Family Practice

I’m at the annual meeting of my state family medicine association this weekend, sitting in the business sessions; I see a lot of women and there are some medical students and residents and that is a great thing to me.   I’m catching up with some residency friends, some of whom are a lot more involved in my Academy than I am, and some of whom are budding members of the Old White Guys Club™ coming in hung over after a night of drinking and smoking cigars and eating Denny’s.  I am not a budding member of the Old White Guys Club™, and I never will be.  I will one day, if I let myself, be old.  I will always be white.  But I will never be a guy.

In my row, there are two Old White Guys™ and me; our president-elect is a woman who used to be my advisor in medical school.  I’m looking around the room at all the white hair and at all of the newer people around me, in between exchanging hugs with men and women alike, thinking about drinking single-malt bourbon and smoking cigars and how that is the kind of party I will not be invited to any time soon, but they are all so glad to see me and when I was a medical student, I was the only one who came sometimes, and maybe it’s familiarity alone that makes them glad.  I’m thinking about how when you do a search on my state Academy’s home page for “GLBT” or any other permutation, or “gay”, that there are no results, but the AAFP Advocacy committee is considering resolutions with titles such as “Healthy benefits of Same Gender Marriage – Not Just a Social Issue” and wondering if maybe I should have brought a resolution to the table this year, in this state, on the issue.  After all, we are family practitioners.  And for the first time I’m putting something on my CME needs assessment, when they ask what you feel like you need more education on.
But all of that is inside my head, and outside I’m making small talk with the Old White Guys™ in my row and taking a good-natured ribbing from the other doc in my town for seating with a different district (I have privileges in two counties, which are in two separate districts).  I’m renewing some old acquaintances with people who would never invite me to drink single-malt liquor and smoke cigars but who are happy to have me on their commissions.  Among all of this I’m bustling out between sessions now and again to feed the Cap’n, since we didn’t think to ask if we could have a fridge in our room so we have no stored milk, and the topic turns at one point to women in medicine.
“We have a PA in our office, has school-aged kids, and all the dance recitals and things are at like 3:30.  So we try to accommodate her, but…”  And he’s talking about how the men in the office never take time off to go to their kids’ things; how it seems like they’re put-upon sometimes to accommodate this woman’s needs.  I’m cringing inside, already, and I know I have to say something – because this is the secret core of the Old White Guys Club™ in medicine: we can’t let women in because they won’t put the work first.   So I make my opening gambit. 
“But they ought to.  They ought to be as much a part of their children’s lives as the mothers are.”  I believe this; I believe that children need all of their parents to be involved with them.  And I believe that this is part of feminism, that if we are only going to argue that women ought to be able to work just like men that we are not making the argument that all people are created equal.  Men ought to be able to work just like women too.  And I’m ready to argue this one against him but he makes a surprising turn right about then, and breaks ranks with the Club™.
“I think that’s part of what’s happening in medicine – you have 50% of medical school graduates being women, and it’s changing the face of it.  There’s more focus on family.  I don’t have kids, but I bet if you asked a lot of the kids in my generation, they wouldn’t say they had a bad father – because it was mostly fathers, then – but they’d say he was never there.  I think we need to find some balance.  I think men should be able to take a few weeks off when their wife has a baby.” 


Balance.  There’s the word that defines my entire struggle with family medicine; the complex and delicate dance between personal concerns and patient care.  It’s something I’ve felt acutely through two pregnancies, through struggling with breastfeeding and pumping and working, doing midnight deliveries and coming home to a husband who’s just finished feeding the baby a bottle because he didn’t know when I would be back.  It’s sending my nurse over with a note to pick up my daughter from daycare because at 5 PM I still have patients to see.  It’s children who know where the crayons and the snacks are on the OB unit and Saturday mornings spent watching DVD’s in the doctor’s lounge.  It’s something every female physician with children I know struggles with. 
We spent some time talking about it, he and I – a childless Old White Guy™ and a young woman with two kids and a husband with his own professional aspirations.  The culture is changing, but slowly, and I’m afraid it’s only changing for some of us.  I hear physicians bragging on forums about only taking two weeks of maternity leave; of coming back after surgery before they would ever release a patient; of missing their children’s activities and family vacations and all the wonder of growing up.  They veil this under the guise of it’s for the patients but I wonder sometimes if it’s really hubris; if we as a profession have become convinced that the sun can neither rise nor set without our surgical intervention. 

I disagree.  I think we have forgotten Luke’s admonition of “Doctor, cure yourself!”  There is a need for balance.  There is a need for us to be models – not only in our professional lives, but in our personal lives.  How can we talk to people about their children when we do not even know our own?  There is value in school plays, in sports events, in dance recitals and taking your children to the museum.  There is just as much value for men as for women, and perhaps even more when your child has all of his or her parents there.

I do primary care.  I do preventative maintenance.  I spend hours every day talking with patients about taking care of themselves, about balancing their lifestyles, about making choices that make them healthier.  It makes you a better person, taking care of yourself.  It makes you a better doctor, taking care of your personal life.  And if it takes an influx of women into medicine to make that change then so be it. 

But I don’t understand why it has to.

Working motherhood...

Mom and stepdad were over tonight, a rare occurrence since they live several hours from us. They gave up a day of their spring break to come sit with Cap'n while I worked and Angel went to go tour this university that he's going to be doing his Ph.D work at in the fall. Mind, he'll be gone all night and part of tomorrow, which makes me a single working parent of 2 for the second 2-day stretch in the last week. That's right; I'm trying to juggle Cap'n and Cups and my job and feed us all and still have a house left when Angel gets home tomorrow. So far we are all fed and the kids are bathed and I have not heard a peep in the last 5 minutes from the Eye in the Sky in Cups's room so maybe the repeated instructions about how she is not going to get any toys or books back if she continues to jump on the bed are having an effect. I know she was very angry about no stuffed animal to sleep with.

Dinner was lasagna that we made and froze in the pre-baby blitz of preparation, along with some asparagus that l saved my mother from steaming and ruined a cookie sheet broiling instead, along with peas for Cap'n, whom we are trying to start on foods now that he is 5 months old and interested in it. As I was Ninja-ing the peas from a previous night's supper (peas, a little water, blend until no longer round) I started thinking about what I am doing with the baby and how I'm not sure what demographic I fit into any more.

I plan on breastfeeding this baby as long as possible, but I am acutely aware of the crushing emotional stress that made me give up with Cups at 6 months. We have planned better this time. I don't buy baby food; we make our own. We use cloth diapers most of the time but keep disposables for short trips or where others are caring for the baby. He'll have his first excursion to daycare tomorrow since I have nowhere else to send him but mostly he stays at home. With his dad.

But the kind of blogs that cater to people who make their own baby food and read food labels and wash cloth diapers and breastfeed their babies are mostly written by stay-at-home moms. And most of them seem furthermore to be written by moms who are ecstatically content to spend their time staying at home. They are, occasionally, smug in their ecstasy even. And I find it hard to take.

I like working. I love being a doctor. I love running out in the middle of the night to deliver a baby and I we gelting shy smiles from kids in the clinic and I love what I do. It is exciting and fulfilling and hopeful and tragic and it is part of who I am, this being a doctor. But that means that Cups goes to daycare and Cap'n will too; that some days I get up at the crack of dawn and come home after dark. It means that I have made sacrifices, and so have my family. And I am not a stay-at-home mom and I don't intend to become one - so where are the websites for me? Where are the tips on how to chart over a nursing baby; how to organize so when I come home on my afternoon off with two kids, one Tae Kwan Do class ending at 4:30 and Angel not home until 5:30 before leaving for his class at 7, I can cook dinner and play with Cups and feed Cap'n in 90 minutes, including time to shop for whatever I didn't know we didn't have?

Where is the blog that tells me that a Bamboo pen tablet wasn't a frivolous waste of money but a way to write this blog entry one-handed instead of the laborious hunt-and-peck one-handed typing I had been doing?  Why is it always that I can work or I can be a real mommy? Who made that rule? Who says that I can't know my beautiful, creative, eclectic daughter and work a full day in the office?

She knows her mommy is a doctor and she's okay with that. She knows where the snacks are on the OB floor and she carries charts to the nurses' station and she is a part of my life every single day. And I hope Cap'n, who has finally fallen asleep, will be the same way. This is who I am. I want my children to know that mommies can work and daddies can do laundry and that both of us carry them with us, even when they're not right there with us. I want them to be free.

Ice cream.

I've told this story before.
This was in medical school, sometime in the clinical years, on my trauma surg rotation. I had a quiet rotation, as these things go; considering I was at $ major_trauma_center and had no interest in doing surgery, even, at the time. lt was overall enjoyable. But it was also my first brush with death.
So there I was, on an ordinary call day, walking into the ED for a neck wound. I remember the patient - I don't think I'll ever forget her - older, frightened. Very frightened. I talked to her, as we were wheeling her down to the OR for exploratory surgery, held her hand, told her about myself. She listened. I think the politeness helped her pretend she wasn't so afraid.
They went to lay her down on the table as she was preparing for surgery, and she fought them - suddenly, as if she were fighting for her life. The gentle frightened woman turned strong with fear, and then she said "I can't breathe. I'm going to die."
And she did. There was no amount of swearing or chest compressions or needles or effort that could get her intubated and breathing; she slipped away despite it all. And I looked at her and up at the trauma surgery team of tough guys and surgeons who dropped the F-bomb like my mother taught me please and thank you. And all I could think was "I can't cry now."
Chief resident looked at me; big and bad as the rest, but I know it hit him hard too. Said "Come on-we need to do burn unit-rounds." I jumped at the pretense of normality. We went up to the burn unit and we saw one or two folks and then he cut through the kitchenette.
"Here." he opened the freezer and took out an ice cream bar. "Go eat this somewhere where the nurses won't see."  I ate my ice cream and I had my cry and we never said anything about it after that. We didn't have to.
Sometimes I miss knowing someone else is taking final responsibility for what I write; knowing I have someone looking over my shoulder and making sure it's that much harder to make a big mistake. But mostly, these days, I just wish I had someone to hand me an ice cream bar and tell me to go eat it somewhere that the nurses can't see. It makes everything just that much smoother.

Lonely

First set of rounds back from maternity leave.   The patients who know me and remember me from visit to visit asked about the baby.  The ones who weren't on my schedule stopped by the nurses station asked about the baby.  It's good to have you back.  I walked by one door and got scolded into coming in: You tryingto dodge me, girl?I brought pictures, showed them off, listened to them marvel - ten pounds, really? 
And then there were the patients with dementia, the ones who ask me every visit who I am, who are pleased to meet me for the third or tenth time.  I know them all, even if they don't remember me from month to month.

Trouble stopped up at the nurses station to call his wife for the tenth time that shift, waved and smiled at me.  The only thing he ever asks me for is to let him go home.  Problem is, he can't get around and the stroke that took his legs away and put him in a wheelchair also took away a significant portion of his cognitive abilities.  He needs someone to help him with the little things in life, like staying safe.  Dressing.  Bathing.  Getting out of bed.  She can't take care of him and his family can't arrange for twenty-four hour coverage.  I've explained this over and over.  He just wants to go home and be with his wife.

I stopped at one bedside - it's usually a quick visit, in and out; she doesn't ever remember me and she doesn't have any complaints - and I reintroduced myself.  Twice.  Told her my first name. Twice.  Spelled my last name.  Yes, I'm the doctor.  How are you doing? Can I do anything for you?  And she looked at me for a long moment, her face as expressionless as it always is.
What do you do, exactly? 
I was taken aback.  Well, I doctor. I make people feel better.  It wasn't much of an answer, but I wasn't certain she'd been delving for the existential truths of the art of medicine -  it really was the longest sentence I'd ever heard from her.  So I repeated my usual parting words:  If you need anything, let me know.
How?  How will I find you? 
The nurses could find me, I explained.  They had my number.  And I was halfway to the door when she said, very softly: Stay and talk to me a while?
I've never seen her family in there.  I've never seen her talking to anyone at all.   And so I turned around, sat down on her bed, and talked for a bit - about the pictures on her wall, where she grew up.  Nonsense chatter, really; I didn't know what to talk about.  About the baby I'd just had.  And when I got up a few minutes later, pleading the need to get home and feed my baby, she looked almost happy.


Walking down the hall a while later, I saw a woman in a wheelchair staring out through the double glass doors that serve as a fire exit, framed by spray-on snow with flowers stenciled into it.  It was snowing out, blowing and drifting, a landscape of white on white.  I wondered what she was thinking.

Stay and talk to me for a while?

Lost in Translation

From a discharge report I received today:

"Questionably noncompliant with 2-minute therapy with admitting INR 1.2"


Coumadin.  I think they mean Coumadin.

Attaining Balance

Nobody in the three acute early afternoon appointments at the moment.  Gives me a chance to breathe.  I think the laptop on its docking station is about 2" too tall for ergonomic typing; there is a Bluetooth keyboard in its future.  After I get paid. 

I'm the only one who stays back here during the lunch break - it's quiet, no distractions.  A chance to sort of sit in my new office (blue and red walls!) and soak up the reality of what I am.  Alone, at lunchtime, with CCR humming off of the iPod and nobody asking my opinion on anything, I don't have to be sure of myself.  I don't have to tell anyone how they're supposed to do it...
Now you get to do it your way. I've heard that refrain a lot these days, at work. How do you want me to do it? And it turns out that despite doing things the way everyone else does it for the last four years, I do have preferences. And all of a sudden everyone wants to know how I want it done. I'm supposed to give orders - expected to, really. 
It's moving slowly.  I'm used to dictums coming down from above - and yet, for four years, I complained that I wanted it done my way - so now's my chance.  The locus of control has moved to me, and that takes some getting used to.

But at home, it's different - because I'm not the boss there.  Angel and I have run this marriage as an equal-share partnership since before we were married; each of us giving it everything.  And it works that way, because we are equal share partners.  The trick is to go from being the boss here - the doctor that I am and I'm expected to be, who's in charge, gives orders, tells people how it's going to be - to go from being that to being a wife.
I don't run the house.  Lord knows, if I did, some things would never get done.  But I have to do my part in running it - and finding that balance has been a difficult thing.  Faced with the constant encouragement to manage and my natural tendencies to try and run things, I've found myself becoming more and more of a hands-off dictator at home: lists, orders, and a whole lot of "why didn't you...?".  And that's not what's held us together for the last twelve years, and it's certainly not forming much cohesive glue these days.

Doctor, it hurts when I do this.  Well, then don't do that.

Open season on interpretations: Slipstream

I see you
child
in the electronic static
lost among
the clickety-clack of keys
and data

And I knew you once
then
before time grew short
and I could not see.

You were there.

Come out come whisper
child
we still can play if I
have not forgotten that,
too.

The static streams are loud
and you -
Did I only just
look away?

NsB 10-Aug-9