that still pervades medical training, especially surgical training.

Everyone I've read on the subject, even the ones that don't think this sicko's action is "all that bad", have taken for granted that patients have autonomy, both bodily autonomy and autonomy of action. It's a given, a fundamental tenet of medicine, right?

Maybe. The three pillars of American medical ethics* are patient autonomy, benificence and non-malificence. We accept that patients have the right to accept and refuse medical procedures and (as long as they retain the capacity to make decisions) they have complete autonomy over their treatment. We also act in their interests only (benificence) and do not ever act against their interests (non-malificence). (I believe that participating in drug company marketing violates the non-malificence tenet, but that's a rant for another day.) I learned those three terms in the first week of medical school. Everything I've done since then, every conversation I've had about withholding or withdrawing care, every DNR order I've signed, every time I've talked with patients about surgery or screening tests, has been informed by those standards. But if you look at the sweep of history, they are almost brand-new.

Current thinking about medical ethics developed in the 1960s and 1970s in response to the explosion of medical technology and the demand for increased patient involvement in care. For a profession that claims Hippocrates as an ancestor, forty years is the blink of eye. My grandfather practiced medicine from 1927 to 1980. He started compounding arsenicals for the treatment of syphilis, and using creosote for coughs, and retired in the era of ICUs, CT scans, MRIs and pacemakers. But the real revolution in his professional lifetime was the acceptance of patient autonomy. That not-so-simple idea has changed medical practice more than all the technology put together.

Despite the widespread acceptance of patient autonomy, paternalism is not dead. I do believe this particular loon is a one-off, a deeply troubled man who deserves censure and probably also needs help. But PalMD is wrong when he writes

The days of systematic pathologic paternalism on the part of doctors is long gone. It may linger in places, but it's just not part of the culture anymore. Doctors are authorities. We know things that others do not, and use that knowledge to help people. We have an unequal part in the doctor-patient relationship which is potentially (but rarely) abused. To level this relationship senselessly, to claim that doctors have no different skills or knowledge than others, is to abandon our responsibility to our patients. (emphasis mine)

In the first sentence he announces the death of paternalism and in the third he brings it back to life. I am not an authority, and neither is he. I may know more about the pathophysiology of insulin resistance than the patient I saw at 11:00 AM today, but she is the authority on her diabetes. She knows how it affects her life, how her sugars react to what she eats, how her body responds to the medications I've prescribed. We are in an unequal relationship, but I have to work to overcome that in order to help her. It's not enough to sit on my stool and be confident that I'm not abusing my position. I have to recognize the ways in which that power imbalance interferes with my patient's health, and figure out a way around it.

The asshole who placed a tattoo on a young woman's body may be an anomaly, but our colleagues who still place themselves above their patients are legion. We need to recognize all the ways in which we deny our patients their true agency. I am grateful to those who went before me - including a bunch of second-wave feminists - who started this conversation, and I will continue to honor them in my work and my daily life.

_______

*By "American medical ethics", I really mean "mainstream-English-speaking-mostly-white-American". Other cultures, including many with a substantial presence in the US, hold very different beliefs about the role of the patient and the physician, and about the role of the family and community in decision-making. My obligation to autonomy also obliges me to figure out what that means to each patient and how to honor each person's values without compromising my own. Other countries, even Western European countries, strike a different balance among individual autonomy, social stability and resource utilization. The ethical structure I describe here cannot be assumed to apply elsewhere - or even everywhere in the US.

New Normal ~ by Jay

Tigermom describes the new normal at her friend's house. How do they do that? people must wonder. I couldn't possibly....

and maybe we couldn't. Maybe we would find a nice nursing home for our family member. That would be OK, too; it would be our new normal.

How do they do that? Lots of ways. Often it happens gradually, the way we acclimate to a change in altitude. Our bodies adjust, our psyches make room for the unimaginable. Or what would have been unimaginable last year, last month, even last week. Now it is the stuff of daily life. It is the new normal.

How do they do that? Sometimes by not thinking about it. Denial is not a river in Egypt. It's also not always a bad thing. Denial is our mind's way of allowing us to keep moving, keep walking, keep eating, keep on keeping on, even while something deep and important is shattering within us. Denial is a survival mechanism. Denial is the way we unconsciously turn a sudden change into a gradual adjustment. See previous paragraph.

I used to ask myself how do they do that? every day. How do people go on after a tsunami? How do people joke and play cards with someone who is dying? How do you go on after you bury your child? And I know people ask the same about me; how do we go on after two disrupted adoptions?

I don't remember much about the conversation I had with Sam when my father died. I know he told me what he knew, and I told him what it meant, and then I said "I can't do this". And he said "You don't have to do it alone". That's my answer. I don't do it alone. Like Tigermom's friend, I keep on because I have to, because I can, and because I don't have to do it alone.

Life Interruptus ~ by Tigermom

Friend has a husband with a terrible illness. Their lives have changed over a few months from regular busy to tragic. Friend's Husband now needs 24 hour skilled nursing care. Prognosis unclear, but likely not so great.

Yet, their kids still go to camp and activities, Friend still goes to work, kids even crawl into bed with their Dad to watch DVDs together on a laptop screen while they snuggle. Dad can hardly communicate, but they have a life.

This is their new normal.