A Pink Ribbon I can Get Behind ~ by Jay

You can buy one here.

From The Sacred to the Mundane ~ by Jay

Rabbi Joy Levitt (with her husband, Michael Strassfeld) has enriched our Seders for the past ten years, and Rabbi Joy Levitt has a piece in the Times that made me cry.

Go click that link to the New York Times and read her piece. I'll wait here.

She writes

But now, when I think about that afternoon, I am in awe at the intimacy of what we experienced together. In its best moments, what we clergy do is live in our congregants’ lives, sometimes — too frequently — in their pain. Why they let us in has always been somewhat of a mystery to me. But when they do, as Harriet did that afternoon, we get a glimpse of holiness that is so luminous it is sometimes hard to go back into the world.

Anything can become routine if we do it often enough, and especially if we are doing it by rote, without our full attention. Death creates a lot of paperwork. Rabbi Levitt's essay reminds me how important it is to be fully present, even when it's the third patient to die that day, even when I was hoping to leave a half-hour ago, even when I'm tired. Those moments of holiness don't just happen; they are created by our openness to connection.

Just as the Rabbi took the patient's pulse, I speak to my patients of God, and of meaning. The moments surrounding death are a liminal space. The boundaries between body and spirit, between medical and pastoral care, between family and caregivers, become blurred and fade away. We stand together in the presence of mystery, and the survival of love beyond death.

Conversations With Sam ~ by Jay

Sam, I just got home and saw this morning's paper. Did you see that article about the car accident?

Yeah. It sounded kind of like Dad's car, and it said the driver was killed and couldn't be identified at the scene. I've been worried all day.

Why didn't you do something?

Like what? They didn't have any more information.

I'm calling the coroner to find out if they identified him....they did, and it's not Dad.

Well, that's a relief, but you know, Jay, normal people don't have the coroner on speed dial.

This is how I walk ~ by Tigermom

My friend The Happy Hospitalist talks a lot about preventative medicine. He can cite you chapter and verse about how much Americans can reduce their incidence of diabetes and heart disease with lifestyle modifications. And how Americans can reduce their health care costs by not being having diabetes and heart disease.

Tigerdad got on the healthy lifestyle bandwagon about 3 years ago. He started to eat more fruits and vegetables, less red meat, and fewer carbs. He had always run on the treadmill we have in the basement. In the old days he ran 2-3 times a week for about half an hour.

New Tigerdad put up a TV in front of the treadmill complete with Tivo. Tigerdad ramped his runs up to 6 days a week for 45 minutes. I make him rest one day a week.

He started to feel better. His stamina slowly improved. The distance he could run in those 45 minutes got longer. His started to tighten his belt more. His dress shirts began to look loose around the collar. His jackets started to look ridiculous. He was all caught up on Must See TV.

And Tigerdad is not someone with lots of extra time. He works hard and when not at work he plays with the cubs and goes on Saturday night dates with me. So how does he do it? He did something I cannot do, he gets up an hour earlier.

So ten months ago, I got on the bandwagon too. Something clicked for me. Yes, I had a family event coming up complete with pictures to be taken and I wanted to take a few off. But more than that I felt the epiphany that I am a grown-up and that I really did not want the many joint replacement surgeries that my mother has had. Really anything to avoid going under the knife for me.

So I started to walk on the treadmill.

Only on days I was not in the office at first. No way am I getting up early like Tigerdad.

Tivo'd soap operas were a good incentive. Guilt free TV.

I started to walk two times a week at first. For 25 minutes - the amount of time of a Tivo'd half hour show with a warm up and cool down. Then three times a week. In 3 months I started to negotiate with Tigerdad for morning time on the treadmill. I asked him to either skip his day or get up even earlier so I could get in a walk before work.

I started to feel better. My stamina slowly improved. The distance I could walk in those 25 minutes got longer. My pants started to feel a little loose. My shirts started to hang. My thigh muscles started to feel rock hard. I was caught up on my soaps!

But this last month I have been a slug. I moan when it is time to get up. Tigerdad has to blare the radio alarm for me and I still fall back asleep. My kids are dressed and ready to go before I am. And I have been eating lots of junky food.

That's when I realized ... I have been behaving like a bear! I was getting ready to hibernate and enough was enough.

So I make this public commitment to you dear readers to keep a log of my walks like Happy logs his runs.

October 27, 2010 I walked 2.7 miles and for 25 minutes.

Feel free to join me on my walks. Let's stay awake this winter.

Why We Surrendered

Dawn has two posts up about a custody case in the midwest. Grayson, now three, has been living with the same family since he was 8 days old, but they have been unable to adopt him because his biological father has not consented to the adoption. Grayson's father first indicated his desire to parent Grayson when the boy was 17 days old.

This is why we surrendered Jesse.

Dawn says "I'm sure the Graysons were told to sit tight". Yes, I'm sure they were. While the attorney we were using - also the agency's attorney - told us we had to surrender, many of our friends told us to sit tight. Jesse's mother was isolated, estranged from her family, and without significant resources. Our friends suggested that the longer we dragged it out, the less likely a judge would be to remove the baby. They also told us that she probably couldn't afford a lawyer, and she might just go away. Sit tight. Get another lawyer. Fight.

We couldn't figure out how any judge would ever rule in our favor. We knew that when we took custody of Jesse, his mother retained her parental rights; we knew she had time to change her mind; we knew she didn't want to complete the adoption. We also knew that she had been pressured into placing the baby by her partner. We knew we had no right to keep him.

But it's in his best interests to stay with you, said our friends. You can offer him so much more. Sure, we had more money, but we don't actually believe that makes us better parents. It couldn't possibly have been in his best interests to remain with us if he wasn't going to be able to stay. We surrendered Jesse when he was 10 weeks old. It was horrible for us, but not for him. If he had been older, it would have been so much worse for all of us.

Grayson's father has actually been much more consistent than Jesse's mother was; she went back and forth for two months before actually requesting his return. The separation will be difficult, but that's not the dad's fault. As Dawn says, he's not the one who tried to cut the baby in half.

This is why we surrendered Jesse without a fight. We acted in his best interests, because that is what parents are supposed to do.

Shabbat Amidah

Crossposted from PoeTry in response to an assignment about steps

It is traditional to take three steps forward and bow before beginning the silent Amidah.

Women's Ward, 1929
(Ancestors)

My grandfather sits in the photo on my desk in his
White jacket with one button undone. He has all his hair.
His mustache is trimmed as I remember but an unfamiliar dark color
He sits on the edge of the bed, almost in the shadows.

At the center of the picture is a young woman,
Startling in her resemblance to my oldest friend, born 30 years later.
They are both smiling, and the nurse
Hovers in the background, adding a note of propriety.

Blessed are you, God of our ancestors, who acted as the strength of Abraham and the shield of Sarah.

Wyoming Night, 1982
(Divine Power)

In your arms I first saw a shooting star
Power of God in the western sky.
So bright I hid my eyes against your chest.

So bright, our love that night, that I imagined
Everyone could see through the thin fabric of the tent.
Awesome and terrifying, the power of God.

Awesome and terrifying, next morning,
As we packed up camp and I turned away
From the light of the star, from the joining,
From the comfort of your arms.

Blessed are you, Sovereign of the Universe, who gives and renews life.

Bed 9, ICU, 1987
(Hallowing God's Name)

She waits.
The noise of the ventilator whooshes the air
In and out. The monitor
Beeps its message of alarm - blood pressure! oxygenation!
Her children murmur.
Please, they asked. We understand
But our sisters are missionaries - in Africa, in Siberia - And we need them here. Please. And so we continue.
Whooshing and beeping, clicking and humming,
The bed groans as it rises and falls
With the height of today's nurse.

And then I hear only singing.
Her children, come home from their calling,
Stand in a circle around her bed.
They fill the space with harmony, with joy, with love
For their God, for their mother, for each other.

And she is lifted up.

Holy are you, and awe-inspiring is your name, and there is no God apart from you. Blessed are you, Eternal One, who creates holiness.

Saturday Morning, 2007
(The Day's Holiness)

Quickly, while my mother is upstairs, I pile the newspapers,
move the as-yet-uncarved pumpkin to the other counter
and race through the dishes.

Our ballerina is warming at the barre, bending her head with neat bun
over her knee in line with all the other girls, but to my eye
more graceful. Her father
is at shul, I am praying.

We will have a lost Saturday, giving up
our routine to honor the visiting grandmother, forgoing
our chores because it's hard for her,
after 52 years,
after a life,
to spend a weekend alone, to look at the chair
in the kitchen, the cover over the pool,
the porch furniture under its tarp,
and not think of him dying on the driveway.

It is her gift to us today, an excuse
To skip the grocery store
Ignore the bills
Dodge the committee planning
Go outside into the autumn
And perhaps,
over lunch or ice cream or while we walk the dog,
to lay ourselves to rest.

Blessed are you, Sacred One, source of the holiness of Shabbat.

Alto Section, 1976
(Worship)

Blend! he shouts, and we stop mid-phrase.
I look at my feet, quite sure that I'm the one
ruining the sound, the voice that sticks out, too loud,
too flat, too something.

Listen to each other - softer, now, not shouting,
exasperation still evident in every syllable.
Listen. He raises his arms, nods to the piano, and we begin again,
measure 24, the sevenfold Amen.

Listen. I open my ears to the sounds behind me, and open my mouth
but I do not hear my own voice. Blend. And we do,
and each of us is in the music and the music is in each of us,
and there is harmony, and for the first time in my life,
transcendence.

Blessed are you, The Faithful One, who brings your presence home to Zion.

Hospice, 2010
(Thanks)

I know everyone says this, don't they?
Everyone says you all are angels.
But I mean it, I really do.

Last night the nurse came in.
It was dark, I couldn't make out her face;
she thought I was asleep.

She came over to the bed
and bent down.
I saw her touch Mom's face, just for a moment,
and I could tell how much she cared.

An angel, I tell you,
like all the rest of you.
Brought here by God because we needed you.
I never knew this place was here.
I must have driven by a hundred times.
From now on, every time I'm near,
I'll offer a prayer of thanks.

Blessed are you, The Gracious One, whose name is good, to whom all thanks are due.

Bedtime, 2004
(Blessing for Peace)

Mama, what is war?
War is a fight between countries or groups of people.
Is it bad?
Yes, it is. People are killed and hurt in war, and it doesn't really solve anything.
So why do we have war?
I wish I knew for sure, sweetie. We have wars, I think, because we haven't come up with a better way of settling our differences.
Will there still be war when I get big?
I wish I could say "no", but I think there will still be war.
When I grow up, my friends and I will figure out how to make it better.
I know you will, honey. I know you will.

Blessed are you, Compassionate One, maker of peace.

But He Meant Well ~ by Jay

What do you tell your daughter to do when a boy she doesn't know, two years older and much bigger than she is, drapes his arm across her shoulder and says "so how ya doin' "? If you're the mom and you hear this story a couple of weeks later, how do you respond?

I would have responded the same way my friend Cassie responded to her newly minted sixth grader: get more info (no, she doesn't know him; he did it a few times the first week of school and not since then) and then remind her that no one is allowed to touch her without her permission. Cassie added that sometimes saying "Hey, cut that out!" very loudly will stop the guy in his tracks, and that she would like to know if this happens again.

And, like so many of us, she wondered if that was enough, or too much, or just right. So she called on the mom network by Email, and the rape culture replied to her.

Oh, it was a reasonable response on the surface. We don't know what he was thinking, after all. Kids are kids; they're young, they don't know better. How nice that an older boy is taking an interest in your daughter. We don't want to hurt his feelings. We don't want boys to feel like they can't touch girls, do we?

Well, yes, we do. We want boys to know that they need permission to touch girls. We want them to know that yes means yes and that if they keep going until they hear "no", they have already done something she doesn't want. I don't give a damn if men and boys feel deprived that they can't touch women whenever they want. They can give up that piece of privilege in exchange for the safety of Cassie's daughter, and mine.

Telling girls that they should assume boys mean well is rape culture. Telling them to ignore their own discomfort and "be nice" is rape culture. Letting boys drape their arms over the shoulders of girls they don't know is rape culture. I don't care if it's middle school. I don't care if it's elementary school or day care or a college mixer. I don't care if it hurts someone's feelings or makes some guy feel confused about what he should do. If you're confused, ask. If you're not sure if it's OK to touch her, then don't. And don't make excuses for other people who do.

Things That Work ~ by Jay

Sometimes I'm appalled at how dependent I am on my technology. When my cellphone can't access my calendar, I can't get find the addresses for my home visits. When my computer freezes, I can't write my visit notes (or send in my billing). When my Bluetooth headset keeps disconnecting, I can't safely use the phone when I'm driving. I no longer have a paper address book - everything's in my Contacts. Which reminds me, I should back up the computer tonight.

The last few weeks I've been increasingly aware of that dependence, since my phone wasn't working well. Some days it couldn't hold on to the Bluetooth signal from the headset. Some days it couldn't find the cellphone signal. Lately it can't find WiFi about half the time, which makes it much harder to use the calendar. It's a small thing, but it's like having sand in my shoe - it rubs constantly and slows me down.

There's a voice in my head that says I should be able to do fine without a cellphone at all, and I certainly shouldn't need WiFi and Bluetooth. Entitled spoiled brat, the voice whispers. The voice wasn't swayed by the ways in which my job requires me to use a cellphone. The voice didn't care about the fact that this was my third version of this phone; the company replaced it twice because of other hardware problems. You're not eligible for an upgrade, said the voice. You have to wait. I could have spent another four or five hours trying to solve the problem with software updates, phone calls to tech support, and a trip to the service counter. Tonight I decided that I valued my time and my peace of mind enough to tell the voice to go hang. Turned out when I got to the store that I am already eligible for an upgrade, so the voice was not only sanctimonious and self-righteous, it was wrong. So there.

I am deeply grateful for the material privilege that allowed me to do this, and, again, amazed at how much happier I am when I have the tools I need. I think I've balanced my work and my life well, and that balance is resting on top of a pile of technology. As long as the power stays on, I'm good.

National Coming Out Day ~ by Jay

Today is National Coming Out Day. I am a straight ally. I want to work to create a world in which no one needs to come out, because no one needs to be closeted - a world in which children and the adults they become are accepted, loved and celebrated for who they are and are free to love, in turn, the people who are right for them.

I donated my Facebook status via HRC's Facebook app, but didn't put my name on the WE COME OUT announcement in my college's paper. I'm not comfortable equating saying that I'm coming out just because I identify myself as a straight ally. I have finally learned that when someone comes out, it's not about me.

The wording of the college announcement also seemed to me to exhort closeted GLBTQI folks to come out, as if it is their obligation to do so in order to fight injustice. I will not tell anyone they should come out. When I speak out as a straight ally, I may lose a relationship with someone who disagrees with me. When my friends come out as gay or bisexual or transgender, they are literally risking their lives. They may be ridiculed, ostracized, bullied, harrassed, assaulted, or killed. They can be fired with impunity in many states. Their kids could be taken away. Who am I to say they have to take those risks? It's my job to push the rest of straight society to reduce that risk. We need to use our straight privilege to fight injustice. We need to tear down the walls of the closet - and until we do, we need to respect those who stay in the closet for their own protection.

Arwyn addressed this issue in a recent post about how allies often let our righteous outrage get in our way. I'm sure I've been the hapless speaker in both of her scenarios, and not that long ago. Now I hope I can be a better listener when my marginalized friends talk to me, and save my outrage for the conversations with others who hold privilege, which also means we hold the power to create change.

"It is not your obligation to complete the task,
but neither are you at liberty to desist from it entirely..."
Pirke Avot 2:16

Football Takes On Violence Against Women ~ by Jay

I wish I were talking about the NFL. Ben Roethlisberger is playing this weekend after serving a four-game suspension. he was accused of rape - for the third time. He was originally suspended for six games, but it was reduced to four on appeal. Three accusations of rape, and he sat out four games.

I wish I could imagine anyone connected with the NFL making a video like this one, from Australia:



It's not perfect. I know Australian footballers have their own issues with sexual assault. I'm also not entirely thrilled with the video. I don't like the "what if it were your mother/daughter/sister?" meme at all. Women's safety matters because women are people, and not only because they have men who care about them.

On the other hand, it's a really good start. The video talks about emotional as well as physical violence. The message is clearly aimed at boys and men, and the footballers recognize that it is their responsibility as men to change their behavior in order to end violence against women.

I'd love to see something like it from the NFL, but I'm not holding my breath.

Quote For The Day ~by Jay

Forgiveness is not the misguided act of condoning irresponsible, hurtful behavior. Nor is it a superficial turning of the other cheek that leaves us feeling victimized and martyred. Rather it is the finishing of old business that allows us to experience the present, free of contamination from the past.

-Joan Borysenko

Blogging Anonymously ~ by Tigermom

So this week Mothers in Medicine is hosting a Metablogging week. What is that? It is blogging about the experience of blogging. Navel gazing for sure, but stuff that hits me to the core.

I write infrequently here, though I comment freely on my favorite blogs, because of my conflicted feelings about blogging.

I love to read blogs. I enjoy practicing writing out my thoughts. I live for Fizzy's cartoons, the things people say to Dr. Grumpy, and The Happy Hospitalist's analyses about healthcare.

But I worry about being judged. I worry about my own privacy. I worry about my patients' privacy.

I learned about blogs when Mama told me she had started one and I started to read hers. A curious first read escalated quickly into nightly reading sessions while sitting with Cub #2 at bedtime. When Mama and Jay started this blog, I wondered if I would ever feel brave enough to do similarly.

Reading blogs lets me into the worlds of so many people. And it is that privilege of listening to peoples' stories that appeals to me in my work as a psychiatrist.

But I would rather disappear than tell my own deepest darkest secrets.

While I think it is therapeutic and thought provoking to let it all out, I fear being judged more.

So, I could blog instead about everyday things, not deep dark secrets: the vagaries of parenting, work/family life issues, medical practice issues?

I feel too busy parenting to write much about that.

I feel more or less in balance with my work and family, ie never quite in the right balance.

I cannot see any way to write about my patients and still respect their privacy.

And Dinah, Clink, and Roy at Shrink Rap channel everything I think about how to practice psychiatry already even when they disagree.

My first post was inspired by a real event that moved me. As was my second or third. Being moved seems the right motivation to write. So maybe I have a high threshold for being moved. I shared my blogging with Tigerdad, my sister - who is a real writer, and my mom - my eternal support. And they all have been supportive.

But I struggle with privacy.

Psychiatrists grove on conflict so feel free to interpret, but gently please.

Booze and Babies, Redux ~ by Jay

Yeah, I'm wading into this again.

The Journal of Epidemiology and Community Health recently published the results of a prospective study investigating the impact of various levels of alcohol consumption during pregnancy. This is the best evidence we have yet, and it confirms previous research. They performed cognitive testing on five-year-olds, and found that two drinks a week during pregnancy does not correlate with any cognitive decline.

I suspect that women who drink more heavily than that during pregnancy have other problems as well. I'm not saying that women should drink during pregnancy. It's clear, however, that the tsk-tsk-tsk, don't touch that glass, approach we've been taking is not supported by the evidence, and it ignores a host of other issues that put women and their children at risk.

Bluemilk said it best in her comment on my last post on this subject:

If only strangers felt the same readiness to intervene on behalf of an in utero baby when its mother is being beaten (ie. the frequency of domestic violence is much higher for pregnant women than for non-pregnant women), going without enough food, or being forced to live in highly polluted neighborhoods.

Alas, drive-by concern for a baby's health is not so eagerly pursued when it does not also involve controlling women's bodies.

We should use the power of the government to put decent grocery stores in poor neighborhoods and reduce the levels of heavy-metal contamination in the soil. In the US, we should also make sure pregnant women have access to decent prenatal care. We should address prenatal education as a collaborative process, not an opportunity to shame women and express our racism and classism.

If we really cared about children (and their mothers) we'd be doing a lot more to address the societal issues that put them at risk. What we're doing now is abdicating that responsibility and trying to control individual behavior instead. That's precisely backwards.

Things I Could Do Without, Survey Edition ~ by Jay

I like to be a good scientific citizen, so when a professional organization sends me a link to a brief research survey, I click on over and do my duty.

Today I was asked to opine about whether I discontinue certain medications (like the cholesterol-lowering medicines called statins) in patients when they are referred to hospice or palliative care. I was not happy about the way the two disciplines were lumped together. Patients who are not yet on hospice usually want to continue active treatment of their disease; for patients with a history of heart attack, statins are active treatment. Hospice goals of care are different and do not include active treatment of disease. Hmm. Not sure about this research group. On the other hand, it was a 20-item survey; what would it hurt me to answer? Onward.

And downward. 10 questions about scenarios in which I "routinely" discontinue "some or all medications" at the time of referral, or continue them until "the patient can no longer swallow". The scenarios varied by disease process, life expectancy and history of heart attack, but the answers were the same, and for every one I checked "other" and filled in the text box. After the second I started pasting the same answer in every box. I do not discontinue or continue medications "routinely", or in any other unilateral fashion. I discuss options with the patient and family and they make choices based on their priorities and values. I offer them the option of stopping, but it's not my decision.

I was clicking along, rolling my eyes, until I reached question 15:

How often do you discuss your decision with the patient?

A) Always
B) Frequently
C) Sometimes
D) Never

I stopped rolling my eyes and starting muttering under my breath. Seriously? Are there people out there who stop medications and don't discuss that with the patient? Are you kidding me? Who has to swallow the damned things? Who has to suffer the side effects? Who, in the end, has to pay for them? Not the doctor.

We're supposed to be the specialists who listen to our patients, who take values and opinions into account. We work collaboratively with nurses, but we're not supposed to use them as shields to protect us from conversation with out patients. No, I don't think statins have any significant benefit for patients who elect hospice care (and I'm conservative and skeptical about their use in primary prevention). Some of my patients are relieved to learn they can give them up. Some of my patients think statins are life-sustaining, and they are terrified to stop taking them. My job is to take both beliefs seriously. No decision is "routine" if it's your life that's being decided. My patients have autonomy. I am the coach on the sidelines; they're actually playing the game.

Conversations With my Daughter ~ by Jay

Why did you let me order two scoops of ice cream?

Because you asked for two scoops, and you wanted different flavors.

That was too much ice cream. I didn't eat it all.

That's OK. You ate what you wanted, and you enjoyed it.

Mommy, sometimes you're not very sensible.