Thursday, February 16, 2012

Sixteen Breaths

Today at the grocery store, my husband barked at me for picking up a bag of candy off of the belt in the self-check line and making the automated voice lady all cranky-pants (“if you wish to purchase the item, please place the item on the belt.”)  I spun on my heel to face him and said, “don’t talk to me that way.”  I thought I was going to actually shoot lasers out of my eyes, but it turns out I just shot spittle out of my mouth.  He put the candy down and said, “you’re right, I’m sorry.”  It caught me so off guard.  I had all this anger all stockpiled by the entrance of my mouth and all of the sudden he’s just saying “I’m sorry.”  Like, that’s great, but what am I going to do with all this venom?  I looked around for someone else to yell at, but I didn’t see any republicans.  I felt like I had a mouth full of gristle at a fancy party and had to wait till no one was looking so I could spit it discretely into my cloth napkin.  I’m not good at changing gears this fast.  Last time we had a fight and I was wrong, I had to sit with my eyes closed and take sixteen deep breaths without saying anything before I could apologize.  It took sixteen deep breaths for me to rearrange my whole idea of myself into someone who could sometimes be wrong.  My pride was limping around giving me pitiful looks for days.

We did our taxes tonight and it was actually sort of fun.  Married life is weird.  We had stockpiled all these medical receipts and I read them out to Benjamin while he entered them into a spreadsheet on the computer.  It feels so nice and ordered to know that basket of scraps of paper is now a nice organized spreadsheet.  I’m not type A enough to do that sort of thing on my own, but I am type A enough to appreciate it when it is done.  My brain feels like it has good feng shui now. 

I went to the coffee shop today to work on my thesis and this nice young woman asked if she could sit down with me.  We talked for almost two hours.  I didn’t get much of my thesis done, but this is why I don’t work at home; it’s harder for the universe to tell you about something more important you should be doing.

The baby is either practicing her Olympic tumbling routine or I am about to have explosive diarrhea.  I really cannot tell which.  This is the weirdest thing my body has ever done.  Way weirder than the time I was twelve and realized I was growing little dark hairs in my armpits.  Puberty was rough; I feel like I just got used to that body and now here it goes changing on me again.  I have stretch marks on my breasts.  When I complained about this to Rosemary she arched one eyebrow so high it threatened to give up and join forces with her hair, “didn’t you have those already?”  I guess I am not going to get a lot of sympathy for the boob stretch mark thing. 

Yesterday was a terrible day.  Halfway through my third bout of sobbing I thought, “Oh yeah, depression, I remember you.”  Remembering that this was called depression did not really help me feel any better, but at least I had a name for it.  If I hadn’t remembered that it was called depression, I was going to christen it “Frederick.”  Today was much better.  Hopefully tomorrow will be bearable.  

Sunday, February 12, 2012

What I Learned from Triplets (In which I alienate my new found readers)

So pretty much all of the 10 people who read this blog come from one of two places on the wide-wide internet.  One is The Baker’s Dozen and Apollo XIV ( , a blog I have been reading for several years about a homeschooling family with 14 kids, and (though Renee rarely if ever delves into politics) a social/political leaning on the more conservative side.  The other place my readers hail from is the forum at The Feminist Breeder (, a mecca of natural/organic/gluten free/gender-neutral/liberal parenting. 

If I got all these people together in a room, I am sure they could find a lot to agree about: cooking nutritious food, cloth diapering, homeschooling.  I’m sure they could also find plenty to disagree about: marriage equality, feminism, the 2012 presidential race.  But fundamentally, I think both groups share a set of “family values,” that aren’t about politics but instead are about understanding that adults and children thrive in home communities where everyone is cared for, nurtured, and respected.  I am guessing that a majority of my readers are stay-at-home-moms (or, if you are a savvy blogger type, “SAHMs”), and that part of these common family values would be about the importance of mothers in these home communities.

And I figured, as a fledgling blogger, that the best thing I could do is to piss everyone off equally.  Here goes:

Last year, I took time off from medical school to go to graduate school (because I have an education addiction, I know).  During this time, I thought it would be sensible to get a part-time job.  And despite my seven years of higher education, the thing I was most qualified to do was still childcare.  And so I became the nanny of five month old triplets.  Because if I’m going to do something, I do it all the way.

I love children.  I grew up the oldest of a gaggle of neighborhood kids and developed a maternal instinct at a young age.  I have been working in childcare since I was fourteen years old.  I have always wanted to have kids (except for a brief, angst-filled period in college when I wondered if my genes were worth passing on).  I also figured that I would want to stay home with my kids (maybe even homeschool them) but that this likely wouldn’t be possible for financial reasons.  (I don’t think I knew any SAHMs growing up, it just didn’t seem like something that real people got to do.) 

When I found myself in medical school, the second best thing to being with my own kids seemed to be to take care of someone else’s kids (all kids are adorable, after all).  Despite some of my classmates referring to my chosen profession as “veterinary medicine,” I planned on going into pediatrics.

But during the year that I was taking care of the triplets, I realized two important things about myself:

1.  I don’t want to be a pediatrician.
2.  I don’t want to be a stay at home mom.

I’m going to be perfectly candid here: triplets are a bad idea.  Three babies is two babies too many.  When one baby screams, you can pick her up and bounce her around and check her diaper and fix her a bottle (of breast milk and/or organic goat’s milk, to be sure!).  When three babies scream, all you can realistically do is try to keep yourself together enough to avoid joining in.

During previous nannying gigs, I had two main approaches to babies.  The first was to hang out at home with NPR in the background, reading books and playing with blocks and all that good stuff.  The other was to get the heck out of the house.  I love taking kids on fun outings, and babies are easily entertained.  No need to take a baby to the aquarium when the fish tank at the local Chinese restaurant is just as interesting!  As an added bonus, this means I get to eat some Chinese food.

With the triplets I couldn’t do either.  There was no NPR signal anywhere in the house.  I could not fit three car seats in my Ford Escort.  We were marooned at home, doomed to silence or the tortures of Sprout television.  How I longed for the dulcet tones of Diane Rehms and her Friday News Roundup!  How I longed to simply parade the babies around the mall!

It turns out, babies are really boring.  Without adult conversation or novel stimuli of any kind, I was going crazy.  I was forced to focus all my attention on the pre-mobile, pre-verbal, spit-up machines under my care. 

I realize this is considered ideal by most parents and is probably what my employers (the triplets’ parents) were hoping for when they hired me.  It is what I thought I was doing with all my other nannying jobs.  But I must not have been.  Because the level of boredom I was experiencing was all new to me.  When I went home to my apartment at the end of day, my thoughts remained stuck in an endless loop of inane things like, “I wonder if L will roll over tomorrow.  Did I remember to record how many ounces A had to eat today?  Will sleep-training three babies ever work if they keep waking each other up?  Is there more frozen breast milk in the back of the freezer that needs to be rotated to the front?”

A few of these thoughts are fine.  If they had been interspersed with thoughts about stimulating conversations I had with other adults, or interesting books I had read, or even cute guys I noticed at the bar that night – it would have been fine.  But it was just all babies all the time.  (Grad school was not enough of a diversion from the serious baby immersion experience I was having).

As someone who has been pining for children of my own since puberty, I was for the first time really missing adults.  I really like how adults can speak to you and participate in their own toileting and are doing things other than just developing.

I realized that while I love kids and babies, I don’t want to spend all day, every day with my own kids or someone else’s.

My adult patients are painters and poets and engineers.  They want to talk to me about how their sexual relationships changed after menopause and how they are handling retirement and how their new antidepressants are working.  And I want to hear about these things.  And I also want to hear about how little Nora can roll from her stomach to her back but not from her back to her stomach.  I don’t want to have to give up either.

Professionally, I am so glad that Family Medicine exists.  I think it is a spectacularly good fit for me. I’m excited about the prospect of building a practice that includes multiple generations.  I find that environment to be the most stimulating and supportive.

Personally, I am so incredibly lucky that my husband wants to stay home with our child.  I am extremely lucky to have such a caring, supportive partner in general, but in this particular arena I feel like I’ve got an ace up my sleeve.  Much of the guilt associated with being a mom who also wants to have a career is alleviated by this simple truth: my child will be loved and cared for while I am at work by someone who is still her parent and who wants to be home with her.

[Note: We do not know the sex of our baby/fetus and probably won’t until he/she is born.  However, I find “he/she” awkward and “it” unacceptable, so I will just be alternating between gendered pronouns.]

Wednesday, February 8, 2012

The Real Reason I Want to be a Doctor

One of my favorite blog authors (Renee at A Baker’s Dozen recently wrote a post about how she lost faith in doctors that has gotten me thinking about various issues in medicine, especially why I wanted to be a doctor in the first place.

In my application essay for medical school, I wrote something very poetic about how I wanted intellectual stimulation and to “be the change you seek in the world.”  Basically, I’m a science geek and I want to help people.  Very original, I know. 

I think we were all lying; at least by omission.  Because sure, some of my classmates really, really do want to help people, and almost all of them are science geeks.  But those weren’t our real reasons. 

For a lot of people, the real reason is something along the lines of, “my dad was a doctor and this is the only way he will take me seriously.”  Similarly, “I want to be a respected and impressive member of my community and enjoy all the perks that go along with that,” is a popular option.  “I was good in school and didn’t really know what else to do with myself,” is also common.

For me, I wanted to be a doctor because I hated doctors.  I wanted to prove I could do better than the doctor who took care of me growing up.  I wanted to prove that medical care could be nurturing rather than degrading.  And, as a fringe benefit, I figured that as a doctor myself, I would never have to go to another asshole doctor in my life (ha!).

My pediatrician was a pensive guy with a bushy beard and lots of novelty ties.  I don’t think he was a pioneer of bedside manner with either kids or parents, but he did ok.  I got my shots, I earned some stickers.  When I had terrible sore throats that my mother was convinced were strep, he would peer into my mouth and declare that my throat looked, “not too bad.”  He wasn’t a great doctor, but I had no complaints. 

Until I was twelve, and my mom brought me in to his office for “vaginal discharge.”  She had noticed crusting on my underwear. 

Being dragged to the doctor for this was mortifying.  I sat on the exam table with my eyes closed while the doctor asked my mom some questions.  He never addressed me except to tell me to slip off my “panties” and lie back on the table.  I hated the word panties, it sounded both juvenile and dirty.  I wanted the exam table to swallow me up.  Barring that, I wanted his Cat In The Hat tie to come to life and strangle him.

He put on a blue nitrile glove and poked his big fingers around at my labia.  It was so embarrassing and humiliating I thought my heart would stop. 

Before my mom dragged me in here I had not realized that my body was doing anything unusual, but now I felt alien, defective, contaminated.  The doctor made some “hmmm,” sounds and then had me sit up.  My “panties” were still around my ankles and fell to the floor.  He continued with a lymph node exam, without removing the glove. 

Here I was at the doctor for having this weird stuff coming out of me…down there… and now here he was getting that stuff on my neck and in my hair.  I just wanted to go home and shower with hot bleach.

He concluded his exam by mashing idly at my stomach, and then told my mom that this “probably a normal part of early puberty,” and asked her to step out and talk with him while I put my clothes back on.  Then he came back in without my mom and asked me if my friends were using drugs or if I was “sexually active.”  I mumbled “no,” to both questions.  He assured me that if I ever wanted to talk about “that stuff,” that I could talk with him about it. 

As if.  I never wanted to see him or his stupid ties again.  I never wanted to see another doctor, either.  Even though I was very confused about what “early puberty” entailed and what actually caused this vaginal discharge, I did not feel like he was even remotely a person I could ask about these things.

And that is when I decided to become a doctor.  I decided to become a doctor who would never make anyone feel as miserable and ashamed and dehumanized as I did that day. 

I’ve learned a lot of things since my experience with the insensitive pediatrician.  I understand why he acted the way he did.  (Except for not removing the glove before doing the lymph node exam.  That still seems sketchy.)

But for the most part, he did things by the book.  I was under eighteen, and so addressing the questions to my mom made sense. Moreover, it is the medical-legal tradition in pediatrics.  He probably even thought he was letting me off the hook by not forcing an obviously embarrassed tween to talk.  Since I was not the medical decision-maker in the room, and because it is usual to assume consent for the physical exam, I can understand how he did not ask my permission before touching my genitals.

That whole awkward song and dance about drug use and sexual activity is also totally by the book, even though at the time it felt forced, formal, and invasive.  And because physicians don’t want to overwhelm their patients with too much information, it is not unreasonable that he didn’t tell me anything about puberty.  After all, I didn’t ask for any information.

Overall, the way he handled the visit was exactly the way we were taught to handle it in medical school.  And this approach might have been fine for a different kid.  But it was not really fine for me, his patient.

Because what they don’t teach in medical school is how to connect with people, how to know people, how to read their reactions and gauge how you’re doing.  They don’t teach you how to be a human being.  In a lot of ways, they specifically teach you to abandon your humanity, to replace your own interpersonal judgment with the “by the book” approach.  And whatever book they are using is terrible.

Tuesday, February 7, 2012

Body Image, Pregnancy, and Obesity Stigma

I’m sixteen weeks pregnant and I have officially given up on all my non-maternity pants.  In a fit of nesting, I bought a bunch of clear plastic storage bins and stowed away all my too-tight pants under the bed.  The bin was nicely labeled, and I think that come October or so when I may fit into those pants again, I will remember where they are.  I would like a sticker, please.

Maternity pants are awesomely comfortable.  I had no idea pants could be this comfortable.  I especially like this one pair of jeans that have an elastic waistband rather than the huge elastic panel (though I know I am destined for panel-pants-land eventually).  The only problem with these pants is that I am constantly hiking them up.  Hence, long comfy maternity shirts.  Bingo!  As an added bonus, I got almost all my maternity clothes from a friend, who was clearly on the purge portion of the gather/nest/purge cycle.

I’m digging the new pants.  I am digging my “baby bump,” (though I agree with Lake Superior University that this phrase should be banned I’m enjoying constantly palpating my abdomen to locate the firm edge of my uterus.  (Do pregnant people who are not medical students do this? I don’t know.) 

Other than the debilitating heartburn, I am feeling pretty good about the whole situation.  Until I read an entry on one of my favorite blogs, The Underwear Drawer, whose author, doctor-mother-extraordinaire Michelle Au is sixteen weeks pregnant with her third child.  The blog post contained one of those ubiquitous belly-shots, which you can see here:

Michelle is tiny, and in pregnancy seems to be remaining tiny.  Or maybe before she was pregnant she was actually translucent.  In any case, it made me feel like a giant pregnant whale.

Then my “What To Expect” week-by-week pregnancy guide tells me, “It’s hard to watch yourself gain weight during pregnancy, even when you know there’s a wonderful reason for it.”

Is it?  Should it be?  Why do I feel chastised by another woman’s belly shot? Why are we so concerned about gaining weight? 

We’re concerned about it because we have internalized the societal stigma against overweight people.  Studies on weight stigma have shown that people are more likely to judge the obese to be lazy, unintelligent, and incompetent.  

I suspect that the embarrassment of gaining weight during pregnancy comes from a desire not to be confused with “those people.”  You know, fat people.  Especially in early pregnancy, when you know people are debating whether you are “with child” or “with Chipotle.”  We want to represent ourselves accurately, “I’m not lazy and unintelligent, I’m just pregnant!”

Um, fat people aren’t actually those things either.  Fat people are no more likely to be lazy, unintelligent, or incompetent than thin people.  (See my master’s thesis on Obesity Stigma for full details, you know, as soon as I finish writing it.) 
Rather than carving out a social exception for ourselves (“I’m not fat, I’m pregnant,” we should be questioning why society judges fat people so harshly.  We should be questioning why it is socially acceptable to disparage people based on weight in ways that it is no longer to disparage groups of people based on race or sex.  (There are tons of examples of this, and I will get to them in a later post).

I am making it my goal during pregnancy and afterwards to eat well, exercise, and just not worry about what I weigh.  And I am also making it my goal to examine my attitudes towards others and challenging those attitudes when they are based on stereotypes and prejudice.

Andreyeva, T, Puhl RM, Brownell KD.  Changes in perceived weight discrimination among
Americans, 1995-1996 through 2004-2006.  Obesity Journal. 2008;35.

Puhl, R. M., Andreyeva, T., & Brownell, K.D. (2008, January). Perceptions of weight
discrimination: prevalence and comparison to race and gender discrimination in America.  International Journal of Obesity.  1-9.

Puhl, Rebecca, and Brownell, Kelly D.  Bias, discrimination, and obesity.  Obes Res

Puhl, R. M., & Brownell, K. D.  (2006, October). Confronting and coping with weight stigma: an
investigation of overweight and obese adults.  Obesity, 14(10), 1802-1815.

Puhl, R.M. & Heuer, C.A.  (2009). The stigma of obesity: a review and update.  Obesity,
17(5), 941-964.

Puhl, R.M. & Latner, J.D. (2007).  Stigma, obesity, and the health of the nation’s children. 
Psychological Bulletin, 133(4), 557-580.

Roehling, MV.  Weight-based discrimination in employment: psychological and legal aspects.
Personnel Psychol. 1999;52:960-1017.

Rothblum, ED, Miller CT, Garbutt, B.  Stereotypes of obese female job applicants.  Int J Eating
Disorders. 1988; 7:277-83.

Wednesday, February 1, 2012

Thoughts from the ER

I don’t live in Charlottesville anymore, and this is my last rotation here.  I’m staying with friends who live nowhere near campus.  To get to the hospital, I have a half hour drive, a hunt for a parking space, and then a 15 minute walk.  I arrive breathless (pregnancy seems to be using all my blood elsewhere) and stand by the door of the ER for a minute, catching my breath and waiting for the sweat on my forehead to dry.  I did a triathlon less than six months ago.  I backpacked from the north rim to the south rim of the Grand Canyon.  Now the sloped driveway to the ambulance bay gets me huffing and puffing. 

I’m not the only one.  My first patient is a 66 year old man with shortness of breath. 

Working in the ER, my resident gives me four pieces of information about each patient before instructing me to go to see them: age, sex, chief complaint, room number.  I scan the computer for the fifth piece: the patient’s name.

“Hi Mr. Hiles,” I say, sticking out my hand, “I’m Mali, the medical student on your team.  What brings you in today?”

Mr. Hiles is skinny and tan, he looks younger than 66, he has long stringy hair under a dirty baseball cap.  He sits cross-legged on the gurney in bay 50.  He is not wearing oxygen, which is standard for people with shortness of breath.   “Well, I’ve had this knot on my leg for a while now.” 

Don’t you hate it when you only know five things about someone and one of them is wrong?

“I’ve had this knot in my leg and it gets to hurtin’ real bad and the pain goes up the leg and spreads across my whole body and I feel dizzy and uncoordinated and it is hard to breathe.”

“How long has this been going on?”

“I’ve had the knot in my leg for six months, but the rest of it has come up in the last eight weeks or so.”

I’m having trouble making this fit into any particular pathologic process.  When I hear leg pain and shortness of breath, I worry about pulmonary embolism, but the time table isn’t right.  Asthma, COPD, heart failure, and heart attack are all also still on my differential, but he looks very healthy and comfortable, and none of them really address the leg pain.  “This sounds like it has been troubling you for a while.  What made you come to the ER today?” I ask.

“I tried not to come in, I made an appointment with my regular doctor for this afternoon.  But this morning I felt like I was fixin’ to die.   I didn’t think I would make it to 3:30.”

This gets my attention.  A feeling of impending doom can be associated with pulmonary embolism or a heart attack.

“I got worried I was having a blood clot somewhere.”  Way to steal my thunder, Mr. Hiles.

I continue his history.  He has no chronic medical conditions, does not smoke, has no reason to have blood that coagulates too easily.  He does have severe anxiety that occasionally keeps him from working or going out in public.  He has never seen a psychiatrist or therapist or taken any medication for this.  He has never discussed it with his primary care doctor or anyone else. 

I choose my words carefully.  “Thanks for telling me about that,” I say, “in the ER today we want to make sure you aren’t having something life-threatening like a heart attack or blood clot in your lungs, but you should definitely talk with your primary care doctor about the anxiety.  Some people feel like it isn’t a real problem, but it can make you feel really terrible.  It sounds like your anxiety is pretty serious, since it is keeping you from working or going out.”

Mr. Hiles nods at me.  “Maybe I will keep that appointment this afternoon and talk to him about it.”

I pray silently that Mr. Hiles’ primary care doctor will not let us down on this one, won’t act like he doesn’t want to hear about it or doesn’t have time to deal with it or try to refer him to some expensive psychiatrist right off the bat. I hope he’s one of the good guys, and that he’s having a good day.

“Good,” I say, taking out my stethoscope, “can I take a listen to your heart and lungs?”

I love the quiet moment of listening to a patient’s heart, hearing that reassuring lub-dub, lub-dub, getting to steal a few seconds to organize my thoughts, concentrating solely on being with that person.  Mr. Hiles’ heart and lungs sound beautifully normal.  His vital signs are all normal.  His left calf is not swollen or red or warm to the touch.  The knot seems to be some scar tissue from a construction injury. 

I tell him we are going to run a few tests, but that I am very reassured by his physical exam.  I don’t think he has a blood clot.  He is visibly relieved, and I am surprised that the words of a lowly medical student are enough to reassure him.

I describe his symptoms to the resident, who cuts me off midway through my second sentence, “Is this guy sick or not sick?” he asks.

“Not sick, but I want to check and EKG just to be sure, then I think we will both be reassured enough to send him home to follow up with his PCP about his anxiety.”

The resident rolls his eyes about the anxiety.  “If you are thinking PE, does he need D-dimers, CT Angio?”

“No,” I tell him, feeling like the only person in the ER concerned with medical costs.

Mr. Hiles EKG prints out and I stare at it.  I am still at the stage where I follow the outline in my pocket medicine guide to look at EKGs.  For good measure I google the EKG signs in pulmonary embolism, but no matter how I look at it, this EKG is normal. 
Mr. Hiles is thrilled, feels much better, and promises that he will talk to his doctor about getting some therapy and medicine for anxiety.  The resident signs his discharge papers.

To the Emergency Medicine resident, this was not an exciting patient, just another example of people using the ER when they don’t actually have an emergency.  But to me, this was one of my favorite patients.  I prefer my patients to not have anything serious wrong with them (in part because I lack confidence in my medical abilities, but mostly because I want people to be healthy and well).  Mr. Hiles needed help, and I was able to help him, so I consider it a job well done.  Also, I am hopeful that he will get long-term help for his anxiety, and long-term solutions are few and far between in the ER.