Catharsis

I haven’t written much the last few months. In part because I’ve been busy but also because I’ve had this huge 800 lb gorilla standing in front of my view, blocking the flow of any simple, smaller vignettes that might want to come trickling out. And until I get rid of the gorilla (don’t worry, I’m only going to write her away), I’m stuck. So here she is…

I hate the health care system.

This may not sound shocking and it may not sound debilitating but it is tripping me up. I am a “work within the system” sort of woman but right now I'm having a hard time seeing my path. I want to go "Hulk smash!" on the whole damn thing. Which isn't productive for a number of reasons. 

The thing is, I don't feel disillusioned about choosing to revolt from within. I have few illusions about the difficulties that entails. I’m not romanticizing how much of a difference I can make or how much I can even change said system. But the realities of the role of physician as cog in the wheel are pretty fucking demoralizing. In time, I will arrive at a place where I have power and influence (to a limited extent) within the system. Until then, I’m at the bottom of the pile (can’t say bottom of the totem pole anymore, even in hyperbole, since I learned that’s where the important folk go). And the bottom of the pile is a shitty place to be.

During my brief 2 year stint as a public school teacher, we had some union troubles. Just short of striking, we adopted a “work to rule” position for some time. We came to work, we did our jobs, but only what was required by our contracts. The point, I suppose, was to show the powers that be just how much they were already getting out of us.

If physicians were to “work to rule” the entire health care system would grind to a shocking halt. The things that are required of us, they are not actually possible for a human to accomplish.

There’s this thing called the Hidden Curriculum of medicine. People have varying opinions about what exactly this curriculum teaches us but it is the implied undercurrent messages that we absorb as we progress through our training & careers. The problem with a Hidden Curriculum is that there’s no telling what people will learn from it. The lessons aren’t explicit and a great deal of one’s own personal baggage informs one’s lessons from the Hidden Curriculum. Handling criticism, giving feedback, working in teams, managing colleagues and underlings, these things are not taught in medicine but they are key, KEY parts of your work as a resident. If you internalized self-loathing (not hard to do) from the Hidden Curriculum, then you are going to be a crappy manager and mentor. But there isn’t a lot of room (like, any) in the Hidden Curriculum for self-examination, self-reflection, self-awareness. We aren’t encouraged by the system to reflect, just push on through and Do. The. Job.

(Parenthetically reminding everyone that I work at a fantastic residency program where these sorts of things are things we can address, we talk about respect and teamwork and we have opportunities built into our curriculum to reflect with our class and plan as a cohort for the next year. I never violate duty hours, we have great administrators. And I’m doing okay, this isn’t a desperate plea for help or a cry of despair. This is observation, reflection because I’m incapable of NOT navelgazing, this is me coping with the reality of the broader system I am becoming a part of. I’m just writing away the 800 lb gorilla that is blocking my Qi)

My plan will allow me, ideally, to live apart from this hierarchy someday. I’m going to open a community based clinic, it is going to have family medicine services, Ob/Gyn services, birth & abortion care, trans care, it is going to have a community board that helps us run it. It is going to be constructed specifically to deconstruct colonialist, patriarchal, capitalist power structures that oppress, oh, just about EVERYONE. I’ll get there. I’ll have my ideal clinic someday. Because I have a plan, I will have the skills, the connections, the capacity, the social capital and the power to create this sort of existence. I’m really looking forward to it. But to get there I’ve got to get through several years of learning from, working within and tapping into the current resources available for my training (and a few years after that to get financially stable after hundreds of thousands I had to borrow to get here at all). These all require me to work in a system I HATE. Most of the time I’m totally okay with that. Fight the power. From within. Change the system. From within. Often I forget that to do that, you have to KNOW the system. You have to be able to function within the system first. I can do that.

Bye-bye Gorilla.

Some stuff about work

On Fridays we have a procedure clinic where women who have had abnormal pap smears come for next level cervical biopsies called colposcopies. This clinic is busy with lots of patients and often lots of residents. It is an anticipated clinic as well as it is considered a straightforward office visit (we aren’t addressing ANYTHING else usually) and the documentation is easy to get done as you go. Unfortunately for me, I’ve had a bad run of luck in colpo clinic - difficult cervixes: to find or to biopsy. I am NOT superstitious about my work flow (I generally don’t believe the notion of a person being a “black cloud” or a “white cloud” and I’m not afraid to say that a service is looking QUIET for fear that the heavens will open on our heads) but I feel like I’ve been cursed in colpo clinic this year. The interns do colpos during 2 of our 4 rotations so we spend half of the year doing colpos on Fridays. After tiring of always having such a hard time, I have been collecting advice from upper levels and troubleshooting my technique with people. Today for the FIRST time, colpo clinic didn’t suck in its entirety. Of course I’ve had a few easy biopsies, but not even enough to count on one hand. Today I took bigger samples, I squeezed instead of pulled, I turned the Tischler (the tool that takes the biopsies) so it was oriented a particular way relative to the lesion I was biopsying. And I finally get it why people like colpo clinic! Part of my issue is that I can’t believe we are taking tic tac sized chunks out of people’s bodies without any anesthesia. Part of my issue was a steady stream of rubbery cervixes. And honestly my technique was faulty. I can do a stat cesarean section but until today, I couldn’t do a colpo with any sense of confidence. Huzzah! Intern year must finally be almost over, I’m finally getting the hang of it!

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My kids are almost done with the school year. We have 2.5 more weeks until they are done! A few days after that they are going to SF to stay with their dad for about 8 weeks. That is longer than our agreement lays out but they wanted to spend a lot of time with him, he could manage it and I didn’t want to refuse any of them the opportunity to be together. I’m pretty upset about the idea of them being gone for 8 weeks, I’m going to miss them so much! And because the human mind is a vast and infinite place, I’m also really looking forward to having the break. I don’t get weekends off, we don’t share parenting time, it’s all Larissa all the time. It is fucking exhausting. I don’t know exactly how I’m going to handle it (though I’ve got the dog walking figured out) but I think 8 weeks is enough time for me to be at loose ends for a little bit and then get into a routine on my own.

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Did I tell you I did a stat c-section recently? A stat is a circumstance where, likely, the baby is not looking great and needs to get born quickly. There are a few things with regard to the prep and the equipment that are different (so we can be ready faster). The surgery is basically the same except you worry less about going through the tissue from skin to uterus carefully and do it quickly then if there are problems, you fix them after the baby is born. And you don’t get to use the nifty tube retractor (it’s called an Alexis retractor and I love it) because it takes too long to set up. We still have time to administer anesthesia, scrub our hands & prep the patient, then we get down to a baby as fast as we can and hand him over to the awaiting NICU team. 11 months ago when I started doing surgery, I could handle about half a cesarean before the adrenaline would fade and I’d wilt. Looks like I’ve learned some things this year after all.

Regarding delivering the baby during a cesarean:

In that stat section, I did everything in the delivery as the primary surgeon except delivering the baby. I probably could have done it but it is a task that takes attention to detail, awareness of passage of time, physical effort and finesse. I started to try but after 10-15 seconds decided to let my upper level do it. There are a lot more things to think about than just sticking your hand in a uterus and lifting a baby out. We make the smallest incision possible (there’s only so much room between the Uterine arteries) and babies can wedge themselves in there in a myriad of different ways and it is pretty important that we flex the head in a way that makes it possible to lift.

On the latest cesarean I did, I explicitly told my upper level I was going to work on delivering the baby until he took it away from me. Having that explicitly stated gave me the freedom not to worry that I was taking too long. I knew he’d take over if it was time. Turns out, I was able to do it. Practice practice practice!

Almost none of this is work stuff, even the work stuff

Sometimes I look at ADHD life hacks and realize how many of these things I have already crafted into my life. Just watched one that suggested:

• Wear a work uniform: for me, when it isn't scrubs, it's black pants, a shell and a cardigan, I love the ease and reliability of it!
• Eating the same thing every day: Right now there are 5 Ball jars of yogurt & 5 sandwich bags of granola in my kitchen!, 
• Apparently hitting snooze causes decision fatigue and makes ADHD brains tired. I don't hit snooze anymore though I do have my AM blue light which helps me with the sleep-to-awake transition. In my experience, changes in body/mind states are hard on ADHD folks, and I struggled with the snooze button every morning when I was a teen and in my 20s, my daughter struggles with it now,
• To reduce strain of thinking of meals, have themed dinner nights (like "leftover mondays" and "mexican tuesdays"): that isn't quite what I do, but I do make sure I have the stuff for a week’s worth of meals and I post the things we can eat on the fridge, then I just have to decide any given night which of those things I feel like making. I often have frozen pizza, wontons, tamales, etc. that I can make instead if I decide the things on the list are too labor intensive for my energy level,
• They had things to say about grocery shopping, keeping a list and all that. I use an app called Picniic that has a number of family coordination tools. My kids are not as enthusiastic about them as I am but I paid for the upgrade so we could all share shopping & to do lists, calendars and other features that I’m still working on maximizing. 
• I also have a bowl where I keep my keys, right by the front door, no thought involved, keys go in the key bowl. End of story. 

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Working with a private doc in the community today and I saw that he has his own order set in the computer. Got me thinking about my orders and how I customize them and what I’d do it I were writing my own order sets. Some of the things are really technical and not interesting except to other people who need to write orders. But one of the tangents my mind explored was the communication between L&D nurses and doctors, what needs clearance to order and what gets done and then told to me later. I’m thinking of epidurals. It is really common for a patient to get an epidural and then I’m told about it afterward. I wonder if I would like to know this beforehand when I’m in private practice - managing patients who I know, with whom I have a relationship and have had a chance to do some prenatal education. I’m super supportive of people getting epidurals. I just think we don’t do a good enough job talking about how they change labor. I want to do a better job as a doctor and as a patient advocate. I know I’m not a doula anymore and I won’t usually be able to help manage the moment to moment, contraction by contraction experience of labor. I just want to be sure my patients are clear about what they want, what they get and how decisions influence the unfolding of events. 

Clearly this is not a fully formed thought, but it is where my mind went this morning.

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I’m back in a missing being married phase of mourning. It is tough, and I’m feeling the loss of something that I had for a long time- a partner, a helpmeet, a friend. Someone to roll their eyes at our kids being obnoxious teens with. Part of my pain is due to my own healing, I’m dating, it’s going well, but it is still dating. Getting to know people, deciding when I feel like spending time with or communicating with a near stranger. Also this is an anniversary time, of graduation, of moving arrangements, it was all so fresh and raw and painful last year, and I remember that. I miss what I wanted to have here. And some of my reaction is due to things happening in my coparents life - decisions he’s making and that make me think “if only” and why did he have to decide to do these things now and not 2 years ago, when there was still time. Why? If my study of the human body has taught me anything, asking why humans do anything is a question destined for dissatisfaction. Whether it is inquiring why a body develops autoimmune responses or why blood vessels clog or why the mind thinks anything at all, who knows why? No one knows and asking is just inviting frustration.

But why? Why can’t I have a life, the life I wanted. Why? I am a cope-er, and a survivor and even at times a thriver, so I’m going to be just fine. I’m going to fix things and I’ll be okay. But I can’t stop asking why.

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Regard something you know about yourself that you just know. You don’t think about it, in fact, it is just there. Your toenails grow, you have all your fingers and toes, knees bend, ears on each side of the head. Something like that. Something that is bedrock to your existence to the point that you don’t think about it.

Here’s what I know: my body is disgusting. It just is. I know this with a fundamental certainty that you take for granted regarding your toes. Sometimes I have feelings about it, sometimes I manage not to think about it, sometimes I even put lipstick on the pig and feel pretty satisfied with myself. I mean nothing in the world is all bad, so my body grew and fed people, has been fit and active, and while it is relatively deconditioned right now it has been capable in the past for sure and I’m sure will be again someday.

Let me be clear: I’m not saying this to garner pity or attention, or to get you tell me your opinion of my opinion or worse, your opinion of my body. I’m not saying this to GET anything. I’m saying it because I’ve only recently realized that this bedrock assumption exists and is different from how other people view their bodies. I spent a few days kind of rocked back by the insurmountable reality of it. I have deeply internalized that while I may be more disgusted with my body right now than I have been at times past, there really is no point in the game when I get to be happy with it, only varying degrees of displeased.

In a way, this is a victory. In the past I have set bars for myself, if I were to fit into those clothes, do these exercises, weigh this many pounds, THEN I would be okay. But now, I realize, that was a finish line I was never going to cross. There is no moment in time where I say that I have arrived, I have achieved the body that makes me happy, makes me feel satisfied. I can stop trying to come up with the perfect set of circumstances under which I will be satisfied. Sure I am disgusted, but I’m also free.

On vacation

I’m on vacation right now. Sitting in my dear friends’ home looking out the window at a sunny day getting ready to go to the beach with my kids. Except it is 8:30 and they are still sleeping! Maybe I’ll go for a bike ride first then wake them up at an hour decent for teenagers.

Yeah, I pulled my kids from school and lied about it. I don’t feel even a little bad. I was vague and the secretary at school filled in blanks to mean “something along the lines of an ailing grandparent” and I did not dissuade him. I said it was a “planned, medical, necessary absence.” Because mental health is you know, medical, and the stress of our lives and the difficulty we have forging connections with things like regular meals and family time is real. My kids and I need to bond, we need to relax. We are going to the beach. We will get ice cream, we will play mini-golf, we are going to do an Escape Room. We got assignments from teachers before we left and they know they are going to spend some time doing homework. But this week is going to be a little break from reality.

Since you heard from me last, I had my Gyn Oncology rotation and an OB rotation. Now I’m on a Benign Gyn rotation. This rotation has me in clinic about half the time and I really like it. I miss being in clinic. I like seeing patients. Onc and OB are tough rotations for different reasons and it was hard to have them back to back. Next year is going to be hard for lots of reasons but one of the nice things about the schedule is that it rotates reliably between OB and outpatient or benign gyn (no Onc for 2nd years, mercifully). We’re switching (back) to 6 week rotations (apparently the 4 week thing was an experiment that didn’t work out) so I’ll have 3 weeks of night, 3 weeks of OB days then 6 weeks of either OP or GYN.

I’m talking about next year’s schedule to avoid processing this year. First step is to see the hole. Maybe next time I write I’ll shine my light down in it. But for now, vacation time.