Sunday, December 16, 2012

Overwhelmed

I cried in front of my attending today. Not my favorite moment of residency. She asked how the week went and I just told her the truth - that I feel like no matter how hard I scramble I can't figure these patients out, mostly because I don't know what the fuck I'm doing. Ugh.

Tuesday, December 4, 2012

Omg

I am psychotic with fatigue. And this is only 3 admissions...

At one point tonight, while I furiously scribbled a note in a patient's chart, I thought to myself, 'at least I haven't been paged in a few minutes.' Nope, turns out I had left the pager on another floor. Fml.

Sunday, November 18, 2012

Quiet Sunday

I'm writing this from my lactation suite. And by that I mean the bathroom in the back of the family medicine team room. Luxury.

I hesitate to even say this, but it is a quiet day on the service. We only have five patients, and nothing too crazy is going on with them. I feel like I've hit my stride a little bit. I even had time to write out a discharge summary, and I think it went ok.

I think it's all going to be ok.

Saturday, November 17, 2012

New Plan

Residency and parenthood are starting to be a blur. So my new plan is to write something here every day. It won't be long; I only have about 2 brain cells and 4 minutes at the end of the day. But I want to have some record of this year, because it it quite a year.

Today was my day off, which was glorious but not long enough. We had breakfast with Rosemary, then puttered around the house, then went to the mall. I had an appointment at the eye doctor to get contacts and then got a haircut.

Bear is a great baby. He is very smiley with me and even more so with Benjamin. He can sit up with support and moves his hands purposefully enough to play with toys. For our mall trip he wore his argyle sweater outfit, which I remember buying with Rosalind when I was pregnant. The time has gone by so fast.

Unfortunately, Bear has a serious rash- I'm pretty sure it is seborrheic dermatitis. Anyway, I've been fretting about it for the past few days, and the conclusion I have reached is that I'm glad Bear has a doctor who isn't me. If one if my patients came in with this, I know what I would do to treat it, but somehow with my own child, I feel crippled with uncertainty.

My one day weekend was not nearly long enough, but it seemed even shorter because I started worrying about work tomorrow almost as soon as I got up. I've got to work on living more in the moment.

Monday, October 29, 2012

I'm alive

I swear I am alive. I have this post about "having it all" that I've been meaning to write. But it turns out that I'm too exhausted from having it all to write it.

It's our anniversary today. This time last year, it was snowing. This year, hurricane. In any weather, I am so ridiculously glad to be married to my favorite person, Benjamin.

Saturday, August 25, 2012

My Brief Experiment with Elimination Communication

The other day at a baby-wearing workshop, Benjamin and I met a woman who practices elimination communication (EC) with her 12 month old. God, we are such hippies. Seriously.

Anyway, we were intrigued, having never met someone who does this in real life. For the uninitiated, Benjamin explains the concept in his vlog:

http://www.youtube.com/watch?v=rY6FbqITL6k&sns=em

So we've been thinking about this concept and today I thought I would give it a whirl.

1pm: Watch 4 YouTube videos on EC while nursing my 5 week old. Am now an expert.

1:30: Bath time. Also known as water torture.

1:45: Wrap diaperless baby in towel and nurse him to aid in psychological recovery from water torture.

2:20: Still nursing. Hasn't peed on me yet.

2:25: Baby makes soft grunting sound, wiggles left leg slightly. Could this be an elimination signal?

2:26: Dash upstairs with naked baby, drop towel on bathroom floor, nearly drop baby in the toilet. Hover-squat over toilet seat, holding baby aloft over the bowl. Don't have enough hands, baby's head flopping side to side.

2:27: Baby is not peeing. Whisper pssssst at him as instructed per video.

2:27: Still no peeing. Begin to feel foolish.

2:28: Thighs cramping. Have clearly fallen for elaborate attachment parenting practical joke.

2:30: Admit defeat. Struggle to stand. Limp to changing table, apply diaper to baby.

2:31: Diaper completely soaked.

Tuesday, August 21, 2012

Show the Way

I don't know the lyrics to many songs. Usually, this doesn't really matter because I can't sing. Or as I like to say, I can't carry a tune in a bucket with help. But something about a crying baby in the middle of the night seems to require singing, if only as a last ditch attempt to keep from screaming myself.

Have you noticed how ... problematic the lyrics to lullabies are? Themes of rampant consumerism (papa's buying you what?) and traumatic arboreal cradle accidents don't seem very restful to me. Plus I only know 2 lines of each of those songs anyway.

So anyway, there is one good, appropriate song that I know all the words to. And that song is "Show the Way" by David Wilcox. You probably haven't heard of it, because David Wilcox is not exactly top 40 material. He's more like Methodist church basement concert circuit material. He's a middle-aged guy with a guitar and his lyrics typically use a Metaphor to talk about some Big Idea.

Usually, my cynical brain would dismiss this construction as simplistic and these Big Ideas as quaint, which they are. But the other part of my brain is trusting and optimistic; and this song is that brain's anthem.

Here's David Wilcox singing it:
http://www.youtube.com/watch?v=6aQR1FUANVc&feature=youtube_gdata_player

Lyrics:

You say you see no hope,
you say you see no reason
We should dream
that the world would ever change
You're saying love is foolish to believe
'Cause there'll always be some crazy with an Army or a Knife
To wake you from your day dream,
put the fear back in your life...

Look, if someone wrote a play
just to glorify
what's stronger than hate,
would they not arrange the stage
to look as if the hero came too late he's almost in defeat
It's looking like the evil side will win,
so on the edge of every seat,
from the moment that the whole thing begins
It is...

Chorus:
Love who makes the mortar
And it's love who stacked these stones
And it's love who made the stage here
Although it looks like we're alone
In this scene set in shadows
Like the night is here to stay
There is evil cast around us
But it's love that wrote the play...
For in this darkness love can show the way

So now the stage is set.
Feel you own heart beating
in your chest.
This life's not over yet.
so we get up on our feet
and do our best.
We play against the fear.
We play against the reasons not to try
We're playing for the tears
burning in the happy angel's eyes

One time I sang this song for a group of my college friends, temporarily ignoring the fact that I have all the melodic talent of a cucumber. They all smiled and nodded politely, (and most if them refrained from covering their ears) but none of them seemed to really GET it. Guys, guys - the metaphor is about a play! Isn't that amazing?

I was a drama major, I was very excitable.

I don't think I have inflicted my performance of this song on any other adults since then, having gotten even more self conscious about my tone-deafness over time.

But babies are a captive audience, and at some time or another I have sung this song to every child I nannied. Partially because I know the words, but also because it has been my hope for all these children that they believe that love wrote the play.

And now, singing to my own child, I am filled with this hope for him; that he grows up to believe that the universe is a fundamentally good place and that the goodness and worthiness of people outweighs the instances in which those people are assholes and that standing up against fear is a worthwhile way to spend one's life.

And I also hope that he learns better sentence construction than I have.



Tuesday, August 7, 2012

One Handed

I'm typing this with one hand, which is how I've been learning to do lots of things over the past two weeks.

Bear is beautiful and perfect and I love him completely.  After years of nannying, I keep looking at this baby and marveling that I get to keep him, this one is mine.  And that is just as wholly wonderful and utterly exhausting as everyone predicted.


Monday, August 6, 2012

Bear Thomas

Hey there, all six of my readers!  Please forgive the lack of updates - I was busy having a baby! :-)

39 weeks - an absurd amount of belly.

Here he is! Bear Thomas, born 7/22/12 4:24am EDT, 8lbs, 10.5oz after 5.5 hours of labor.






Wednesday, July 18, 2012

Late Pregnancy


Late pregnancy is super glamorous.  It’s 3:30 in the morning, I was awoken by heartburn so bad it was in my nose. Once I got vertical, I realized I had to go to the bathroom anyway.  Once I waddled down the hall to the bathroom, I noticed I also had a nosebleed. 

So yeah, that’s what I’ve been up to. 

But mostly the hard part is fighting the boredom.  My maternity leave started weeks ago – which is good because I feel too swollen, acid-laden, and exhausted to really function as a new intern.  But it is also bad, because I have nothing to do.  And as anxious as I am about being a new intern, part of me just wants to get it over with already.

Even without the anxiety of eventually starting this whole new career, I don’t do well with unstructured time.  This is the understatement of the year.  I really, really don’t do well with unstructured time.  I get bored and depressed and lonely and become basically worthless to everyone around me.  I’m sure I will be begging for some unstructured free time once I am an intern with an infant, but I wouldn’t know what to do with it anyway.

So the main problem of being a million years pregnant and having so much free time is that the repertoire of things I can do to entertain myself is pretty limited.  Normally, I would be trying to plan this time chock full of Habitat for Humanity builds, camping trips, hiking, kayaking, horseback riding, etc.  I would be off to the beach and the zoo and aquarium and the amusement park.  But I just can’t do those things.  I did two laps around the mall today and then tried to go grocery shopping and nearly collapsed. 

Benjamin has been doing a great job entertaining me and taking care of me despite the fact that I haven’t exactly been a bundle of joy to interact with.  He’s working on starting a video blog about being a stay at home dad.  For his first video, we are doing a montage of natural ways to induce labor.  It’s good to have a project.  Today (after a crucial afternoon nap) we filmed “driving on bumpy roads,” “eating spicy food,” “walking,” “eating licorice,” and “galloping.”  We’ve got some other stuff on deck for tomorrow.  Or rather, later today.

It’s now 5:00 in the morning.  In between writing this I have read everything worthwhile and most things not worthwhile on the whole internet.  I have eaten a fistful of Tums and several pounds of papaya tablets.  Benjamin, who was failing at sleeping downstairs on the couch, has come upstairs and is now snoring adorably into my ear.  Baby Zuses is practicing his acrobatics.  Abby-dog is snoring downstairs.  I’m going to see if I can join this log-sawing chorus.

Tuesday, July 3, 2012

Graduation


So, I didn’t fall off a cliff or anything, it’s just been a little busy around here.  And no, not busy in the way that I’ve had a baby.  I’m still massively pregnant.

Let’s catch up, shall we?

Graduation happened.

I went back and forth a lot about whether I would even go to graduation.  At one point, Benjamin and I were thinking of skipping it to go off to New Zealand to visit his parents instead.  And I am pretty sure New Zealand would have been way cooler than graduation, but now that I know what the third trimester of pregnancy is like, I am really quite happy to not spend 48 hours of it on airplanes. 

In addition to the lure of NZ, I was thinking of skipping graduation for several reasons.

1. Since I took an extra year to get the Master of Public Health degree, most of my friends graduated last year.  I don’t actually know most people in the class of 2012, so I don’t have this need to celebrate with my class.

2. My parents were being butt-faces and so celebrating with them was unappealing or not an option.

3.  UVA graduation is a clusterfuck (that’s the technical, medical term).  All the various schools graduate together on the lawn and then there are separate diploma ceremonies all over campus.  The proud parents, grandparents, half-uncles, and step-cousins of six thousand students descend on Charlottesville and everybody wants to go out to dinner, drive on the one lane main street, park where you want to park, etc.

4. Graduations in general are sort of….stupid.  Commencement speeches are long and generally not entertaining or full of good life advice. 

But I went anyway.  My parents recently had a major change of heart and have been being significantly less butt-faced, which is great.  And they wanted to go, and I was not in New Zealand, so why not?

It was exactly as hot and crowded and logistically difficult and as boring as I predicted – and I am still really glad I went.  My parents were exactly as wacky and exasperating as I expected them to be, and I was really glad that they were there to celebrate with me.  After months of agonizing over my relationship with them and coming around to a place where I don’t crave their approval – it was still great to have them say they were proud of me.  I didn’t need to hear that, but it was good.

We had a picnic on the downtown pedestrian mall and it was good to have a meal with my family – my parents, my sister, and my husband all together.  I felt honored that they were all there for me, and I felt good knowing that they would all be able to come together for the baby, too. 

And the graduation itself was more meaningful to me than I expected.  Sure it was hot and there was a lot of standing and my feet were so swollen that I thought my flip-flops would become permanently embedded in my skin.  But I stood with the other MPH-ers (the only people in the class I really know well) during the lawn ceremony, which was fun.  And during the medical school ceremony I got called last (yay Z last name) to get my diploma – so the general applause sounded like it was all specifically for me, which was pretty awesome.  And in general I had fun waddling my super-pregnant self around in my Dr. Seuss t-shirt and getting lots of thumbs up and smiles.

So overall, even though I was totally exhausted afterward – I am really glad I went.  For me, I would always rather err on the side of having an experience that turns out to be bad, rather than missing out on something.  (This does not always work out as well as it did in this case.)

Whew.  I’m a doctor now.  Graduation didn’t totally make that sink in, but acknowledging this transition in public with my professors and classmates and family is certainly a good way to start integrating this part of my identity.

More catching up soon.  (Seriously, I promise.)

Friday, June 1, 2012

NYC Large Soda Ban: Right Law, Wrong Reasons


So New York City is banning the sale of sugary beverages over 16oz.  (http://www.cnn.com/2012/05/31/us/new-york-sugar-drinks/index.html) Bloomberg is touting this as his administration’s way to “do something” about the city’s obesity epidemic, and he claims that sugary drinks are the leading cause of obesity. 

One of my favorite bloggers, Regan at Dances With Fat, recently wrote a post about her opposition to the law (http://danceswithfat.wordpress.com/2012/06/01/sixteen-ounces-of-dumb/).
Regan and I usually agree – in fact, her blog was my primary introduction to Health At Every Size and Size Acceptance.  In this case, though, I strenuously disagree with her.

While I also disagree with everything about the phrase “obesity epidemic,” I do think this law is a good idea.

Now, don’t get me wrong, Bloomberg’s obesity-based justification for the law is problematic.   In fact, he should just stop talking.

Obesity is not a health problem, it’s a body size. When people talk about the “health consequences of obesity” what they really mean to address (I hope) are the health consequences of sedentary lifestyle and poor diet.  Conflating obesity with poor diet and lack of exercise is problematic for several reasons.  First, good diet and lots of exercise don’t necessarily make obese people thin.  Secondly, plenty of thin people have a bad diet and get no exercise – these people are not healthy by virtue of being thin, they’re just smaller.  Thirdly, you’ve muddied your discussion of an important public health issue with the rhetoric of anti-fat prejudice.

So let’s just leave obesity out of it.  Poor diet is still a public health problem.  It’s a public health problem that affects people of all sizes – the consumption of thousands of calories of sugar-water is not good for you, whether it leads to weight gain or not. 

A 2007 meta-analysis (Vartanian, et al. “Effects of Soft Drink Consumption on Nutrition and
Health: A Systematic Review and Meta-Analysis,” American Journal of Public Health) found that increased soda consumption led to increased caloric intake over and above the calories in the soda itself, suggesting that soda consumption stimulates the appetite or affects satiety.  Increased soda consumption was also associated with decreased milk and calcium consumption.

In terms of health outcomes, daily soda drinkers had double the risk of developing type 2 diabetes compared to infrequent soda drinkers.  This was true even when controlling for BMI.  Let me say that again - the behavior of drinking soda was associated with increased risk of developing type 2 diabetes, regardless of weight.  Skinny soda-drinkers – you are not safe!

So type 2 diabetes is no fun.  It is a legitimate public health issue.  In fact, I might even let Bloomberg call this one an epidemic.

So soda is not a benign substance – what is the best way to address that?  One ever-popular approach is to encourage individuals to “make good choices.” (Can’t you just hear Michelle Obama’s voice saying this?)

“Making good choices,” is appealing to Americans, because we tend to believe in this fantastical individualism myth – individuals can pull themselves up by their bootstraps, it’s the American dream, etc, etc.  (The more conservative you are, the more likely you are to subscribe to this worldview). 

Regan argues the other side of the individualism argument, asserting that people have the right to prioritize or not prioritize their health.  This comes up a lot in her blog, where she argues that while it is possible to be fit and fat, it is also not the responsibility of every fat person to be fit; that fat people have just as much right to have unhealthy habits as thin people.  And in general, I agree, that individuals have the right to prioritize health as they see fit for themselves; but as a public health scholar, I am interested in maximizing the health of populations.

And I take issue with the idea that freedom means being able to buy a Double Big Gulp.  New York banning large sodas is not the nanny state restricting individual freedom.  It’s a public health measure countering the enormous marketing pressure of the beverage industry.  Your choice to buy a Double Big Gulp isn’t a free choice, it cost Coca-Cola many billions of dollars in clever polar bears, dancing young people, and a cultivated Pavlovian response to their red logo. 

Individuals can’t realistically resist a mammoth like Coca-Cola using will-power alone.  Instead, systemic unhealthy influences are best countered by public policy.  And the large soda law is a great example of putting the pressure in the right place, not on the consumer, but on the seller. (I’d love to see the law targeting the beverage companies themselves, but at a city-wide level, targeting restaurants is probably as high up the food chain as they can go.)

Regan argues that using the obesity justification for this law will make thin people resent fat people for restricting their choices.  I agree the obesity justification for this law is terrible.  But the whole anti-obesity campaign is terrible.  Thin people already resent fat people.  Fat people are blamed for everything from health care costs to global warming. 

So yes, it is important to resist anti-obesity rhetoric.  But pitting Size Acceptance against public health is not the way to go.  A broader understanding of both Size Acceptance and public health reveals that Size Acceptance is public health – it’s a movement advocating for the improved social standing and mental health of 2/3 of American adults. 






Monday, May 28, 2012

My Fetus is Against the Patriarchy


At 32 weeks gestation, it recently occurred to me that in addition to shelter and food, the kid is going to need some sort of clothing.  We were in Richmond, VA last weekend and hit up some thrift stores for cheap baby threads.  Incidentally, if anyone is in Richmond, I recommend Diversity Thrift, which benefits GBLT-friendly HIV organizations (a direct counter to the philosophy of the Salvation Army) and has baby and kids’ clothes for 25 cents. Twenty-five cents, people!  On top of that, we are planning a major tie-dying event, so slightly stained items were desirable.  We may have gone a bit crazy, but anyway, the kid will have plenty to wear.

On our shopping trip, there were some prime examples of problematically gendered baby clothes:

Boys are all about danger and trucks and football!


And girls are all about shopping!




A common critique of gendered baby clothing is that girl clothes focus on looking cute and boy clothes focus on actions and non-aesthetic attributes (such as strength and intelligence).  But don't worry, value based on your attractiveness is now equal opportunity: 



"Does this diaper make my butt look big?"  

Seriously, people?  This is not cute, this is not harmless, this is not a joke.  This is introducing body hatred to BABIES.  It is not ok.

(I understand that babies can't typically read.  However, I would argue that 1. Our baby will be a genius, and can probably already read, and 2. emblazoning a child's torso or butt with such slogans will inevitably affect the way literate people interact with him/her, and allow the message to be sublimated).  



It feels very…greedy to say that this is why we aren’t telling people the sex of the baby.  But it's more than that.  It isn’t simply that we don’t want to receive clothes like this for gifts.  It isn’t just that we don’t want to dress our child in this absurdly gendered clothing.

The fact that baby clothes like this exist shows that these sexist, body-shaming, consumerism-frenzied, and generally problematic ideas in our culture are being delivered directly to people small enough to wear a 0-3 month onesie.  And I am not sharing the sex of my child because I want him/her to be sheltered from these gendered expectations for as long as possible.  At least until, you know, birth. 


Tuesday, May 15, 2012


Sorry again for the lack of updates – the thesis is finally done!  I graduate on Sunday! If all goes as planned I will have a baby in 7-12 weeks! (Holy shit, how did that happen?)

So yeah, there has been a lot going on.

But before I catch you up on that stuff, I wanted to take a moment to reply to some great comments I got on the last post. 

Lou de B made some great critiques that I would love to address.  Here is Lou’s comment, reposted for archival purposes:

Ok, but here is the thing. First the disclaimer: I am a linguist, not a medical Dr. I am overweight so this is not a thin person ranting at fat person thing. I have a long line of short tubbies above me on my Mum's side. But...

you cannot deny that obesity is a bigGER problem in the US, Aust etc than in - say - I dunno, Siberia. And that we just happen to be those that eat HUGE servings and a load of crap. In the US (I've been a dozen times or so) I have so much trouble remembering to ask for small everything so I get something equal to large in Aust. I am not kidding. Some of those coffee or drink cups are buckets. Not cups.

IF people are not drinking gallons of sugar etc AND they are still overweight, then sure, they can be healthy. I bushwalk, climb, canyon etc as do many friends who are overweight and fit. But if I'm drinking gallons of soft drink (you call soda) then my Dr should tell me to stop it. It isn't good for my health. Or my joints (which is where I'm having trouble).

This is not to deny other issues. I read The Beauty Myth at Uni and Real Gorgeous by Kaz Cooke etc. I'm very aware of the role of the media to distort images etc. But being overweight DOES lead to an increase in some conditions AND we did not evolve joints etc to be that size.

Feel free to rip all this apart. I know you know more than me!! And I ought, I guess, just read your thesis when it's done.

So let’s break this down point by point (mostly because my brain used up all its transition sentences over the past 9 months).

1. Obesity is more prevalent in the US and Australia than in places like Siberia.

This is absolutely true.  According to data collected from 1994 to 2002, the prevalence of obesity (BMI >30) in the US is 27.6% for men and 33.2% for women (Baskin et al 2005, "Prevalence of obesity in the United States"). According to a 2005 paper (Thorburn, "Prevalence of obesity in Australia") the prevalence of obesity in Australia is 19% for men and 22% for women. I could not find data for Siberia specifically, but in Russia as a whole, in 2000 the prevalence of adult obesity was 16% (Jahns, Barturin, & Popkin, “Obesity, diet, and poverty: trends in the Russian transition to market economy”). 

2. The places where obesity is more prevalent have larger serving sizes and more junk food and soda.

I can’t find any articles to specifically support this, but based on my personal experience alone, I agree.  (I know that is really flimsy, but stick with me, I will do more research on this in the future.)

That being said, the implication here is that the larger serving sizes are responsible for the increased prevalence of obesity in the US.  There are a ton of differences between the US and Russia – we could really pick any of them and make an argument.  For example, it is colder in Russia than it is in the US.  Thermogenesis burns calories.  Therefore, the temperature difference could be responsible for the difference in obesity prevalence.  I’m not saying I believe this to be true, I am just saying that the causes of obesity are very complex and singling out any one thing is unlikely to be instructive.

3. It is possible to be fat and fit.

Yes, yes, a million times yes.  This is one of the concepts that a lot of people have trouble accepting, because we have been so conditioned to believe that fat = unhealthy.  Here is one of my favorite graphs that I found in my research (Matheson et al, 2012 “Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals”):


This study looked at four different healthy habits – eating 5 fruits and vegetables a day, getting moderate exercise, not smoking, and drinking in moderation.  Researchers grouped people according to how many of these healthy habits people had adopted (0 – 4 on the X axis) and then further divided people based on BMI (normal weight, overweight, or obese).  On the Y axis, you have mortality hazard ratio – the risk that someone will die prematurely compared to a thin person with all four healthy habits.

So, for people who have none of these healthy habits, we see that BMI matters – those in the obese category are 7 times more likely to die than thin folks with all four healthy habits, while those in the normal weight category are only twice as likely to die.  However, as people adopt more healthy habits, the difference between the normal weight and obese groups disappears. 

Remember, these people are not losing weight as they adopt the healthy habits, because they are still in the obese category.  Just having the healthy habits is enough to change their mortality risk, independent of weight loss.

I would also like you to look closely at the middle bar of each group – the overweight category.  As soon as overweight people have just one healthy habit, their mortality risk is actually lower than normal weight people.  (This is a whole separate rant for another day).

4. Some fat people are not fit – they have poor health habits such as drinking soda.

This is absolutely true.  There are also thin people who drink a lot of soda.  This is a poor health choice in either group.

5. Doctors should tell fat people with poor habits to improve their habits for the sake of their health.

Yes, I agree.  Doctors should tell their fat patients that drinking two liters of Pepsi a day is not a great choice.  But there are a number of caveats I would add:

  • ·         The purpose of lowering the Pepsi consumption should not be to lose weight, because it is unlikely to be effective.  I know, I know, it seems like eliminating 830 calories from the diet would cause weight loss, but long term, a ton of research suggests that this isn’t the case (Mann et al, 2007 “Medicare’s search for effective obesity treatments: diets are not the answer”).  The leptin feedback loop is a squirrely little thing. 


  • ·         Instead, the point is just to replace that space in your stomach with some fruits or vegetables.  We actually have proof that eating fruits and vegetables is good for you (it’s one of the healthy habits in the Matheson study above).


  • ·         Suggesting that a patient stop drinking soda is something that a physician should do from a place of understanding of both the broad environmental factors that surround consumption in general and the individual factors that affect that patient’s life.  Pepsi’s 2012 advertising budget is $1.7 billion.  (That’s Billion, with a B!) I’m just some schmuck in a white coat and I certainly don’t have $1.7 billion.  Also, if my patient is the single mother of three kids working two jobs and drinking some Pepsi to stay awake through the third shift…nagging her would be poor form.  And by ‘poor form,’ I mean judgmental and insensitive. (Though plenty of doctors think nagging is their Hippocratic duty).


  • ·         Doctors should also tell their normal weight patients not to drink two liters of soda.  It’s not just unhealthy for fat people, it’s unhealthy for everyone. The other side of the ‘fat = unhealthy’ assumption is that thin = healthy.  But as we see in the above chart, thin but sedentary, drinking, smoking, and eating crap still makes you twice as likely to die prematurely.  Bringing the focus back to habits rather than bodies means bringing the focus back onto things we can actually control that are more likely to make a difference.


6. Though there is cultural bias against obesity, obesity is still legitimately linked to increased morbidity and therefore is a medical problem.

This is probably the part of Health At Every Size that I struggle with the most.  I feel like some of the more zealous Fat Acceptance folks try to argue that obesity has absolutely no corresponding health risks. 

Are all the studies of obesity and health risks done in an environment of unrecognized fat phobia so that all their results are suspect?  Yes.  Much the way those old fashioned studies about how the Negroid skull was associated with lower intelligence were conducted in an environment of racism – the world view of the scientists absolutely colors the results. 

Do almost all the studies of health effects of obesity fail to control for obvious confounding factors like health habits and socioeconomic status? Yes.

However, I still believe there are some negative health consequences of obesity.  The data on hypertension is pretty convincing.  Also, the joint issues you bring up are a great example.  That’s just physics – more weight on those joints causes more degradation.

But, as we have seen, the cause of obesity is outside of an individual’s control and weight loss efforts are unlikely to have long term success.  So yes, I think it is silly to say that obesity has no health consequences, but I also think it is silly to say that because there are negative health consequences people need to just try harder. 

Age is also linked to joint problems, cardiovascular disease, and cancer.  And physicians use this information when calculating a person’s disease risk, but no one suggests their patients try really hard to age more slowly.  And I’ve certainly never heard of a doctor refusing to treat the patient until they successfully get younger.

 

So yeah, I hope that helps flesh out my stance – I look forward to your responses/questions/etc!

Also, now that I have learned how to add pictures – here is a picture of me, planting some vegetables.  Which I totally plan on eating at least 5 of per day.  As soon as they grow up.  


Saturday, April 28, 2012

The Thesis - Executive Summary


So sorry about the lack of updates.  I have been working on my thesis.  I thought briefly about posting the whole thing on here.  But then I realized that I don’t want to inflict that on anyone. 

Here’s the executive summary.

1. People seem to think obesity is a big deal.  Two thirds of American adults are overweight or obese – everybody panic!

2. Obesity stigma is prejudice against overweight and obese people.  It’s a real thing in the world, especially the world of healthcare.  It turns out lots of doctors think obese people  are lazy, weak-willed, stupid, annoying, incompetent, non-compliant, and generally icky.

3.  People justify these beliefs by claiming that obesity is under personal control.  See, it isn’t like race, because I am not white on purpose.  But being fat is a choice.  So if fat people didn’t want to be discriminated against they could just stop being fat.  (Kind of like how poor people should just work harder and pull themselves up by their boot straps.) 

4. Nope, turns out that obesity is not a choice.  Turns out nothing else you thought you knew about obesity is true, either:

            Myth: Obesity is primarily caused by poor individual choices about diet and exercise.
Fact: Obesity is caused by a complex interaction of genetic, microbial, neuroendocrine, environmental, social, economic, psychological, and cultural factors – most of which are NOT under personal control.

            Myth: Obese and overweight people could lose weight if they actually tried.
Fact: Diet and exercise do not work.  Not only are 95% of weight loss attempts unsuccessful at producing long-term weight loss, evidence also indicates that dieting often actually leads to weight gain, increased stress, and disordered eating behavior.

Myth: Obesity is a serious medical problem.
Fact: The lowest mortality risk is actually associated with BMI values officially in the “overweight” range, especially for non-whites. Few studies of the association between BMI and health problems bother to control for exercise or dietary quality.  The truth is, you can be fit and fat.

5. Our society’s prejudice against fat people comes from our psychological need to protect ourselves from the possibility of bad things happening to us.  In our society, thin = beautiful, and therefore being fat is a bad outcome.  Rather than just feel sorry for fat people, we need to insulate ourselves against the threat they represent. We need to convince ourselves that the universe is a just place, that hard work pays off, that good things happen to good people and bad things happen to bad people.  Ergo, fat people must be bad. 

6. Obesity stigma is a problem because it is a prejudice just like sexism, racism, and homophobia and it has no place in a just society.  A full two thirds of the US adult population are victims of obesity stigma, so the effects are wide-spread.  These effects include psychological distress as well as more concrete discrimination in the areas of education, employment, housing, parental rights, and others.

7. Obesity stigma is a particular problem for doctors because it means we are violating the principles of beneficence and non-maleficence.  Our current treatment of obesity (nagging patients about dieting and exercising) does not work and is often actively harmful to patients’ overall well-being.  Fat patients find the experience of coming to the doctor to be so shaming (what with the nagging, lack of appropriate waiting room chairs, gowns, exam tables, and blood pressure cuffs, and mandatory weighing) that they avoid seeking care altogether.

8. For physicians and other healthcare providers, the solution lies in embracing the principles of Size Acceptance and practicing a medical model known as Health At Every Size (HAES).  HAES is a new approach to fat patients that emphasizes overall well-being rather than weight loss.  The core principles of HAES include, “accepting and respecting the diversity of body shapes and sizes; recognizing that health and well-being are multi-dimensional and that they include physical, social, spiritual, occupational, emotional, and intellectual aspects; promoting all aspects of health and well-being for people of all sizes; promoting eating in a manner which balances individual nutrition needs, hunger, satiety, appetite, and pleasure; and promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than exercise that is focused on a goal of weight loss.”

9. Health At Every Size interventions have been proven to be effective in improving psychological markers of well-being, decreasing disordered eating behaviors, and improving cardiovascular markers of health such as cholesterol level and blood pressure.  Furthermore, no randomized controlled trial of HAES has shown weight gain to be an effect, and several such studies have pointed to HAES leading to modest weight loss. (Not that we care about the weight loss, but just in answer to all the critics who think intuitive eating will lead to weight ballooning out of control - it doesn't.)

10.  In addition to using HAES interventions with individual patients, physicians should also combat obesity stigma in their roles as practice managers and community health advocates. (For example, resisting public health messages that participate in fat-shaming in the name of advocating for personal responsibility.)

11.  In conclusion, obesity stigma is bad, doctors have been responsible for perpetuating it, and now it is our responsibility to fight it.

Whew.  That is all.


Friday, April 13, 2012

Where I Stand Now

A tremendous amount has changed in the past year, and even more is going to change in the year to come.  And so it occurs to me that now might be a good time to take stock of my life, my writing, and myself.

I set out to write this blog about medical stories – you know, those anecdotes where doctor sees a patient and learns something profound about herself or the human condition or how to be a better doctor.  At the very least, patients often say funny and entertaining things.  But it turns out I haven’t seen very many patients in the past several months; most of the stories I have written have been about old patients or my own patient and family side of interacting with the medical profession.

It isn’t as if the patients I have had have been uninteresting.  I had one particular patient that presented a fascinating medical mystery and was a great character that I really clicked with.  I meant to write a post about him for months, but I never really knew what to say about it, there wasn’t really a point or a lesson to the story.  Talking about how well we got along seemed a little self-congratulating.  And also, the story of what happened to him wasn’t my story, it was his.

I tried to re-read Kitchen Table Wisdom recently and I couldn’t make it through.  It’s a book of essay/stories about healing, you would think it would be right up my alley, but I just found it annoying.  Because every patient story had to have a lesson or universal truth you could extract from it.  It just seemed so reductive and a bit contrived.  Sure, sometimes my patients remind me of things going on in my own life and that lends itself to good blog posts.  But should it?  Maybe if I were less self-involved, things wouldn’t have to relate back to me all the time.  Maybe I would be a better healer if I were focused enough on my patients that they reminded me of themselves. 

Writing a blog makes you look a little self-obsessed by nature.  It’s a place for self-reflection, yet that reflection is all public. And really, self-reflection for public consumption is a strange phenomenon. 

I re-read all my posts so far and I realize that I have mostly been processing the same theme from every angle: the medical experience is dehumanizing.  I am so glad to have gotten a chance to process this, to move from analyzing my own experiences as a patient to integrating how I will do better as a doctor. 

Personally, having this time and space for self-reflection is a blessing. (Both the blog as a place to record my thoughts and having the past two years of relatively relaxed academic schedule to have time to reflect).  This time and space was instrumental in my re-defining myself as a healer, re-examining existing relationships and forming new relationships, and re-engaging with some of the “big issues” that had gotten shoved aside for lack of time.

But one of the most important transformations that I’ve been taking stock of lately is one that I haven’t written much about.  I’ve become an adult.  I’m twenty-seven years old.  The process feels a bit delayed to me.  I thought I was an adult at fifteen.  I thought I was an adult at twenty.  I thought I was an adult at twenty-three.  So maybe this is nothing new or special; maybe at thirty I will think how silly I was back at twenty-seven.  And I’m sure part of me will think that, because I don’t think I will ever be done growing. 

But I do want to acknowledge that an especially important transition has been happening over the past two years.  The major transition has been in the relationship with my parents.  I haven’t written much about this, because it has been incredibly difficult and feels very personal to be putting on the internets (even though I realize that functionally means sharing the information with about six people). 

But here is the shortest of short stories:  I got engaged to Benjamin and my parents lost their minds.  They strenuously objected and tried to break us up.  We got married anyway. 

This whole situation has exposed an area of my life that I don’t know I ever would have examined if I weren’t forced to.  I thought my relationship with my parents was good.  I knew we had some differences during the teen years, but I thought that we had a good relationship now and didn’t need to work on it at all.  But it turns out I had never actually separated from them in any meaningful way.  I was still looking to them for approval. 

The wedding situation became explosive because it was one of the only times in my life when my parents had actively disapproved of something I was doing.  Growing up, I was always looking for their approval.  I always wanted to impress them.  Nothing I ever did seemed to be enough; I distinctly remember my dad saying he was proud of me at my white coat ceremony because it was the only time I remember hearing those words. But nothing I did was ever met with active disapproval either.  Every accomplishment seemed expected rather than noteworthy, and every decision I made was merely interesting, never good or bad. 

Now, in the aftermath of this explosion, it’s really clear to me just how much I crave their approval, even as an adult. It’s also clear to me just how unhelpful that is to me having a good relationship with my parents, to my growth as an individual, to my marriage, and to adult functioning in general.  Seeing how much I want my parents’ approval also opened my eyes to how much time and energy I spend ferreting out approval from others as well. 

And ultimately, it is unimportant.  I don’t know how I came to this place, really.  I have always been so driven by external judgment that it would have felt impossible to accept that this is actually unimportant. But now, I find myself at peace with it.  It feels like a weight has lifted, like a requirement has been dropped.  It feels like getting to the end of the semester and having your professor tell you there won’t be an exam after all.

Approval-seeking is still my M.O. Unconsciously, I will slip back into this mode almost automatically.  It takes mindfulness to break out of it.  But now that I have given myself permission to do so, I feel stronger, more centered, more myself.  I look forward to seeing how this plays out in my role as a daughter, partner, parent, and healer.




Saturday, April 7, 2012

Quick Updates

1.  I got my maternity leave details - they are simple pushing my start date back from 6/25 to 9/17.  So yay, I get maternity leave and don't have to worry about working when I am about to pop.  I will have to make up the three months later.  Also, this means I don't use up my vacation time, which is excellent because I am betting I will want some vacation.  The only bummer is that health insurance coverage does not start until the start date.  Welcome to the world kid, don't you wish you had been born in Australia?

2.  The day after my post about how I don't like to cook and am not good at it - I got volunteered to be the assistant teacher of a cooking class.  Woot.

Tuesday, April 3, 2012

On Cooking

I am not good at cooking.  I don’t particularly like doing it.  It’s not really my thing.

Turns out, cooking should sort of be everybody’s thing, because everybody eats.  If cooking isn’t your thing, you end up eating a lot of EZ-mac and Chipotle.  I didn’t eat great when I lived alone – things certainly got repetitive and sometimes there was some emergency EZ-mac.  Ok, there was a lot of canned soup.

Choosing, preparing, and eating food has always been sort of stressful, actually.  In high school, my mom had what I would now call an undiagnosed eating disorder and there wasn’t a lot of edible food in the house.  (Though there was always a lot of spoiled, slimy, or mold-covered food that she felt too guilty to throw away).  So perhaps I did not have the sturdiest food-behavior foundation.

Then, when I lived alone, food choices always represented this three-way balancing act between cost, health, and time.  If it was healthy, it took forever or cost too much.  If it was cheap, it was full of processed sugars and simple carbohydrates and had never seen a vegetable.  If it was quick, it cost too much and had never seen a vegetable.  As a medical student, I was short on both time and money and felt like a hypocrite if I ignored my health. 

One of the best things Benjamin did when he moved in was start cooking me dinner.  I was trying to drag myself to the finish line of my semester fueled only on coffee and desperation, and he swooped in and steamed some broccoli.  I thought he was a god. 

And he still often does this.  Last night, a girl friend came over and we hung out and Benjamin made turkey burgers and oven fried potatoes and mixed vegetables.  It was amazing.

But I’m not really pressed for time so much these days.  I have my internship and my thesis, but it is nothing like the end of the semester crunch.  Or, you know, residency.  So I feel like I should still contribute to the household eating by occasionally preparing a meal.

And it is still stressful.  I still feel that juggling act between health, time, and cost (though I have both more time and money than I did before). But the new layer I have to deal with now is performance anxiety.  I want Benjamin to actually want to eat what I cook, and I feel self-conscious about my lack of culinary talent.  Perhaps it’s some internalized sexism that makes me feel that as the woman, I should be better at cooking than he is.  Or maybe I’m just a competitive person.  But in any case, I just want to be better at it than he is.  And I am just not.  The man has talent.  And I have...a semi-edible track record.  There was some artichoke pasta I made recently that he soldiered through but I just could not even stomach.

Tonight, I made this recipe: http://www.epicurious.com/recipes/food/views/Mashed-Potatoes-with-Carrots-and-Leeks-109125.  It’s really just mashed potatoes with leeks and carrots thrown in.  It tastes like mashed potatoes with leeks and carrots thrown in (nothing magical happens with them really) but it was pretty tasty once I got enough salt in there.

I was feeling very flustered and hypoglycemic the whole time I was cooking.  And I thought seriously about just asking Benjamin if we could divide up the food chores from here on out – I would shop and do dishes if he would cook all the dinners.

But I didn’t.  Because I don’t think partnership is necessarily about specializing and not developing diverse skills.  It’s about specializing in the moment – dividing and conquering everything that needs to get done that night and still being flexible enough to switch jobs the next night.  Deconstructing rigid gender roles should mean something more and better than “I always mow the lawn and my husband always cooks dinner,” it should make men and women more competent and flexible. 

So in the name of self-improvement and a flexible partnership, I will continue to struggle through preparing dinner once in a while.  And Benjamin will continue to struggle through eating those dinners.

At least until July, when I fully anticipate everything to go to hell.  

Monday, April 2, 2012

Race and the "Default Experience"

Following the Trayvon Martin story has gotten me thinking about race. 

First, I just want to say that I am probably not properly qualified to speak on any of these topics.  These thoughts are not the well-crafted ideas of someone who has a deep and nuanced understanding of race issues.  These are the fledgling ideas of a privileged white woman who learned the word “privileged” within the past year.  So bear with me. 

As a white blogger, I feel it is important for me to share these thoughts, rather than just, say, continue to whine about the uncertainty of my maternity leave status.  Because the black community doesn’t have the option of not being affected by this story. 

I was listening to Elon James White’s podcast, “Blacking it Up,” where he describes just feeling hopeless and confused about what to do.  An older woman called in and said she was just “broken.”  How do you react to concrete evidence that your society simply doesn’t value the lives of people who look like you?

I have trouble wrapping my mind around that, I have trouble engaging with it.  It’s too big, too scary, too unjust.  And I think this is why a lot of people just walk away from this discussion – or justify why Zimmerman’s actions were legitimate.  It’s a lot easier to deal with one kid who really was up to no good than it is to acknowledge that the society you live in (in which you may be personally very comfortable) is fundamentally dehumanizing, wrong, and unfair.

I’m not ready to bite off a chunk that large.  So, I have tried to stay aware of race in other ways.  Here are just two of the things I noticed in the past few days:

1. I volunteer at a sliding scale clinic and wellness center in East Baltimore.  Most of our patients are black, most of our staff and volunteers are white.  Today I was helping with a session on stress management and we showed a movie about the physical effects of stress.  The doctor they interviewed was a black man, but all the actors that they had demonstrating the effects of stress were white.  Moreover, they were all white men in ties.  The language the narrator used was generic, he would say “stressful jobs,” but the actor would be a white guy in a tie massaging his temples as he sat before a computer screen in an office.  Clearly, he had a very stressful pie-chart presentation to give.  Bummer. 

This is not the kind of stress my patients are dealing with.  My patients are dealing with losing their jobs for taking too much sick time after their daughter was killed and they took over raising their autistic grandchild.  My patients are dealing with having a stroke at 45 and re-learning how to walk.  My patients are dealing with being laid off from the job that was already barely getting them by.  And sure, on some level stress is stress and we can all relate to that experience.  But it’s always non-whites who have to do the relating.  Because my experience as an upper middle class white person is always the default experience, even in places like Baltimore where it is not the majority experience, either in terms of race or in terms of class.

When I can expect that my experience as a white person is the default experience, that is privilege.  When you are in a position to craft how you represent the default experience, and you perpetuate that privilege – is that racist? It’s not racist the way not arresting Trayvon Martin’s killer is racist, no.  But I think it’s probably a more subtle angle of the same beast.

2. Later, I was working on my thesis, which is about obesity stigma.  I was doing some research into the Body Mass Index and found that one of the problems with it is that the cutoffs for overweight (>25kg/m^2) and obesity (>30kg/m^2) is that they were developed based on studies of mostly white people.  Theoretically, the normal weight range (BMI 20-25kg/m^2) was chosen because it represents the range associated with lowest all-cause mortality.  But it doesn’t apply to non-whites. 

For African-Americans, the lowest mortality rates are found at BMI values in the “overweight” range.  This means the NIH has duped thousands of (probably) well-meaning doctors into nagging black patients to lose weight when they are already in the healthiest range. I myself have done this, I am sure, trying to be the good little medical student supporting lifestyle change.

Here we see the consequences of white being the default experience.  Studies are done on whites and results inappropriately extrapolated to every other race.  Even when studies on other racial groups demonstrate that there are differences, the guidelines remain rigid.  The NIH claims that “there are no studies that would support the exclusion of any racial/ethnic group from the current definitions of obesity.” 

I think this example is particularly interesting because it exists at the intersection of two different kinds of prejudice – that based on race and that based on body size.  (Please note that I am not stating that one is worse than the other or that they are comparable, just that both are coming into play in this situation.)  It isn’t overt racism – no one is using the N word or shooting anyone.  Instead, it’s just this insidious and officially sanctioned suggestion that black people should internalize discomfort with their own bodies, that they should conform to medical standards designed for white people. 

I guess I am frustrated and anxious to move on to the next step.  I’ve noticed this, so now what do I do about it? Even the relatively smaller examples seem too large to wrap my mind around when I consider how to eliminate them. 

So, in conclusion, I am frustrated that racism still exists.  I was raised by hippies and would say I am oriented towards activism (not that I am particularly good at it).  But I have a feeling that on this one, I have a lot of internal work to do before I start grabbing petitions or taking to the streets.



Saturday, March 31, 2012

Trauma Surgery

I wake up in the pitch black to a sound, some sort of beeping that won’t go away.  Waking up is arduous; my limbs feel like tree branches, even my blood feels sluggish.  I don’t just not know where I am, I don’t know who I am, or what “awake,” is.  That is how deeply I was asleep. 

And then it dawns on me, that I am a medical student and I am in the on-call room, and that god-awful noise is my beeper.  I reach for my glasses and end up knocking the lamp and my pager off the bedside table.  I flail around in the sheets, trying to reach down and right the lamp.  Finally, I close my fingers around the pager and silence the alarm.  I think seriously about going back to sleep, but I don’t.  I read the tiny display on the beeper, “trauma alert: 39 yo male.”  I struggle to stand.  The beeper goes off again while I am still holding it.  More details: “trauma alert: 39 yo male. sledding accident.”  This should be good.

I stumble into my clogs, pull a surgical cap over my bed-head, and put on my white coat.  I shove a granola bar into my mouth as I trot off down the hall to the maze of tunnels that will take me to the trauma bays.

Trauma Male #1 is just being rolled off the ambulance as I arrive.  He is sitting up on the gurney, neck braced, moaning and holding his stomach, a line of blood dripping from his right nostril onto his shirt.  I pull on a gown, gloves, and a mask, and dig the shears out of my white coat pocket.  As the medical student on the trauma team, my main job seems to be Carrier of the Shears, which are useful for removing pesky things like clothes and bandages.

And this is no exception.  As the nurses swarm the patient and start shouting out vital signs, my chief motions me over, “Cut off the shirt and the pants,” he says, and then whirls off to make sure we are next in line for the CT scan.

I sidle up to the gurney, trying to introduce myself to the patient before I cut off his clothes and avoid getting in the way of the nurses, who seem to be doing actually important things, like placing IV lines and taking a history.

I stand to the left side of his head as he tells the nurse, “I was in the toboggan and couldn’t steer and we turned sideways and slammed into a tree.”  He points to the upper left side of his abdomen. “It hurts right here,” he draws a perfect circle over his spleen.  Hmm. I remember that spleen lacerations are graded, but I can’t remember what the criteria are.  Hopefully I will have time to sneak off and look this up before my resident pimps me on it.

“Hi sir, I just need to cut off your clothes so we can see your injuries without moving you too much,” I tell him. 

“You don’t need to cut them, it’s just right there, I can just pull my shirt up.”

Well shit.  Cutting off the clothes is my one job, and my resident will not be happy with me if I fail to do it.  Also, while I see his point that the area is already pretty accessible, it could be that this pain is distracting him from other injures. 

“I’m sorry sir, but we need to make sure you don’t have any other injuries.  I will cover you up with this sheet--”

He cuts me off, “please don’t cut my clothes.”

My resident appears behind me, holding his own pair of shears. (Way to make me feel useless.)  “Sorry sir, it is protocol here in the ED.” And then starts cutting.  “You get that side,” he says to me.

So I do, despite the fact that I am pretty sure this is assault.  Gritting my teeth, I start at the ankle and cut his jeans all the way up the leg to the waist band.  My resident does the same, and soon we are able to peel off his pants.

Which is when we notice that in addition to whatever sled-related splenic injury he has sustained, Trauma Male #1 has been shot in the penis.

My eyes dart up to the patient’s face – he looks horrified and humiliated and also a bit pale.

I have a sinking feeling in the pit of my stomach.  Partially, I am sure it is a visceral reaction to this type of injury, which I must admit squeaks me out the same way the all-wrong angle of broken bones still makes me queasy.  But the other part of this feeling is just knowing that we are in a rural hospital in Virginia.  I don’t believe the social and psychological awareness of the medical staff here is going to be sophisticated enough to deal gracefully with any of the scenarios that could lead to a man being shot in the penis.  We deal well with tractor accidents.  But mental illness? gender dysphoria? domestic violence?  These are not our strong suits.  And above and beyond the relatively temporary violation of having his pants cut off against his will, I have the sense that this man is about to have a whole prolonged interaction with healthcare that will be marked by violation.  And of course, I will participate in it. 

The resident raises one eyebrow and then sort of shrugs.  There is some dried blood around the patient’s crotch, but no active bleeding.  No one else on the trauma team seems to have noticed our discovery – it’s a small caliber hole and I guess most people make an effort not to stare at the patients’ junk.  My resident grabs the sheet from my hands and covers the patient up before directing the team to roll him onto one side and inspect his back.  We roll him up, and the intern runs her fingers down his spine. “No visible injuries,” she reports, and we lie him back down.

The resident listens to his heart and abdomen, pokes his belly a bit to elicit some groaning. Apparently nothing is concerning.  “Ok,” he says, “take him to CT.”  Lead-covered technicians appear and whisk him down the hall to the radiology suite.  I stay behind and look at my resident.  “I’m paging urology, go see if he has any spleen lacs.  If not, he’ll be on their service.”

Obediently, I trot off to the radiology control room.  If his penile injury is visible on CT, it certainly isn’t visible to me, and no one else comments on it.  We stare at his spleen, which looks normal.  The radiologist confirms – no laceration to the spleen.  We also “clear” his cervical spine – meaning we don’t see any fractures, so he is allowed to remove the horribly uncomfortable collar.  Normally we would probably discharge him now, but the resident appears to tell to technicians who are maneuvering him off of the CT scanner and back onto the gurney, “take him to room twelve.”

Room twelve is one of the more private ER rooms, with a real door that closes and is not made of glass.  Usually this room is occupied by women with gynecological complaints, so that a pelvic exam can be performed in relative privacy.  We wheel Trauma Male #1 in there.  A nurse gives the resident a questioning look and he says, “we’re waiting on a consult from uro – just keep him comfortable until they get here.”

And then the pagers are going off again – mine, the resident’s, the nurse’s.  “Trauma alert: 62 yo male. MVA.”

“Motor vehicle accident,” my resident explains, “bay two.”

I ready my trauma shears, hoping my task is less complicated this time. 

After the whirlwind of Trauma Male #2, I try to go back and check on #1, but he is nowhere to be found.  It is hours later, he could have been admitted to urology’s service or discharged home or he could have left AMA (against medical advice).  I don’t actually know his name or medical record number, so I can’t check the computer.  On our next shift together, I ask the resident, and he says he has no idea either.  Then he says, “I hope that guy did ok.”

I’m impressed with the way the resident handled the situation – maybe not with a nuanced theoretical understanding of the various issues that could lead to someone shooting himself (or being shot by someone else) in the penis – but at least with decency and discretion.  Decency and discretion delivered immediately after he cut the man’s clothes off against his will (which I still think is wrong and feel wrong for participating in).  

But it’s good to be reminded that people aren’t all one thing.  We aren’t either all good or all bad, we have good moments and bad moments.  I hope that Trauma Male #1 did ok, too.  And I hope that I will do better next time.




Monday, March 26, 2012

Match!

I matched!  To my first choice program in Baltimore, where I already live.  No moving!  Now all I need to do is figure out the best way to tell them I will need maternity leave immediately following orientation. 

Thursday night, Benjamin and I went out to dinner with an old friend of ours from the youth group where we met.  We went out to the Indian restaurant that catered our wedding, and I got the same dish we had at the wedding.  I had been feeling pretty queasy all day, which was unusual since this has been a fairly nausea-free pregnancy. 

Next thing I know, I am excusing myself from the table and hanging out in the restaurant bathroom, splashing water on my face.  I threw up a few times, rinsed my mouth out, and went back to dinner.  I still felt queasy but not terribly sick.  For the ride home, Benjamin fashioned me a bucket by sawing the top off of a plastic one gallon gas can with his leatherman. 

We woke up early the next morning to drive down to Charlottesville for the Match Day festivities (makeshift vomit bucket in place).  And my financial aid exit interview.  Let’s just say that over the past five years, I have borrowed an absurd amount of money.  It’s not that I couldn’t have figured this stuff out on my own, but I feel very lucky that Benjamin happens to love financial planning and filling out forms. 

Benjamin thought it was fun to keep saying things like “only eleven hours until Match,” “only four hours until Match,” etc.  I found this very helpful and calming.  I only hope he is this supportive during labor. <eye roll>

Finally, it was time to go.  It isn’t traditionally a formal event, and I opted to wear a maternity top that is form fitting enough to make it clear I am either pregnant or shoplifting a frozen turkey.

We gathered in the Old Medical School Auditorium.  Since we are now on the 3rd medical school, I guess I should say that this is the oldest existing medical school auditorium.  The atmosphere started off festive and escalated to insane.  Benjamin and I found seats in the back but quickly realized that we were in the middle of the loudest, drunkest group of medical students. 

The Student Affairs folks stood at the podium and began reading names.  When a name was read, that person would go down the aisle, deposit a dollar in the box for good luck, get their envelope, hug the dean, and pick up a champagne flute.  Then they had to sit down, holding their envelope but not opening it while the rest of the class was called.

When my name was called (mispronounced though it was), I waddled proudly down to the front and got my envelope and my sparkling cider.  I had forgotten to count how many names had been called before mine (and they are not called in alphabetical order) so I had no idea how long I was going to have to wait to open my envelope.  The ceremony went past noon, and my phone was already buzzing with text messages from friends, asking about the result.

Then, finally, the last person was called, and we all toasted and tore open our envelopes.  University of Maryland Family Medicine, my first choice.  I was very happy, of course, but it was also a bittersweet moment, because it meant closing the door on all those other possibilities.  Having all those open doors had been frustratingly vague, but the not knowing was also sort of magical.  I was especially sad about giving up my second choice program in Greensboro, NC.  I think I would have been very happy there, but ultimately UMD is a better place for me.

I am usually excited about setting off on an adventure, but in this case, I am really excited to be staying home for an adventure.  Baltimore is my home.  My family is here, however dysfunctional my relationship with them is at the moment.  Benjamin’s sister and her husband are here – and they are expecting a baby, too, so the cousins will get to grow up together.  Benjamin’s parents will be returning here after their year in New Zealand. 

But even aside from the family, Baltimore is the physical infrastructure of my childhood.  The culture here is the one that shaped me, for better or for worse.  I went to these city schools and learned about the Chesapeake Bay and Lord Calvert and the Dominos Sugar sign on the harbor.  I know how to say ‘hon’ and pick crabs and cheer for the Orioles even though you know you will be disappointed every year.

I get to be an adult and a parent in the city where I was born; and that is really cool.  I get to bring back all the things I learned in Virginia and use them to serve my home community, and I am really honored to have that opportunity.

And now, all the things I can’t do until after Match – I can do them now.  Yikes.  

Thursday, March 15, 2012

The Waiting Game

In my life right now, there is a spectacular amount of interesting stuff that is about to happen.  And what that really means is that none of it is happening right now.  Right now, I am just waiting.  Waiting to find out where I matched for residency (and all that entails), waiting to find out how much maternity leave my residency program will give me, waiting to graduate, waiting for my family drama to get better, waiting to meet this little person I’m growing in my abdomen.

I’m not a good waiter.  I’m on the cusp of all this life-changing, interesting stuff, but right now I am mostly just bored and frustrated.

Picking up where I left off yesterday: after interviews are over, the Match starts.  You (the applicant) rank the programs in order of preference and enter them into the National Residency Match Program (NRMP) website.  They give you several weeks to agonize over this list and make changes before locking it down in February.  I changed mine three or four times.  It was just tortuous. 

The programs, meanwhile, are making a ranked list of applicants, in a process that I can only imagine is more tortuous, as it involves group decision-making.  They enter these into the NRMP website as well.  And then the computer runs an algorithm and spits out a letter that tells you where to move.  Theoretically, the algorithm is applicant-centered and attempts to give all the applicants the highest ranked program possible. 

If you want to see how it works, a fairly good explanation is here http://www.scutwork.com/cgi-bin/links/page.cgi?page=Algorithm

I like how they stress over and over that you should rank programs according to your true preference.  As if “true preference” is totally obvious to everyone.  But really, how do you weigh “close to my family,” when that family is only 17% speaking to you?  How do you weigh, “I feel comfortable around these residents,” when you can’t ask them how they would feel about you having a baby as an intern?

Whatever, there is nothing else I can do about it now.  I just have to breathe deep (increasingly difficult) and wait for Friday.








Wednesday, March 14, 2012

A Quick Recap of the Career Path So Far


I find out where I am going for residency the day after tomorrow. 

But before I get into that, I thought I would back up and give a quick recap of US medical training.  I know the whole process is confusing, as various relatives and Quaker meeting members ask me how it works every time I see them.

Ok, so, say you want to be a doctor.  We’ll start at college – you will need a four year undergraduate degree.  What can you major in?  Turns out, anything you want.  I double majored in Biology and Drama.  (People are always asking me how I am going to use my Drama degree.  I use it to act like I know what the hell I am doing.) 

There are some prerequisite courses, like Organic Chemistry that tend to be of the “weed people out” variety.  It almost worked.  I had this amazingly terrible Organic Chemistry professor – he didn’t seem to know any organic chemistry (drew some amazing molecules where carbon had five bonds) and sometimes forgot to wear pants to class.  (Literally, he showed up in boxers and dress socks and a button-down shirt.) The school hadn’t given him a relocation allowance and so he slept in his car in the parking lot of the gym, though I am not sure if it was out of protest or economic necessity. 

It was all just sort of wacky and annoying until The Incident.  He left a mercury thermometer inside a very hot melting point apparatus all afternoon, eventually breaking the glass thermometer.  My classmate went to pull the thermometer out and saw that it was broken.  The professor insisted that it was an alcohol thermometer and that the student had broken it by pulling it out of the melting point apparatus at an angle.  The professor made him clean up the (clearly beading and metallic) liquid with paper towels.  It turns out that much of the mercury was actually vaporized at this point and so the student was inhaling mercury vapor the entire time.  He ended up being hospitalized for several days and losing all his hair and having some neurological effects.  I am not sure why or how there was not a massive lawsuit about this.

Anyway, if you survive Organic Chemistry (literally and academically), you get to take the Medical College Admissions Test, or MCAT.  Oh god that thing was fun.  And by fun, I mean a torturous pain in the ass.  Nothing on that test is remotely useful in medicine.  There’s physics and I don’t even remember what else.  Some sort of essay question.  The scores go from 15 (worst) to 45 (best but statistically unattainable).  I think they usually say 30+ is pretty safe for med school admission. 

Then, you apply to med school.  Lots of personal statements and official transcripts.  Your personal statement will probably explain how you want to “help people.”  Of course you do.  <pats your head>

When you decide to apply to med school and where to apply, you won’t know anything useful about medical school, because of course you have not been there yet (unless you are a time traveler).  Now that I have been to medical school, I can tell you they are all probably pretty much the same.  I picked mine based on the fact that Charlottesville was a prettier place to live than Philadelphia or Baltimore.  I probably should have weighed being close to my family and paying less tuition a bit more heavily than I did, but there you go.

Another thing I knew nothing about was that there are two types of medical schools in the US.  Allopathic schools award the M.D. and are historically more “science-y” while osteopathic schools award the D. O. and are historically more “touchy-feely.”  The jobs each can have upon graduation are indistinguishable.  My undergraduate advisor just told me to apply to allopathic schools because they are theoretically more prestigious.  Clearly, I should have researched this a bit more.  I think it would have been slightly easier for me to find philosophically aligned peers and mentors at an osteopathic school.  Oh well.

Anyway, once you pick a medical school and get accepted, you complete four years of medical school.  Traditionally, the first two years are your classroom or “pre-clinical” years.  They will be absurdly difficult.  I assume these years are some sort of hazing, as much of the information you are required to memorize is quite useless for actually treating patients.  Try not to focus on this, just accept the experience for the hoop-jumping that it is and trust that you will learn real patient care ….eventually.  I spent a lot of time reinventing my note-taking and studying style, bemoaning how difficult it was, and questioning if this was the right path for me.  I recommend not wasting quite so much time on these things, as all they did for me was produce some very dark, Sylvia Plath-esque writing pieces. 

After the second year, you will take Step 1 of the United States Medical Licensing Examination (USMLE).  It’s an eight hour multiple choice test.  Somehow, after first and second year I sort of enjoyed this test.  The test review materials were well-prepared compared to our course materials, and the test is standardized, not written by a bitter research PhD who has been saddled with lecturing needy medical students about the nerve conduction system in the giant electric eel. Still, the fact that I enjoyed it is concerning to me.  Perhaps I am becoming a robot.

During the first two years there is usually some sort of workshop during which they teach you, “how to talk to patients,” and “what to do with your stethoscope.”  Invariably, throughout training, half the attendings you talk to will think that a really good physical exam can locate a brain tumor and diagnose appendicitis and tell what you had for breakfast.  The other half of the attendings you work with will just order a CAT scan of every patient.

Finally, after Step 1, the clinical years start.  During third year, you rotate through all the various specialties such as internal medicine, obstetrics & gynecology, pediatrics, surgery, etc.  These rotations or clerkships are 4-8 weeks in length and each is followed by an exam called a “shelf.”  Third year is really the only year of medical school actually worth the tuition, as you get to act like a real live doctor and learn a ton of stuff that is actually useful in caring for patients.  Also, if you went into medicine to “help people,” you will enjoy actually getting to talk to people again. 

On the other hand, this year has high potential for burn out – mostly because you realize the asinine hierarchical brown-nosing culture of the pre-clinical years does not disappear during the clinical years.  But now, the casualties of this culture of ass-kissing entitlement and priviledge are real people, your patients.  I don’t know what to tell you – the whole thing made me have a mental breakdown.  Um, stand up for your patients where you can and otherwise just try to keep your chin up.  Don’t forget to feed yourself and sleep – the culture of medicine does not value these things but they are still important for all humans.

Moving on, fourth year is full of “elective rotations,” meaning it could be like an extension of your third year, or it could be full of “fluff.”  Some of the more obnoxious nose-to-the-grindstone type people will insist that you should work as hard as possible during 4th year. To some degree, I see their point – getting your money’s worth and learning useful things are always good.  On the other hand, 4th year is a great time to recharge your batteries before residency, travel, apply for residency, interview for residency, and generally stress out about residency for a full year before it starts.

So, after medical school comes residency – a stage of medical training in which you are officially a doctor but you are not an independent doctor, you are still in training.  To apply to residency, first you have to pick a specialty, which is a whole post in itself.  I picked Family Medicine, which is a 3 year residency.

Then you apply.  Dig out that personal statement you wrote about wanting to help people. Add paragraph about something you learned in medical school.  Stop agonizing over it.

The application process is all online through a program called ERAS.  You pay about ten bucks a pop for ERAS to send your application to the various programs.  How do you know what programs to apply to?  You don’t.  Because you don’t know anything about residency yet, since you haven’t been there (unless you are a time traveler).  I don’t have any further advice for you, since I haven’t been there either.  I will get back to you on that.  Oh, but you aren’t crazy, all their webpages DO look the same.

After the applications are submitted, you sit back and wait for interview offers.  Proceed to lose your mind and spend all your money traveling all over the US interviewing at various programs.  My only advice for this stage: buy a suit that you like and always pack snacks.  I was extremely lucky, my husband happens to be unemployed and enjoy driving, so he was able to drive me to most of my interviews, help out with logistics, etc.  All I had to worry about was dazzling them with my brilliant personality.  Ugh.

Anyway.  That is the process that gets you to the glorious day that happens the day after tomorrow: the match.