All the leaves are brown.

On the ride home from daycare, Elena started chattering about the leaves on trees falling off and turning yellow.  I initially thought she was talking about something she had learned in discussing the seasons, and agreed with her about the leaves changing color, and *then* falling off.  She corrected me, saying that if you pull the leaves off the tree, they will then change color.

"Yes," I replied.  "When we pull the leaves off the trees, they die, and change color."

"Yeah," she nodded, "And someday you will die, too."

"Um, yes.  Is that something that you think about a lot?"

Sad little, "Mmm-hmm."

"Do you want to talk about it?"

*Pause.*

"I ate all my peppers!"  Super happy voice!

I love that when things get rough, my child turns to food.  Me, too, little one.  Me, too.

The Power of Words.

I had a crappy day today, mostly because of what I'm calling a "hate mail" email that I received from a patient whose referral got messed up for a variety of reasons.  I think I'm one of the reasons that our referrals office got its wires crossed--I was late in completing the visit note, and I am guessing that when they went to process the referral through insurance the day before I was able to complete the note, they couldn't send the necessary documentation to the insurance company and so set the referral aside for later... as in a month and a half later.  Yikes.  I think I'd be upset, too.

Last week, on a Friday night just before going out sans kiddos for a birthday celebration (Happy Birthday, Krista!!  She never gets tired of birthdays.), I checked my email.  Late Friday afternoon one of our administrative assistants had sent out a summative form of comments and evaluations of my performance as a supervising/teaching attending.  All of the comments were positive, except one.  My favorite was the use of the descriptor "sagacious."  These are anonymous compliments, so I can't turn around and compliment the reviewer for such a fabulous use of an SAT word.  I'm kidding--especially given that I focused in on the one negative comment (and it wasn't all that negative).  Basically, the person said they "used to" like working with me, but since I've been back from maternity leave something's been missing, and that something is positive feedback.

Most of the time I feel like I'm doing okay striking a (tenuous) home-work balance.  This week I also had one of my beloved patients reschedule as I was running late (again) and she couldn't wait.  We both know I will find time to reschedule her, and she's been great in putting up with my absentmindedness since coming back from maternity leave.  Most of my patients are cutting me slack because they know that I'm worth it to them.  I guess the hate-mailer wasn't impressed at our initial visit--our only one.  Either that or maybe I'm just not doing as well as I thought.  To sum up the feedback that I've received in the past two weeks, I can't see my patients in a timely manner, I can't complete charts on time, and I'm a bitch to the residents.

Praise and criticism, even when constructive, are tricky things.  Apparently a person needs to hear four to five positive things to "undo" one negative piece of feedback.  Maybe I just need to change my self-talk to change my ratio, you know, beef myself up.  Or I could just tell everyone about the praise Elena's lunches received at our otherwise useless parent/teacher conference.  At least I'm doing one thing right in life.

The other area where I've been keyed into words is in reading to Elena.  Kids' books are weird, especially those targeted towards girls.  A few friends have been posting on Facebook about the physical attributes of characters and gender-driven plot lines of children's movies, and what the effect might be on the younger members of our society.  We've got our own antiquated (or is it?) relic of a book hanging around, and Elena LOVES it.  Nurse Nancy is about a girl who plays with dolls in her games of mother, teacher, and--wait for it....Nancy's favorite game--nurse.  Her brothers are "too busy playing big boy games" to hang with Nancy while she wears her cute little nurse outfit and hands out candy pills to her dolls, but when those mischievous boys hit a bees nest and all hell breaks loose, it's Nurse Nancy's calm and focus that not only soothes her brother's cut but leads to an afternoon of playing ambulance/hospital.  One of her brothers offers to be the ambulance driver, and the other offers to be the doctor.  They pull Nurse Nancy along to the "emergencies" in the wagon.  Nancy gets a special hug from her mother and "even an extra cookie" for her care of her patients.

Now.  Elena "read" the book to my mother this weekend, and my mom lit up with recognition.  I understand that gender roles were defined and the norm and such during my mother's childhood, but what I take issue with is my daughter correcting me when I try to change the story.

If I change the words to her brothers being too busy playing "big kid games" she says, "No, Mommy!! It's 'big BOY games'."  We've had a few discussions about why I refuse to say this anymore, and they all center around the fact that girls can do anything boys can do, and can play any games they want.  Hence, to be more inclusive, I will only refer to the games her brothers play as belonging to the gender neutral "kid".  She still corrects me, but at least I'm getting less resistance.  LESS RESISTANCE!!  She's not even three years old, and already, she thinks that there are games that belong to only boys!

I also leave out the part about Nancy getting an extra cookie.  You do not reward kindness or achievement with cookies.  Period.  Hugs are enough.

Elena also corrects me if I just have Dan tag along.  "No, Mommy.  '"I'll be the doctor," cried Dan.'"  While I love that she includes the action that Dan was taking to express himself, the doctor in me is really annoyed with Dan for just all of a sudden deciding that since his baseball days are over he can jet in and be the doctor while Nancy, who set up the doll hospital herself and has been running things since its inception, is swept aside, or at least swept into the wagon where she sits like a good little demure nurse.  Since we have a number of nurses in our families and Elena has first hand knowledge of a female physician, I am not that perturbed at Nancy being a nurse.  But Dan can shove it--it was Nancy washing out Billy's cut and putting the bandaid on when things got crazy.

Anyway, like I said, I had a crappy day and words are powerful things.  Be careful out there with how you use them.

And.... We're Done.

If I was tagging my blog entries with certain themes, this one would certainly go under the "TMI" tag.  So continue reading at your own overloaded informational risk.

Today I am mourning the (reversible if I am ever crazy enough) end of my fertility.  When Nina was born, I looked at Josh and asked, "Are you sure you don't want to do this again?"  Her baby-ness was just too perfect--soft, cuddly, cute, innocent.... a second chance for me to be softer and cuddlier through the infant and toddler phases than I had been with Elena.  "Yeah, I'm sure.  We're done."  Matter-of-fact, no room for argument, not even entertaining romantic ideas of having 8 kids.

As Nina started daycare and our monthly bill swelled to just $20 shy of our mortgage, the financial realities of having multiple children started to set in.  When Elena turned two just a few weeks before my brother's wedding, her mandatory plane ticket purchase tipped our family's east coast flight costs into the quadruple digit range.  Before we had kids, the adage about kids being expensive was just some vague cliché.  Now I get it.

Money aside, there's also an adjustment to the time and attention you are able to spend with your children.  Most kids are resilient enough to handle this adjustment well, and eventually most enjoy having a sibling to pal around with, but it doesn't mean that the adjustment period is easy or without moments of meltdowns.  I tend to over-analyze things, leading to not-so-helpful feelings of uncertainty or guilt, which may explain my feelings of inadequacy when trying to meet the needs of my girls.  Nina is just about 10 months old.  I can't believe it's gone by so quickly.  With Elena, I felt like I was able to savor her baby-hood a bit more.  Nina's just raced by as I was losing my mind trying to keep things together at home, at work, and in my head.  She doesn't know the difference, but I do.  Most of the time, I feel like I'm doing okay.  When the two are simultaneously melting down and howling about the pain of it all, I do feel a little paralyzed.  Which one do I comfort first?  How will that affect the other child in the moment?  And in the long-run?  Should I just let them both cry and get us to our next destination?

Leaving the house in the morning was hard enough when I just had myself to get ready.  With Elena as a baby, she was always pooping on the way out the door or spitting up all over herself.  Now she's amenable enough, but I can't get her to eat breakfast before getting into the car (thankfully it's just the timing she's been most picky about--she still eats a variety of things willingly).  Nina wakes up happy, but she starts to get cranky and tired when it's time to leave and wails if I put her on the floor to get dressed, brush my teeth, eat breakfast, etc.  Our tear-filled mornings are constantly cited by Josh as a major reason we shouldn't have more kids.

And then there's my selfishness.  You know, the desire for "me time".  I need time for myself, and that is inversely proportional to the number of kids we have.

Watching Josh's sisters gain back their freedom by taking their kids with them to later than 9 pm social events, eating/peeing/showering without children climbing on/towards them, leaving the house alone without kids, etc makes me hopeful that we'll get to that place at some point.  That point would just grow more distant with another child, and my sanity has been thread-bare at best lately.  Not really advisable to drawing out the journey towards greater independence.

So I guess I've drawn out a good enough argument to myself why having an IUD placed today was a good idea.  I'm just sad to be done having babies.  It's weird to be on the other side of having kids.  Before having children there was a wide open world of procreational possibilities.  Even after one, there was still the realistic possibility of more.  And now.... we're done.

But I suppose it's just being done with the beginning, and now we're just at the start of the middle which as I've mentioned above, is the parental sweet spot between toddler tantrums and teenage drama.  I've been savoring Nina's early bedtime followed by Elena's request for snuggles.  Indulging Elena is made all the more easy by her clear little girl voice asking politely, "Mommy, can I please have some special time wiff you?"  How can I say no?  Let the parental sweet spot.... begin!

Pick Me Up, Dust Me Off.

This past month has been one of the single most challenging periods of my life.  (I think.)  In one month, I have become totally depleted.  I think perhaps January of my intern year was the last time that I felt this bodily and emotionally exhausted--January was my 7th month as an intern, and I had just finished two consecutive months of obstetrics rotations, one of which was in Phoenix.  I was on my ICU month, and was still waiting for my first vacation that year.  One of my co-interns had already had her second vacation.  I didn't care about anything at that point--I was just numb with exhaustion.

That's how I've felt the past two weeks, only now I have a 2.5 year old who goes from happy and independent to wailing and clingy at the drop of a hat.  Since I am fresh out of reserves, it doesn't take much to set me off these days.  Elena is in parrot mode, repeating everything that is said to her or around her, only she does so at often painfully poignant times.  We visited a college friend, her husband, and her daughter while in Boston a few weeks ago.  Elena's ear-splitting high-pitched laugh was a bit too much for her new friend, who lamented that Elena's laugh was "hurting her ears."  In being the nighttime single parent for three weeks, I've said a few times to Elena in melt down mode while trying to get Nina down, "This is a sleeping bed.  You can cry, but you can't do it in this bed."

Those two things have come together recently.  When Nina starts to cry, Elena says in halting staccato, "Stop. Cry. Ing. Ni. Na!  You're hurting my ears!  No. Cry. Ing. Ni. Na!!!!"  Not soothing.  I get that now.

When we got back from Boston/RI, I thought maybe Weeks 1 and 2 of single nighttime parenting had weakened me to the point of catching Josh's 2-3 week laryngitis virus.  I had weird alterations in taste (salty, scratchy), so started slamming myself with all sorts of herbal concoctions so that I could make it through Week 3.  I had bought some sage and thyme to make tea (bunch of herb in a mug, boiling water, cover and steep x 20 minutes, sweeten with maple syrup or other), but didn't get around to using the thyme until this week.  Everyone commented on how wonderfully it smelled yesterday at work.  I looked up wearily at a coworker and said, "It's my thyme.  I just wanted to feel nurtured."

I've been living off of caffeine and borderline crappy food.  I've still been eating relatively well, though I've also become an expert at justifying my treats.  Trust me--if you were nursing two, were partnerless for three weeks, still working nearly full time, flying cross country alone with two, and trying to keep it all together, you'd find the justification, too.

But now we're in recovery mode, which started last week.  I was half-dreading seeing friends of ours for dinner their first night visiting from NY.  I felt SO BLAH.  But it must have been just what I needed.  Michele, apart from her prenatal yoga teacher training, is home with Elijah, and has been for all of his 19 months.  Our conversation reminded me of an Onion article, which I highly recommend reading.  But validating each other's mommy concerns and successes and failures (okay, let's just say "failures" since they're not really all that bad) must have been just what I needed, because I left dinner feeling hopeful and rejuvenated.  Sitting on the U of A campus on a warm sunny afternoon with Ranee, Michele, Elijah, and Josh was lovely (sorry, girls, daycare for you!) and further movement in the right direction.  I felt compelled to do a cartwheel, and then work a little on my handstand--cartwheels: the ultimate symbol of freedom and happiness.

Now this week is back to the routine since our friends have left.  Wow, have I missed the routine.  I think when you are young and/or don't have many responsibilities, routine sounds like a horrid boredom trap--the allure of safety tethering people down to pitiful little lives.  It's in the routine that I have found freedom--the freedom to know which yoga classes I can make at lunch time, the freedom to buy food and prepare nourishing meals that will fuel my family, the freedom to schedule massages and acupuncture treatments, the freedom to finally write a blog entry.  Basically, the freedom to care for myself.  If you don't have this time carved out in your life in some way, there's a good chance it just won't happen.

Today I went to acupuncture for the first time.  I'm probably cheapening Charlie's skills by just calling it acupuncture, but you get the point.  I've had "Mommy-Baby Hip Carry Syndrome," so named by me, characterized by pain along the upper portion of your pelvis on the side that you carry your child.  Coupled with my above depletion, it has made me exceptionally irritable at home.  Nina craves physical contact, and I've been happy to give it to her until the past couple of months when it just causes me pain.  Apparently I've strained my obliques and sartorius muscles on my left side (at least I'm free to use my right hand!), and all of my yoga stretching has been causing my tendon attachments to become inflamed and "frayed" according to Charlie.

So here's to being gentle with ourselves, even in our journey towards healing.  I hope we both find the time to put our oxygen masks on first before attempting to do so for others.

Healer's Art: On Awe.

In medical school, I took an elective class called The Healer's Art.  Healer's Art is a course that was created by Rachel Naomi Remen, an author of many books on healing.  Remen's own medical training was a huge influence on the creation of this program; medical school and residency are hard academically, physically, and emotionally.  It's really no wonder why so many physicians are calloused and have difficulty relating to patients, but Remen rejects this "thick skin" defense mechanism and urges young physicians-in-training to explore themselves as people, people who have vulnerabilities and can recognize and empathize with others regarding their vulnerabilities.

We are on week 4 of 5 of our course at the University of Arizona College of Medicine.  This is my third time through the course (once as a student, now a second time as a facilitator).  Tonight will be my first talk in the large group setting, and the topic for tonight is "Beyond Analysis: Allowing Awe in Medicine."  Life has been busy for our family lately, with scant time to reconnect with each other, let alone ourselves.  My blog has always facilitated the latter process, so it seemed fitting to draft my talk here.  Forgive me if there are topics that I've explored in the past!


I had been present at many a delivery before Elena was born, coaching moms push, directing their baby's body to the outside world, and handing the prize to proud parents.  Watching my daughter make her entrance into this world was amazing.  When pregnant, I often wondered what my children would look like, but a blurred face would be the closest I could get in my daydreams.  After Elena's head and shoulders emerged, my doctor had me reach down and pull her onto my chest.  The first thing I said to Josh, in true Rhode Island fashion, was, "She's wicked cute."  She was taken to get dried, weighed, and medicated, and then given back to me as a nice little bundle.  I spent the next two weeks in utter bliss as my baby snoozed away, happy to nurse when she was awake.

When Nina was born, the same birthing process ensued,  but this time I asked my doctor and attendants to allow her to rest on my bare chest until she had nursed.  In retrospect, my separation with Elena so shortly after her birth made me sad--I think we've more than made up for it, but I wanted to experience the magic of "skin to skin".  When Nina, wet and wriggly, was placed on my chest, her warmth just melted into mine into a little love puddle.  I believe that sensation will stay with me forever, as no experience has left so strong an impression.

These two exceptionally intimate moments of my life were shared with my husband, and no other family members.  For that reason, they are incredibly special to me.  Interestingly enough, they were also shared with 4-5 other people in the room--my doctor, nurses, techs.  To me, the privilege of sharing in these intimate moments of people's lives is one of the most amazing things about being a physician.

I've always been nosy--maybe that's one of the reasons that I love being a doctor so much.  People tell you *everything*.  My patients have disclosed stories of their most happy and proud moments; devastating sexual and physical abuse; complacency with marriages of convenience; and thoughts regarding the last moments of their lives and beliefs of the afterlife.  I'm not sure what I am doing to create such a safe space for people to share these things that they ordinarily keep secret, other than letting people talk.  Often times there's not much I can do but raise my eyebrows, shake my head, and say, "Huh," allowing for silence as the other person finishes their story and their mind shifts back from their memories to the present moment.  These disclosures work on so many levels--patients often feel better sharing things they've kept bottled up, and these stories help me to see the person in front of me in a richer context.  The combination of those two things leads to a deepening of my relationship with my patients.

True understanding of the context of life often comes at the end of it.  I met R and his wife my intern year during a hospital rotation.  R had been having some nagging pain in his shoulder and a bump on his head--sadly, these ended up being metastatic tumors.  R followed up with me in the office; he was healthy and in his 40's, and didn't have a primary care physician prior to his hospitalization.  I managed his pain as he underwent chemotherapy and radiation; both were palliative rather than curative, but I don't think R understood that fully.  He kept rallying himself to "get better."  Before one of his last appointments with me, his wife called me to say she didn't think they'd be able to make it to the office, so I went to their home instead.  R was lying in bed, with agonal breathing, and didn't respond to my touch or greeting.  His wife had been trying to medicate his pain with the oral tablets I had been prescribing--how that was working was beyond me, as the man could clearly not coordinate a swallow.  We changed his medication to a liquid form, and all I did during that visit was sit and listen to his wife tell the story of his life, and of their love.  He died in a couple of days, and I went again to their home to pronounce him dead.  His whole family was present, mourning.  His brother asked me if I was his oncologist--I had to stifle a smile, as I don't know how many oncologists make two home visits in a 3-day span (though I'm sure there are some!).  I went to his wake, and a few months later, his wife sent me a gift for Easter.

More recently, I was able to spend some time with J, an elderly woman with a strong Brooklyn accent and a lot of spunk.  We spent time together in her hospice room, where she pondered what was going to come next.  I asked her if she was afraid of dying, and she told me she was looking forward to death, as it meant seeing her mother and husband again.  We talked about her childhood, her marriages, her daughter and grandson.  We talked about her faith and mine, and how to address spirituality with my children.

These conversations and experiences inspire awe in that they happen between relative strangers who are brought together in a professional setting.  There is great mystery to be uncovered when view our patients as people, and exploring the unknown based on our experiences.  How lucky we are as physicians to be privy to such meaning in our day to day lives.