Tuesday, March 30, 2010
Monday, March 29, 2010
Sunday, March 28, 2010
Your experiences outside of the classroom or lab are just as important in shaping you as the physician you will become. Live, play, love, listen. Don't let a singular focus for the future make you miss smelling the roses. The roses are key.Yes, they are, and not just because they will shape you as a physician (or, as the poster also writes, because broader experiences will make you a more competitive applicant). All those other experiences are important because they shape you as a person, as a woman, as a human being. Sometimes the most interesting and important lessons and relationships are side trips off the main road. Robert Frost may have been overused and often misquoted, but he had a point: "I took the road less traveled by/and that has made all the difference".
There's a fair amount of irony here, because I was a high school student with a clear career path. I decided to go to medical school when I was 14, and no one who knew me then is surprised that I got there. My mother says "You were determined". My college applications certainly looked that way: 500 hours of service as a candy striper; two years on the editorial staff of the Yearbook; a bunch of AP courses and college-level summer school and science prizes and French language awards and an extra year of math and biology. I didn't do that to polish my resume; I did it because I loved it, and it fit in with the choral singing and music theory and work onstage and off in the theater. No matter what motivated me, I looked good on paper, and when I run into friends from high school, they figure it was just like that all along - a smooth ride all the way.
Not so much. When I got to college - my first-choice BigName college - I found I didn't really want to follow the script. I spent freshman year singing, acting and taking pre-med pre-reqs so I could get them out of the way before junior year, when I'd have to start independent work in biology, because of course I would be a bio major. By sophomore year, I'd realized that being a bio major would require so much lab time I'd have to give up the singing and the acting (and the stage managing and costume designing and writing for the school paper) and I wouldn't get to take any of those really interesting English courses my friends were considering. Second-semester organic chemistry didn't go so well and I really didn't want to drop it and spend the summer taking it again. It just didn't seem worth it. I realize now I was also depressed, but at the time I just felt overwhelmed.
I decided in spring of my sophomore year that I wasn't going to med school. I declared my major as English/American Studies, spent the summer at a local college taking courses in modern poetry and the Victorian novel, and went back to school that fall to study Chaucer and 19th-century American religions and to stage-manage three plays and a musical. It was a great relief.
Partway through junior year, when the depression lifted, I realized I might have over-reacted. I still wanted to be a doctor; I just didn't want to be a pre-med. I'd already taken all the required courses, so I signed up for the MCATs. I met with the pre-med advisors, too, and they said I should get a master's in biology, because I wasn't very competitive. I didn't want a master's in biology. I wasn't willing to give up completely, but I also wasn't willing to waste any more time doing what I was supposed to do instead of what I wanted to do. I decided that I would apply - once - and that was it. If I didn't get in, I'd find something else to do.
I did apply, and I did get in - off the wait list to the school where my father was on faculty, after the chair of his department intervened with the admissions committee. I went to med school with the bare minimum of preparation: a year of bio, two years of chemistry, a year of physics, math through calculus. No biochem. One semester of undergraduate vertebrate zoology, but no physiology. What I did instead: piles of poetry and drama and novels; some art history and sociology and religion; hundreds of pages of writing. I managed to pass all my med school courses anyway, and honestly? understanding narrative and meaning and language have been far more important in my work than the nuances of the Krebs cycle.
Even more than that, though, I enjoyed college. It wasn't just a way station en route to medical school. I learned more from my friends than I did in class. I wish I'd slowed down and enjoyed it even more, but I'm glad I stepped off the straight and narrow, even a little bit. Yes, it made me a better doctor, but it also allowed me to grow into myself as a woman with passions beyond my work.
My advice to anyone who's thinking about medical school is to do what you love. Be a bio major if you love bio, but if you don't, major in art history or drama or Russian lit or psychology or dance. Look for other things you could do besides medicine. Determination is a wonderful thing, but it's not destiny. Live your life, now; don't walk through it as if now doesn't matter. Take the road that calls to you, even if it's the one less traveled by.
Saturday, March 27, 2010
E: My parents call me pumpkin and pie and sweetie and Evo-levo. I wonder what Laura would call me?
T: Who's Laura?
E: My mom. My other mom.
T: Can I ask you a question, Eve? If Laura came here, and she said you could choose to stay here or...
E: (interrupting) She wouldn't do that. She arranged for me to be adopted because she couldn't handle having two children.
T: But what if she did ask?
E: I would say "You should move here to OurState, and live near me".
Thursday, March 25, 2010
If I didn't say anything, I'd have to live with that sense of coming disaster, with the flavor of anger on my tongue. I'd have to live with Sam pulling further away from me, away from the snake that he never seemed to notice. He'd go as far as he could to avoid the thrashing, screaming, crying scene. You always get to choose, he'd say. You choose when we argue, and it's always the middle of the night. It never felt like a choice to me; it was a battle with the snake, between the loneliness and the conflict. Sam told me the snake didn't exist. My mother always said the same thing: you're over-reacting. You're seeing things that aren't there. But I could feel the snake. It was real.
When I was in my 30s, I sat with a wise man when he named the snake. He said "I can deal with trouble". He wasn't talking about me; he was talking about facilitating groups, but I sat still and listened. "Trouble is out there. It's visible, and I can get my arms around it and manage it. What gets me in the undertow. I can't see it, but I can feel it, and it will pull the group under. Sometimes the facilitator's job is to turn undertow into trouble".
Turn undertow into trouble. Name the snake. Dive down into the water, pull it out, show it to everyone and say "Look! Here's a snake. What shall we do with it?".
With a safe space to try it out, I discovered that yes, the snake was real, but it was smaller than I thought - or maybe I was bigger. Naming it made me less afraid. Being less afraid helped me slow my reactions. When I slowed down, Sam stopped withdrawing - or at least didn't go quite so far away. And eventually, slowly, tentatively, we were able to manage the trouble together.
Last week I felt that snake coiling around my ankles again. He's been gone a long time, but I haven't forgotten him. I know his name; I know why he's here. I named him to Sam, but we haven't - yet - been able to bring him to the surface. He's still there, swimming lazily under our days and nights, waiting. Someday soon, before he gets bigger, we'll have to turn this piece of undertow into trouble, too, and hope for calmer seas ahead.
Tuesday, March 23, 2010
If I had a dollar for every time someone asked her about her thumb, I would be a rich woman. Last summer, my first toddler summer, I heard these questions way too often. I started to fret about what 12-step program Nora would need to enroll in to break her of this addiction. Visions of one of my outcast 9th-grade students, who still snuck a suck when she thought no one was looking, haunted me. I worried Nora would become that kind of “freak.Eve sucked her thumb. When she started she was about two months old and we were delighted. She could always find it; it never rolled away or fell on the floor. It didn't need to be clipped to her clothing and couldn't be left behind in daycare. At night we'd hear her start to fuss over the monitor, and we'd whisper "find your thumb" - and sure enough, we'd hear "thup thup thup" and back to sleep she'd go. Bliss for all concerned.
We were happy about it, but other people were not. Strangers stopped me in the store and said "how long are you going to let her do THAT?". She wasn't even a year old. Never mind the whole telling-other-people-what-to-do-problem; I couldn't figure out why it was so distressing to people to see a child soothing herself. Isn't that a good thing?
By the time Eve was three, I had heard enough comments to start to wonder. I called my friend the orthodontist, and she said "When she's six, you'll need to do something, but most kids stop by then". Her dentist - the second dentist - shrugged and said "She'll need orthodonture anyway, because she has a crossbite, so I wouldn't worry about it". The more I thought about it, the more I wondered precisely what I could do if I did decide to take action. I couldn't take her thumb away. I certainly didn't want to start yanking it out of her mouth - if she didn't need to suck it for her own reasons, I figured she'd do it out of three-year-old oppositional habit. Sam agreed, and we let it go.
When Eve was four or five, we had a Very Bad Day. We had driven home from my mother's, and had stopped twice because someone asked to go potty and then refused to use the restrooms in the gas stations. Sam wasn't with us and I was very irritated. We got home and unloaded the loot from Grandma's and Eve continued to fuss and complain and Not Listen and finally I looked at her and realized she was taking every small object she could find and fidgeting with it. She had the baby doll's headband in her grip and was twisting it until I was afraid it would break. I thought "something's wrong with this picture", and said "Sweetie, are you trying not to suck your thumb?" and she burst into tears. "They say I'm a BABY", she wailed. It took me an agonizingly long time to coax her into my lap ("Harry sits in his mother's lap, and Harry is 14 years old") and she cuddled against my shoulder and sobbed out the predictable story - kids at school had seen her sucking her thumb and started to call her names.
The solution - Eve's solution - was to stop sucking her thumb in public, but continue for soothing in private and to go to sleep. We gave her a worry stone to keep in her pocket instead (there are some advantages to being married to a geologist - we have lots of small smooth stones) and we promised, at her request, to remind her quietly if we saw her put her thumb in her mouth in public. After about a month, she gave up the worry stone, and I haven't seen her suck her thumb since then. I don't know when she stopped sucking her thumb at bedtime, but by the time she was 8 and had her palate expander placed to fix the crossbite, she was done.
It was the first - but not the last - lesson in helping my daughter manage something that is entirely out of my control. The dance of parenthood: knowing when to let go and when to step in. And when not to listen to strangers.
Monday, March 22, 2010
Death is so scary that leaders in our field are suggesting we stop using the word. Don't talk about death; it turns people off. I don't agree. We need to keep talking. This is our chance to exert leadership and help move the national conversation forward, to bring death out of the shadows and address the fear directly.
We may address the fear, but I don't think we'll demystify the experience. The more I see of death, the more mysterious it is to me. I wonder this happens to midwives and obstestricians - are they more aware of the mysteries of birth as they become more experienced?
I read about grief, about loss, about making meaning at the end of life, about the physical changes that come as people approach the end. I know how to use medications and non-pharmacological therapies to ease suffering. I understand the ways roles can change as children come to care for their parents. And yet the closer I stand, the greater my wonder at what we can never know. Physiology tells me nothing about the patient who lives for weeks without food or water. Germ theory doesn't explain why the man with resistant bacteria and fungus in his blood is awake and talking to me. Understanding the loop of Henle doesn't tell me why one man with renal failure died in 24 hours and another is alive three weeks after his last dialysis.
The families struggle - will it be easier for her to let go if I'm here? If I go home? Does she want me to sit with her or to get some sleep? We can't know that, I reply. Do what you need to do to take care of yourself. Sometimes, in hindsight, we can see what they're waiting for, but we never know ahead of time.
We do need to talk about it. We need to be witnesses to the journey, loving companions in the struggle, listeners to the story. We need to be proud of what we do, and let that be our brand. We offer comfort and meaning in the darkest of times. But we can't know the unknowable; at the core will always be a mystery.
Sunday, March 21, 2010
I don't know. What do you think?
I don't think so.
Because everyone is good in some way. Everyone has a piece of G-d in them, in their heart or in their body. So if G-d sends people to Hell, He is sending Himself* to Hell, and G-d wouldn't do that.
I never thought about it that way before.
What happens when people die?
Their bodies stop working, and their hearts stop beating.
Do they go somewhere else?
Some people think so. Some people think we're reincarnated as another person, or an animal, or a plant.
I think we don't really die.
What do you mean?
I mean that people die, but if we remember them and we still love them, then they're still alive inside of us.
I use only gender-neutral terms for G-d, and I know Eve has not heard G-d called "He" in religious school, but apparently the image has asserted itself from other sources.
The good news: the weather has been gorgeous, we have a large pile of mulch in the driveway and Sam (now home) is happily redistributing it onto the flowerbeds. I managed to get home in time for (late) lunch and may actually get to stay here. We didn't have time for our usual French toast breakfast today, so we're having challah French toast with bacon and eggs for dinner. Sam came home from Nearby City with a cooler full of fresh fish; last night we had tuna steak, grilled rare, and we now have a pound of home-smoked bluefish in the fridge. My mother made chicken soup, so we're partly ready for Pesach. And Eve is loving having her grandmother around for a few days.
More good than bad, but no time to blog.
Saturday, March 13, 2010
Moses then convoked the whole Israelite community and said to them:
These are the things that G-d has commanded you to do: On six days work may be done, but on the seventh day you shall have a sabbath of complete rest, holy to G-d; whoever does any work on it shall be put to death. You shall kindle no fire throughout your settlements on the sabbath day. - Exodus 35:1-3
I was blessed, when my week finally ended, to find myself leading services last night. I prepared by studying the Torah portion; this week we have the last two portions of Shemot (Exodus). The first verses repeat the commandment to observe Shabbat and, specifically, to refrain from kindling fire. The remainder of the text recounts the collection of materials for and construction of the Holy of the Holies.
Our holy text is usually elliptical, almost cryptic, with tantalizing gaps and omissions that allow us to create midrash and meaning. There are no such blanks here. The materials offered by the community, the size of each acacia plank, the shape of the cherubim - each detail is described. Torah rarely tells us the names of individuals outside the primary narrative, but this week we read of Bezalel, the chief artisan, and his skill at carpentry. Torah rarely mentions women, but we are told that the women wove the hangings that defined the mishkan, and brought their mirrors to make the laver, place of washing, outside the tent. Torah rarely talks about the work of the people, but here we are told precisely how the mishkan is completed.
Why the specifics? What are we to make of this Biblical version of the New Yankee Workshop? And why is that passage about Shabbat stuck at the beginning? What’s the connection?
The injunction about Shabbat is followed by careful descriptions of specific types of labor. From this juxtaposition, the rabbis drew the 39 kinds of melakha (work) that are forbidden on Shabbat. Melakha is not work as we mean it today - work for pay. Melakha is comprised of all acts of creation and all acts of destruction. From this we learn that we are truly created in G-d’s image: as G-d created the world, so we create our own lives and the community around us. We are commanded to work during the week and to refrain from work on Shabbat; the contrast highlights the sanctity of both work and rest. Only by stepping back from melakha can we see it clearly; only by forgoing creation for one day can we fully appreciate it during the week.
When we chant kiddush on Shabbat, we remind ourselves that we have been brought out of slavery. Shabbat is a celebration of our freedom. We cease from work because we can; it is our choice. We sanctify our freedom to work and our freedom to rest.
In these parshot we also learn that all our creative work is melakha. Everyone in the community contributed to the mishkan; those named and those unnamed, those who brought linen and those who carved wood, those who wove and those who hammered copper. We can imagine, too, those who tended the fire and cared for the children and cooked the meals while the mishkan was built. All of that is melakha. All is work. All is sacred.
As they build the mishkan, the people of Israel are transformed from the rebellious tribe who created the Golden Calf and then worshipped the results of their own blasphemous actions. They now come together to build a space within which G-d will reside; they come together to do sacred work. The come together in melakha. And they come together, as well, to rest from that work, to rest as free men and women. They create, and they refrain from creating. That weekly cycle grants our lives a holy rhythm and offers us a pace and a space of healing.
Mordecai Kaplan challenged us to reconstruct the parts of Jewish tradition that do not seem relevant to our modern lives. We're certainly not going to put anyone to death for turning the lights on after dark on Fridays. The underlying value of Shabbat endures and seems even more essential in the 21st century, as Mary has discovered, but it is difficult to define melakha for ourselves. Mary figured that out, too. The rabbinical list of 39 kinds of work, redefined and modified over the centuries, doesn't work for me. My joy is enhanced when I can drum during services. Shabbat offers us the chance to connect with our community; much of my community is online, and many of most sustaining relationships depend on Email. And, of course, my paid work is demanding and consuming. How do I simply walk out and leave it behind?
Leaving my job on time for Shabbat became much more challenging for me last July. For the first 20 years of my career, I had been able to stop work early on Fridays. Even before we began observing Shabbat and lighting candles, I needed that time. I often finished my work week at noon on Fridays. I still had lots to do getting ready for Shabbat, but I had the time to shop for and make dinner, and prepare myself to light the candles and say the blessings. Then I started at hospice, and we had a team meeting at 3:30 on Fridays. It was supposed to end at 4:30, but it rarely finished on time, and then I had to complete the paperwork and write my signout notes and then I was there, and if a patient came in I felt obligated to see her before I left. I rarely got home before 6:00; most often it was closer to 7:00. I hadn't been to a Shabbat service except when I was leading, and then I had no time to prepare myself. Sam was frustrated, Eve was unhappy, and I felt guilty no matter what I did. I loved my work, but I missed my family, and I needed my Shabbat.
In December, we started a process to redesign that team meeting. We wanted to reduce the biomedical focus and spend more time talking about the emotional and spiritual experiences of our patients and their families. Spiritual experiences. I realized that I couldn't attend to the spiritual needs of others while I was ignoring my own. When we met to plan our new approach, I stood up in front of my staff and said "I would like to move the Friday meeting. I need to be home for Shabbat". Of course, they said. And that was that. Now our meeting is at 1:00 PM, and I can finish my notes, do my signout, and often leave by 3:30. I still take phone calls until 5:00, but I am home before Eve returns and I can get to the monthly 6:00 PM service without rushing.
I still have a lot to learn about melakha, and my own limits. I spent two hours today working on the taxes - not very Shabbat-like. It's only a first step - but it is the step I needed to take to ready myself for the extra soul of Shabbat, to honor my own contribution to the creation of our world, to recreate myself in the image of the Divine. To breathe in the extra soul which we are granted on Shabbat.
Shavua tov. May we have a good week, a week of peace; may gladness reign and joy increase.
Thursday, March 11, 2010
I did get some TLC on Tuesday, and that helped. Unfortunately, I haven't gotten a whole lot of sleep, and that leaves me with far less reserve to manage the emotional impact of the week. I can't write about the patients; those stories aren't mine, and they are too raw and too fresh to rewrite. But the adoption losses - those are my own, and they are kicking my butt this week.
Seven years ago this week we surrendered Rose. On Tuesday, I went Back To School with my daughter, who introduced me to her science partner as "my second mom". Today, I walked into a patient's room just when one soap-opera character, sobbing, handed her baby to another woman, saying "she'll take good care of you, I know she will".
For the first time in my life I was grateful that a patient was unconscious and alone, so I didn't have to explain why I burst into tears and left the room.
One more admission to see; five more notes to write; then I can leave. I'm getting my hair cut, so I'll have that luxury of a massaging shampoo, and then Sam will have dinner waiting, and to hell with the paperwork and the dishes and whatever else there is to do tonight. I am going to get into my pajamas and curl up with my family, and go to bed.
Tuesday, March 9, 2010
It means goodbye or see you later or I need to go now. It's rare that I hear it said with real feeling.
Take care of yourself. It's become almost meaningless, like have a nice day, or we should get together soon, or keep in touch. Just a phrase, tossed off as we run on to the next appointment.
I'm thinking about this today because I'm wondering how to put it in practice. I need a little self-care right now. There are too many young patients dying. There are too many small children left behind. There are so many reminders of my father, and so many other losses echoing in my heart.
My therapist used to send my on my way by saying be gentle with yourself. I can't quite see what that would look like today. I could leave my computer at the office and ignore the paperwork I haven't done, but then tomorrow will be longer and harder. I could curl up in the living room with a book, or go upstairs and watch TV, rather than do the dishes and clean up the dining room after dinner, but then the mess will be there to greet me in the morning, compounded by the breakfast dishes.
I can try to be gentle with myself, but tonight I need someone else to be gentle with me. Time to find Sam and ask for some TLC.
Sunday, March 7, 2010
Friday, March 5, 2010
Last night, we planned to have Mim's Thai Red Chicken Curry for dinner. I looked at the recipe on Sunday, put the ingredients on the list (nb: in the US, coconut milk isn't packaged in 270 ml containers. Interesting). Yesterday morning we took the chicken thighs out of the freezer, and yesterday evening I was stuck at work.
No problem; Sam can cook dinner. Except that when I called home and he asked me where the recipe was, I realized I'd never printed it out. Oops.
Then I remember that I'd tagged it for Delicious. I gave Sam my user name, he logged in, and there it was.
And it was delicious, too.
It worked #2:
Even dying patients get clogged ears, and they don't like it. Back when I was in private practice, I'd grab an ear irrigator from our drawer and head out to solve the problem. I'm not working in that office any more and we don't have ear irrigators at the hospice. That's OK; I can make one out of an IV catheter and a syringe. Well, turns out we don't have those catheters and those syringes either. What we have are the syringes used to irrigate Foley (urinary bladder) catheters.
Turns out if you cut off a short piece of the Foley catheter and put it on the end of a catheter-tip syringe, it makes a dandy ear irrigator. I am ridiculously pleased with myself. So is my patient.
Thursday, March 4, 2010
GF was diagnosed this winter with breast cancer, had a double mastectomy, reconstruction, and is almost through her course of chemo.
GF is a work buddy, our kids are good friends and our husbands are colleagues and friends.
I had not seen GF since her surgery. Not seeing Good Friend has not been intentional. We have to plan to have our paths cross since we work on different days at the same office and so on. But I wonder. Why had all this time passed since we had been together?
I met GF at the breast cancer center. She was in the back having labs drawn so I found her husband and sat down. He was doing some work, but stopped and we chatted. I could see emotions just below the surface, anxieties and fears. And all I wanted to do was give him a big hug. But I chose not to. We were in a very full waiting room. Yes a waiting room full of women with wigs and hats and all there for their chemo appointments and in all likelihood everyone would understand, but I chose not to.
Let me tell you about GF. GF is incredibly smart and funny and terrific at what she does. Her patients love her and almost all say they feel she has given them their lives back. She teaches as well and her students love her. They feel nourished and held by her warm attentive care. Her husband adores her. Her kids are smart and funny too. GF makes me feel alive and smart and funny with her. And she carries herself with poise and confidence and yet is the first to tell me her inner fears and concerns.
And GF has a gorgeous mane of thick lustrous shiny alive hair. Well did. Of course GF has no hair now. I knew she would not and we talked prior to her chemo about what that might be like, but it is the one thing that made me want to cry yesterday. I asked if I could see and feel her head. Of course, she said. So I gave it a caress and told her I missed her long thick hair. She told me she does too and that she has a new respect for bald men. She told me about her childrens' comments and concerns and one child's desire for her not to wear a hat because he thinks she looks strong and beautiful with her head bare.
We talks for hours. All day. About everything. Cancer. Chemo side effects. Work. Patients. Desires for the future. Family. Children. The day was really a luxury. How often do two working mothers get to be together uninterrupted for 6 hours?
Afterwards, I drove GF home where all day her mother had been cooking delicious healthy food for her daughter. Her mother fed me too and I took it all in: the food, the smells, the love of her mother, and the quiet strength of her mother's fierce care-giving.
Chemo gave me a gift yesterday, though today I am sure it only gave GF diarrhea.