Impatience

The cognition was fading, more rapidly than anticipated.  An intervention that would likely prevent it was not what the patient wanted after watching a loved one die of the same.  The primary team called an emergency family meeting to get a decision made.  The patient refused to let anyone make decisions except them and yet, they could not follow the conversation.  The family was afraid to make decisions because of past history of animosity and anger if things didn't go the way the patient wanted.  The onus was put on us to get a decision made.

It's amazing how easy it is to feed into that sense of impatience.  I felt like I didn't get to do things the way I prefer to - get to know the patient, figure out what's important to them, determine what treatments they for sure knew they did or did not want before being thrust into forcing the patient's hand on a decision.  Instead, the rapidly fading mental capacity of the patient led to a hard push to try to get a decision made, and it ended in the patient's family getting the silent treatment.  That, I felt, was my fault for not doing things the way I typically do them.

Today, we got nothing from the patient.  The chemicals in the blood already having their affect on the clarity of consciousness.  The edge that was present yesterday, was gone today.  The patient is rapidly becoming a shell of themself.  The family is still paralyzed by the patient's previous indecision.  The team was impatient, angry that we hadn't "made the patient hospice" so they could get rid of them.  It was heartbreaking.

How do you balance doing what feels right for you when it comes to setting up the conversations at hand with the expectations of the primary team and the abilities of the patient?  Knowing that this patient wanted to make all of their own decisions without family intervention makes it harder now because that's not possible.  We have no information on what the patient wants us to do beyond the things they don't want.  How do we proceed.  We know the patient does not necessarily need to be in the hospital, and yet the family is saying they wouldn't want multiple other options that would be supportive of the family.  Where do we go from here?  How do we support the family into inertia to make a decision?  How do we block them from the pressure of the impatience of the primary team?  How do I keep myself from also giving into the pressure of external impatience in the future?

My Birth Story Part 2

The actual birth of my son was as unexpected as I'm sure most births typically are.  My blood pressure decided to go up around 38 weeks.  In retrospect, what I should have done was wait it out as it was a particularly stressful day at work.  However, as a new mom, I did what my OB recommended which was come in for an induction.  Now, for starters, most inductions are scheduled to start in the morning.  Mine, with being done at a new birth center, was scheduled to start at 5 PM on Tuesday, January 28.  I thought nothing of this until the OB on-call slept through his alarm to come break my water at 1 AM and instead showed up at 3 AM.  I had been on increasing doses of pitocin since 7:30 PM, and learned at 3 AM that it hadn't done anything.  Once my water was broken, everything seemed to speed up and slow down at the same time.

I have now also learned that I need an epidural before my water breaks.  I am a wimp when it comes to that level of pain and waiting 2 hours for anesthesia to finally come in was brutal.  I am shocked my husband doesn't have PTSD from not being able to do anything for my pain during the wait.  Once that epidural was in, it was fantastic except for the hip flexor pain that I think was probably triggered by the fact that my son came into the world facing the wrong direction.  In other words, when babies are born, for them to more successfully pass through the birth canal, they should be facing toward the ground if mom is lying on her back.  This makes it easier to pass under the pubic bone.  On the other hand, my sweet little boy came in looking up (and hasn't stopped since then, wanting to see everything) which meant his sweet little top of his head was bruised and raw from smacking into my pubic bone instead of passing underneath it.

I think if I had waited it out, my blood pressure would have dropped, and my baby boy could have had a little more time to get into optimal positioning.  And yet here we are, happy and health.  He finally arrived at 2:04 PM on January 29 at 7lb 10oz.  He is precious and sweet and I don't think I knew how much I could love another human until he arrived and that was after 3 hours of pushing...

My Birth Story, Part 1

It has been almost a year since I last published.  At the time of my last post, there was so much going on.  For starters, in January of 2019, I was told that if I wanted to have children, I needed to start sooner rather than later because my ovaries "weren't getting any younger".  See, at the time, I had gone over a year without a period.  I now know this is because of PCOS, and at the time was also fairly certain of that.  However, there's nothing like your GYN making the above comment to get your biologic clock ticking.  With little support from said doc, I turned to my internist to get the necessary labwork to show I had PCOS (with the help of a friend in endocrinology to tell us what to order).  I will say, the average time to diagnosis for most women with PCOS is several years with visits to several different specialists.  I was beyond lucky to have a wonderful primary care doctor who was willing to do what needed to be done.  I also was fortunate to have bloodwork that shows that my ovaries are doing just fine for their age.

With the diagnosis in hand, we turned to a local reproductive endocrinologist to help figure out just what needed to happen to trigger ovulation for me.  Fast forward to April, and we were talking about using pulse dosing of Femara (typically used to help keep breast cancer in remission when taken daily).  The idea is to mimic what typically happens for egg maturation.  Estrogen levels drop with the Femara which triggers an increase in follicle-stimulating hormone which causes an egg to mature.  It took two tries to finally get egg maturation kick-started and then the use of a trigger shot to cause ovulation.  The next few weeks of waiting to be able to take a pregnancy test were really tough.  And when I could finally take one, I took 6 just to make sure I was, in fact, pregnant.

I had pretty bad nausea during the first trimester, and developed several food aversions that stuck around for the entire pregnancy (I can thankfully say that they are over and done with and I pretty much eat anything in sight at this point).  Pregnancy (like motherhood) is a mix of joy and anxiety on a regular basis.  I felt paranoid at times because I felt like any wrong move would be the end of my little nugget.  I worried about everything I ate, how much I slept, the exposures at work while at the same time being so incredibly thankful for the ability to carry and grow and protect my little one.  It's an incredible experience knowing that I was and still am a safe haven for my sweet little boy.

Speaking of which, little man is needing my attention. Until next time.

Spirituality

I have been thinking a lot about spirituality and the interconnectedness of every living creature.  One of the things that I have been thinking about is "why me? why this?" especially in relation to my career and what I do everyday.  I was talking to a colleague about how so many times I am in awe and completely humbled by how the people under my care or so willing to open up and let me into the most intimate moments in their lives.  People share their worries and fears, their greatest hopes and the wonderful lives they've shared together.  I become a thread in their life tapestry, and am the guide through their last moments on Earth.  It is absolutely incredible that I am allowed into these spaces with these people who I am a complete stranger to.

And, they trust me to the point where some want to confer with me on incredibly huge decisions for their loved ones before they make the choice.  This was especially poignant for me in a recent encounter where I had really only spoken with the family on 2 occasions for less than 10 minutes each, yet when they were asked by another team to make a big decision for their loved one, their first thought was to ask for my guidance.  They trusted me enough, even in those few moments we had talked previously, to request my recommendation.  They had faith that I would help them reach the best possible decision for their loved one.

So many times I want to look at the people I am talking with and say, "do you realize that I have only been doing this on my own for 9 months?".  Yet, that falls into the category of proclaiming my step or shelf or board exam scores.  In that moment, they don't care.  They don't care that sometimes I still feel like I am a baby, that I am just learning how to walk and talk.  They don't care about my insecurities.  They care that I show up, I am there for them, I care about them and their family members, and that I am honest and kind.  As the saying goes, most of all kind.  

Many times over the last two years I have wondered if this is really what I am supposed to be doing, if I really have the intestinal fortitude to be a doctor.  And then I have days like today.  Days where I truly feel like I am where I am supposed to be, caring for the people I am supposed to care for.  I was set on the path of these people's lives for a reason, and they were set into mine.  We are each adding a thread to each other's life tapestry.  Because of that, our tapestries are connected and more beautiful for it.  Even if I am meeting that family at their darkest moment, I am the safe haven where they can drop their guard and let me be the strong one for a moment.  I am the one who listened.

Many times I wonder about what would have happened if I had ended up somewhere else other than where I am today.  While I can imagine I would still be successful and know the people I care for would be equally well cared for by someone else, it would have been different.  I am still exploring my spirituality.  I do know that I was set on this Earth to be with the people I am with, do the job I am doing, and because of that, I am there for the people who most need me when I am supposed to be there.  Even when those cases stick to my heart permanently, I learn to dance with the limp and use that growth to provide for others.  As harrowing as the cases can sometimes be, I still cannot imagine doing anything other than what I am doing today.  I have one life to live, and know I am living it with using my gifts for the purpose they were given to me.  I am forever thankful for this opportunity.

Check-In

The last six months of work have been a roller coaster.  I have had periods of feeling like I'm really making a difference and periods where I feel like an impostor.  I have been told on several occasions to just get over my impostor syndrome, that everyone feels this way, and there's no reason why I need to feel this way.  I have felt like few of my own family even understand the emotional strain of what I do, and there is family who really doesn't understand what I do.  I feel like I am immature, that I can't stand up and fight when I need to, I'm too much of a people-pleaser, and I can't get out of my own head enough to help others.

Then there are times where I really feel like I helped a patient, even if it was only to hear them out.  I have sat by people, cried for people, listened to people vent.  I have been the person others turn to for support, and celebrate the small victories with.  I have helped streamline communication between the patients and teams.  I have come up with ideas for education.  I have built a new curriculum for narrative medicine.  I have taught residents about what I do.  I have turned to the people I work with to help me.  I have learned that I am not always a lone wolf.  I have stood up for myself when I need to.  I have been a team player.

Today, I feel like I have not done any of the things in the second paragraph, and have fallen into the first.  I feel like I made communication worse rather than better, even though I had only met the patient once, and never met the other family.  I have taken the fall for miscommunication I didn't realize existed.  I feel like I haven't been as professional as I need to be.  I have acted immaturely and been scolded for it.  I feel like I'm not really ready to teach fellows since I'm only six months out from fellowship.  I don't feel like I know what I'm doing.  I can't seem to make anyone feel better, and seem to only make people feel worse.  While part of me knows this is a gross over-exaggeration from the events of today, I beat up on myself for feeling like I've messed up.  While most people would have looked at what I did and call me normal, I hold myself to unattainable standards.  I need to cut myself some slack.

I had been so calm and had just enough confidence to be able to carry on without falling apart at every negative encounter.  Today was one negative encounter after another.  There was no stopping.  I got caught in the rip current of negativity, forgot to swim with it, and was swept out into the ocean to drown... or be eaten by sharks.

I feel like the moment I start to feel like I am settling in, finding my groove, on good standing with the rest of my team, the sand shifts and I realize there wasn't actually solid ground underneath me.  Sometimes I wish that I had a lower stakes job, that I wasn't as driven to go into a career that required other to depend on me as part of their healthcare team.  I wish I believed that I was really cut out for this.  I wish that one day of constantly feeling like a disappointment didn't knock me down to zero so quickly.  I wish my self-esteem reserve was deeper and more full.  Instead, I crumble the moment I feel like I've done wrong by a patient or their family or have let them down.  Even if I am not the direct reason for the letdown.  Even if I am not the one fully at fault.  Even if I'm working against a disease that is robbing a person of their essence.  Somehow I am supposed to take away from their oppression, not add to it.  I feel like I added to people's issues, not took some of the pressure away today.

I beat myself up over every little thing.  Every word I say.  Every recommendation I give.  I feel like a failure when I think I did things wrong.  I feel like I am the only person who ever flubs up an encounter.  I don't know the right words to say.  I don't have anything to provide to alleviate the physical pain.  I don't even know how to sit in the emotional or existential pain anymore.  I feel like I have nothing to offer, and anything I do offer is wrong.  Completely and utterly wrong.

Maybe tomorrow will be a better day and I can pick up the pieces so the patients don't see my lack of self-esteem...

New Year's Resolutions

Last year, I set what seemed like a simple resolution.  I would do one thing for my own self-care everyday.  While I did a great job posting my self-care up until mid-March, for the most part, I was able to stick with it.  Some days were less active forms of self-care, and others missed the mark entirely.  However, I am proud of myself for taking the time to focus on my personal growth and emotional stability.  I still have a long ways to go, especially with being a people pleaser and focusing more on how others view me than my own internal moral compass.

This year, I am continuing last year's resolution and adding on.  This year, self-care will be a more active self-care.  I will continue going to pure barre regularly because I love the physical activity and knowing that my body is stronger because of it.  I am also going to do a 6-week course in "Healing through Mindful Movement" which is a 6-week yoga counseling workshop on how "mindful movement can help your body heal your mind".  I enjoy yoga and am always looking for novel ways to help keep me physically, emotionally, and psychologically balanced.  Along that same vein, I need to start doing mindful meditations again with the Calm app.  Finally, my goal is to focus on some of my hobbies: sewing, knitting, crocheting, painting, writing.  I want to have time to do each of these in order to find ways to expand the more creative side of my brain.  I find it helps me think better on my feet.

One of the additions is now continued development of my career.  I have several lectures I am giving this year that need to be developed.  I am applying for a curriculum development scholarship.  I need to build prompts for the narrative medicine curriculum for next year.  It's amazing how little time there is in a day for all these things.  Some will carry over into time at home.  However, I strive to keep the first resolution above at the forefront outside of the hospital.

Even higher than the previous resolutions falls the one to find ways to focus on continuing to improve my relationship with my husband.  Sometimes, this focus can be simple.  Through the Gottman Institute, we have twice weekly marriage minutes to discuss, we have stress-relieving conversations we can have over dinner, we have card decks that we can work through to deepen our understanding of each other.  I want to be more intentional in the energy that I put into the relationship.  My sweet husband has done such a wonderful job of keeping us both buoyed.  I could not imagine having a better life partner.  I want to make sure I devote ample time to showing him my love.  An added bonus is the fact that it will only improve our relationship.

Finally, one of the words that I want to meditate on a little more this year is 'expectations'.  Expectations I set for myself, what I expect of others, work expectations, patient expectations, and so on.  I want to be more thoughtful about which expectations and which are harmful.

I am excited for 2019.  Let's see what the year holds.

Silent No More

"Fear is the path to the dark side.  Fear leads to anger, anger leads to hate, and hate leads to suffering" -Yoda

We put too much stock in blaming inanimate objects or other people or oppression or [enter whatever you want here] as the reason why hate toward others is still so prevalent.  We blame guns for deaths and statues for racism.  We focus on the thought, "if we just tear down x it will make the world a better place" or "if we just control y it will change everything".  Why don't any of us stop and realize that it's our own internal fear that drives the interactions we have with others?  It's fear that leads to "us versus them" mentality.  It is fear that is truly the path to the dark side.  Fear deafens us.  We all scream and shout at each other thinking that if our voice is heard the loudest we'll change other people's beliefs.  Just stop talking!  Stop shouting!  Stop silencing everyone around you!  LISTEN!!

First, listen to the silence.  Listen to what can be heard when you aren't ranting.  What does nature sound like?  What is the Earth telling you?  What sensation does this cause?  Does the silence make you angry?  Does it bring you peace?  Do you feel like laughing or crying?  What is the message in between the silence?

Then, turn to the person you have been shouting over, the people silenced because they are afraid of speaking over you.  What do they have to say?  Learn what is important to them.  We all have something that makes us feel important, that is more valuable to us than anything else.  We all have hopes and dreams and fears.  We all have worries.  We all have a purpose.  What is the purpose of your interaction with the person next to you?  What makes them who they are?  And when you are done with this listening, realize that you only know that one person.  You cannot generalize what you learned from them to anyone else.

Now, listen to the next person and the next and the next.  We are all connected to one another in one way or another.  We all have families, we all have dreams, we all have hopes for the future.  If you think that tearing down one statue or removing all guns from non-military/non-LEO homes is what will change the story-line, then it will be a long road ahead.  You have only asserted your beliefs.  You have done little to hear the beliefs of the people around you.  You may be contributing to the fears of those around you, and that does not make you any better than what that statue stood for or what guns can do if used carelessly.

I applaud people who are willing to stand up for what they believe, but blaming today's bigotry on a statue from 1913 does not really make any sense.  Whether that statue is there or not, the history of the university has not changed.  You cannot change the past.  You cannot change history.  By trying to ignore history, you run the risk of repeating it.  What matters now is how you decide yourself, today, to make the world a better place.  Keep in mind, that world may just be a small piece of the planet we live on.  It may only be the few people you touch in your lifetime.  How are you going to make things better for that small sliver, and how are you going to show them how to pay it forward?  What is more important for your future children: telling them you pulled down a statue once and continued your life as it was or show them how you cared for other people throughout your lifetime?  What is going to have an indelible mark on them: a one time instance of disrespect for public property or a continual show of love toward others regardless of how society sees them?

I choose the latter.  I want my children to see me truly love my neighbor as myself.  I want them to see me sit with other people in their suffering and hear their story.  I want them to know that judgement was set aside, and true compassion for human life shown through.  I want them to understand that we are all equal, that we all experience joy and pain and sorrow.  I want them to know we all laugh and smile the same, we all seek comfort when we are lost or hurt, we all cry in the face of deep sorrow.  I want them to know what anger feels like and know that it is okay to be angry, but that it should never be directed toward another person or creature.  I want them to be curious and have a thirst to better know themselves and their world on a grand and small scale.  I want them to know love, deep passionate love, the love of the simple things in life, and the love that makes us want to care for others.  It doesn't matter how we look or act, we are all part of the same family.

Keeping that in mind, how can you change the world today for the person sitting next to you or in front of you or behind you?  You can listen to the story they tell and know that it is a beautiful thread in the cloth of humanity.  You know where that thread is and can marvel in its beauty.  You can let them know that you have seen and heard them and love them for who they are in whatever way you are capable.  This is what I want my legacy to be.

Days 356-362: The End and The Beginning

June 29, 2018 was the official last day for my hospice and palliative medicine fellowship as well as my status as the trainee.  In August, I will start as the trainer.  What a daunting task.  Sometimes, I'm not sure I'm ready to be in that role.  I feel like I still have so much to learn myself.  I realized that there is always going to be this sense of need to learn as much as I can.  I am excited for my new role and to know that I am not going to have to do too many weeks of back-to-back consults.  I will have medical students, residents, and fellows working with me.  I will be working to make the home calls a more cohesive group.  I will be working on my narrative medicine expertise as well as my role as a mentor.  I will be teaching bioethics for the brand new medical students.  I am nervous and excited.  Before I get too far ahead of myself, though, I have six weeks of rest and relaxation.  Or at least not going into work and packing to move to a new house.

Days 331-355: An end and a new beginning

Today marked my graduation from my hospice and palliative medicine fellowship and the end of my time as the trainee.  In one week, I will be officially done with fellowship.  I get six weeks off before starting as faculty, the moment I have been waiting for since I was a medical student.  In the meantime, I will be packing since LOML and I will likely be moving into a new house before I start my new position.  It's been quite the crazy series of events to get the house we are currently under contract on.  We looked at a group of houses in the neighborhood where we thought we wanted to buy, only to find that the layouts of the houses were not what we liked.  When then started again with a new search, and had two houses we liked at the end of the day: newer construction with vinyl siding and an all-brick house with great updates but on a septic tank.  We went with the newer construction, had everything ready for the offer, and were told it went under verbal contract.  So we looked at another house in the same neighborhood that was the plan we liked.  We put in an offer, only to have the sellers back-out and decide they didn't want to sell.  Finally, I convinced LOML that we really did want the all-brick house because it had everything on our list other than a screen-in porch.  We put in the offer, and it was accepted immediately.  We are now getting the inspections and appraisals scheduled, and will hopefully close the beginning of August.  We've shoved as many big events into one year that we can.  We are excited.  I can't wait to start my new job as daunting as it feels.

Days 318-330: Silence

I have forgotten to focus on my own self-care recently.  I have spent so much time trying to do so many things, I have forgotten about myself.  I have not exercised.  I have not blogged.  I have not written for fun.  I have not painted, meditated, knitted, crocheted, or sewn anything.  The last thing that resembled self-care that I did was the honeymoon.  Prior to that, it was almost back into February, maybe March.  Even then, it was just exercise for maybe 15-minutes first thing in the morning.

When I don't take care of myself, I don't have the energy for pretty much anything else.  I never feel refreshed.  I don't have the tolerance for BS that I normally do.  I barely have the ability to keep it together for a patient visit.  I lack my normal, bubbly, positive personality.  I can't remember the last time I felt care-free.  I can't remember the last time I didn't care what other people think of me.  I constantly second-guess myself because I don't have the energy to overcome and maintain my self-esteem.  LOML is the only person I feel normal and safe around.  He's the only one that I feel is 100% supportive no matter what the situation.  He is simple in that, as long as we are together, that's all that matters.  Even when I lack the ability to show my love as well as he shows his, he knows that we are a team and supportive of each other.  I love him more than I will ever be able to say or show.

My sensitivity level is way too high right now.  I take any comment or critique that could possibly be construed negatively as such.  The general feeling is that I cannot do anything the way I am supposed to.  Even though it shouldn't really matter what anyone else thinks (so long as I don't cause other people physical, emotional, or psychological harm), I feel like I have obligations I am not meeting.  I want to get to a point where I am not phased by what other people think about me.  I want to not care about it.  Certainly if it is going to cause harm, I would like to know, but otherwise, I want to be able to feel like I have support for the decisions I make.