Work smarter, work happier

It is 6am, I am just getting to bed. I was last here 23 hours ago. Yesterday I had lecture at 8am then an afternoon in clinic and an overnight helping out on L&D. I had work, but I also had down time. It was a long night, but I didn’t have to round and I didn’t have to stay through sign out. I was lucky also that I am on a rotation that starts with lecture at 8 and not with rounding on patients 2 or more hours before that. I was just awake for 24 hours. It was hard. I’m tired. And yet it was 5 hours less than a usual Friday overnight shift when you are working on L&D. Appreciate the small gifts

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Today I had a postpartum visit with a patient I saw in the hospital, managed for a day and a half while she was sick, delivered her baby and saw for some postpartum follow up needs as well. By today, I only needed a quick perusal of her chart to remind myself of the details, I got to see her baby and we chatted casually about life. We were both disappointed that there won’t be any real reason for her to follow up with me anymore. It was so great to walk the path with someone so consistently!

I had 7 patients (in 8 slots, one was a double visit) today in my afternoon clinic. 5 of these patients were people I had either seen previously in clinic or seen in the hospital during their latest stay. 3 of them were Spanish speaking and I did their visits without an interpreter. None of my patients today were there for prenatal care though there was some pregnancy management involved along with the multiple gynecologic indications that brought people to see me.

Having continuity with patients is amazing. It is hard for most residency programs to accomplish. I am very proactive about encouraging patients to return to MY clinic. I make plans that I work hard to be able to follow up on myself and patients are usually game to come back when I’m available if it means getting some stability in their care. I look forward to having my own panel of patients someday!

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I’ve worked hard and long to achieve a place of knowledge and social capital to be able to live the way I want. I’m really close to the time when I get to make the decisions about where I go and how I live next. I’m excited by the prospect of being able to take care of myself, my children and to pick a frame for the next phase of my life based solely on my own criteria. Yeah, I gotta get a job offer, of course, but no more Matches, no more considering other people’s needs, no more compromise. Where do I want to go? Who do I want to work with? What do I want to do? It’s all up to me!

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I just worked 19 days in a row, had 2 days off and am about to work another 12 days in a row. On Sunday evening, after a full and exciting weekend, I snuck off for a quick dip in the pool. I LOVE living in a home with a pool, particularly b/c since I don’t have to take care of it at all. I was floating and swimming laps and looking at the sky and realized that I had an enormous sense of satisfaction and peace. I am happy. I’m happy. Wow, how great is that!

I had a rough childhood. Worse than many, not as bad as some. A pivotal time for me was when I was about 14 or 15, the age of going to the mall with friends. I started tossing coins in the fountain at the mall and making what has become my Go-To wish ever since, “ I wish to be happy.” I guess now that it has come true, it’s okay to tell the story! This wish was the start of my internal locus of control, my journey to becoming whole. It has taken a lot of years and after my kids were born I started to realize that I may not ever actually be finished. I’m amused now to think about when I had the audacity to think that I was “fixed” in the year or two before my kids arrived. Becoming a parent teaches you what charming mirrors your children can be, and how very much work you still have to do on yourself!

I'm back, Baby!

I haven’t been here in a long time! But I’ve been drafting posts in my head throughout my day for the last week so I figured I’d start putting some of them down in print. I amy not finish a thought as completely as I’d like but at least I will have some of it down.

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One of the things that bothers me about my job is how gendered conversations are. When we are talking about the babies, gendered pronouns are hard to stay away from. Lately I’ve been trying to use “baby” as if it is a pronoun.

One of the ways I am showing my age and probably my radical-ish feminist roots, is my disdain for the “gender reveal” parties. It isn’t a gender reveal, it’s a genitalia reveal, which sounds as creepy to everyone else as the popular term sounds to me.

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It’s July again, and that means a new year of medicine, a new crop of interns. My relationship to new interns is different this year, I have more opportunities to teach because I feel more comfortable with my job and I’m starting to transition to the end of 2nd year role, training for and looking toward the role a 3rd year has on L&D. This last week, I delivered babies with a med student and with a family medicine intern. Being the “knowledgeable one” in the scenario (with my chief or attending watching most of it from the corner of the room) was a new place to be. It was fun, especially because said student & intern are very competent & enthusiastic about learning OB stuff.

The juxtaposition of learner and teacher requires a nimble sense of self. One night I did an extensive perineal repair under the direct guidance of my chief - it was an excellent opportunity to discuss & learn and improve. The next night I directed the intern in completing another repair, albeit a simpler one.

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My kids are having an important summer in their growing up - they are both engaging with their feelings and navigating the world in response to those feelings in a new, stronger, more resilient way. It makes me so proud to see them growing up into self-possessed, well attached people. Some things have been hard about the summer for them, but I’ve come to peace with the fact that growing up is a messy process and my job in their lives is not to shield them from the splashback but to help them learn to manage it. There’s a lot less pressure on me if I accept how little control I have over the whole thing!

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Daily, I am grateful for the leave of absence I took from residency. I cannot express how much of a difference the time off has made. “Time off” is a really poor choice of idiom in this case. It was not time off. I was working very hard the whole time I was not in residency. I was working on my physical health, my mental health, my children’s health, my family system. I was processing the end of a long marriage that was mostly good but for a few years was in fact pretty toxic and had turned me into something that I didn’t want to be. I started the long, slow process of actually dealing with an eating disorder that, for over 30 years, I have been controlled by or desperately tried to ignore.

The investment in all these parts of myself has resulted (this will probably not surprise anyone) in making me a better resident, a better team member and a better doctor. Frankly, as capable and responsible as I like to consider myself, I was not as capable and responsible as I could or should have been. Now that I do not have a back burner filled with stress and pain, I have more bandwidth to perform at work.

(Bandwidth is one of my favorite phrases. I often describe my choices in terms of my bandwidth - I would love to date more often, to volunteer, to putter around the house, to be crafty. But I don’t have the bandwidth to do everything. It isn’t a question of “want” or “willing” so much as an issue of how much will fit into any given day.)

And I am absolutely LOVING my job. The hours and responsibilities are absolutely insane but the work, the Work, is an absolute joy. Even when I’m taking care of very sick people, even when tragedy is striking or trauma is making a patient’s course frustrating, I love my job.

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Two more sleeps until my son comes home! He’s had something of an unexpected and disappointing summer but also he has done an excellent job of tuning into his feelings, tapping into resources and making lemonade. Amongst other things, he realized he has some roots in Asheville that he missed - his dog, his girlfriend, even me (I was way flattered when he said that he missed hanging out with me!). He’s coming home 2 weeks before his sister. It’s a nice easing back into parenting for me as well. I’m going to work to keep my level of focus at work and not be distracted by unfounded worries or preoccupations with my kids, who are actually doing quite well and don’t need me as much as they did before. It’s okay for me to focus on my own priorities now.

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One rotation that we don’t have as a 2nd year is Gyn Oncology. We are very focused on L&D in 2nd year, spending half our time there. In the other years, we spend 2 6 week blocks on Gyn Onc. The patients are very different from L&D, generally sicker and older. And it’s a complicated dynamic to navigate - there is a Gyn Onc group we work for, we assist with their surgeries and round on their patients daily, we are in-house on nights and weekends to manage most needs. It is a busy service with complicated patients, very involved attendings (rightly so, just to be clear, I’m not complaining about that - but there are 4 of them and every week there is a different style, it takes some nimbleness). I’m a little nervous going back into the Gyn Onc world - it is a different kind of stress than I’m used to on L&D.

One of the differences between our program and the private docs in the community is that we are always in the hospital. There is one group that has a nocturnist, another that has a midwife that works with them but usually they are not here all night every night. Sometimes they have a patient who is sick enough that they really need someone actively looking out for her all the time. We have sometimes taken over care of these patients - their doctor explains to them the level of care they now need, we introduce ourselves and we become their primary doctors.

Something I’ve heard from recent graduates of residency is that the volume of private practice is much lower/slower than residency. One may only do a few hysterectomies a year, not see a patient with preeclampsia for months, or rarely see an ectopic pregnancy. In this community, we help out the private docs however we can. Sometimes they review standards of care with us (our chiefs & attendings) or they ask us to assume care of someone who is really sick or we help them with surgery to save them from having to call in a colleague from their practice to operate with them in the middle of the night. If they have a patient in Triage and she needs a quick set of eyes on her before going home, we will often meet the patient and make sure everything is on the up and up for them, saving them a trip into the hospital in the wee hours. In addition to the patients we serve, we are serving the broader community. It makes me think about how I will manage these sorts of cases in my own eventual practice. Knowing what referrals are available in a community will be an important data point.

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Today was my first grumpy moments back to work. It was 100% because of a misunderstanding on my part that led to some other crap that is no big deal but pushes all my buttons. Also our team has been tumultuous this week, one of the downsides of days is that there is some fluidity in the schedule. This is the time of year that our new 4th years are doing things like job searches and fellowship interviews, so there are days that one or two of them might be gone and we have to patch holes in the schedule. Now I am not in ANY position to complain about that, and I’m genuinely not complaining. BUT having to do that shuffle of people is stressful for many of us - the new person covering for a colleague doesn’t know the patients, has their own communication style and way they like to run a team. We all work together and we can all work well together, but when you have four chiefs in 3 days, it makes for a little bit of nuttiness.

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Here’s another important thing I realize now that I have internalized about doctoring: taking care of patients is in no way like substitute teaching.

Lemme ‘splain…

When you have a doctor, they investigate, examine, diagnose and treat you for a given condition. In many cases, there are multiple ways to manage said condition. There may be a difference in the order of treatment options, different medications, counseling, weighing of certain factors in making decisions. Any individual clinician will have their own concerns, plans and ideas.

When one doctor takes over for another, there is next to no sense of loyalty to a plan just because it was implemented by a previous clinician. I may take over the treatment of a patient with a complication that *could* be treated with meds but wasn’t. I will look at that decision making process, try to get sign out from the other clinician and realize that in this case, I would have done something different.

Often the doctor taking over will try to find a way to bend the plan more to their comfort level. In this specific circumstance, I may document a change in management by prescribing medications that had previously been held. This makes things confusion for patients - they think the left hand doesn’t know what the right is doing. As someone with high health literacy and experience with health care, I didn’t understand this aspect of medicine before I was in the decision-making position myself.

"Divorced with children" is like joining the mob, you can't ever get out

You know that expression, “Poor planning on your part does not constitute an emergency on my part,”? That doesn’t really apply with co-parenting.

I’m working hard not to be angry and stressed out and scared during my last week before I go back to residency. It is taking all my strength and coping to manage. If I may say, I think I’m doing a pretty good job. And I'm trying not to be resentful that this clusterf*ck is damping my joy at going back to a job I love. I'm being less successful at that.

It is a week into June and I have not yet received all the month’s child support. I have had to drag communication out of my co-parent about when any money might be coming and how much. And today I was presented with a duality - either he can pay me what he owes me (what I depend on to keep house for my children) or he can buy a plane ticket for my daughter to come visit. The timing for her visit is based on theatre tickets for a show that is NEXT WEDNESDAY (6 days from today) and he doesn’t have tickets for her yet. So I looked over my finances and figured out how little I could manage with for the next week.

Both kids are in need of plane tickets for their summer plans and they have not been acquired yet either. I have a FB friend who might let me use some points or miles or something to try to help with things if he fails to provide, and I spent some time with my credit union seeing if I could increase my credit limit on my currently maxed credit card.

I am grateful that this is a temporary reality, that I know in 2 and a half years I will have a salary that will make his contributions irrelevant to my survival. Unfortunately this makes the current reality no less dire or stressful.

In the past, I’ve relied on the generosity of friends for these hard moments. In that spirit, I offer an exchange: any sort of support (financial, material, emotional) and I am at your disposal by phone, text or FB messenger to help you with medical questions - interpreting lab results, talking through a problem, helping understand & navigate a hospitalization or guiding you through am interaction with your doctor. Not diagnosing or prescribing, but more of a medical tour guide, helping your health care be more approachable and understandable. I think people who have taken me up on this in the past have gotten some good out of it.

If anyone wants to help us out of the tight spot that we are in for the next couple of weeks, I would greatly appreciate it, whether it is with a donation or a comment on a post - anything that helps me feel your love & support is greatly appreciated. I struggle with isolation during these moments, because I'm very stressed out about the situation and my children are completely oblivious. I try very hard not to expose them to the stress between their father and I, and I don't want my relationship with him to color theirs. Commenting on FB really does help - it increases the visibility of the post and makes me feel good, I swear. If you are able to help financially, I have PayPal and Venmo at my email address, larissa (at) northstarbirth (dot) com. You can contact me there with any questions or comments as well.

Thanks to everyone who has supported us, emotionally & materially, through this arduous process. All of it has been appreciated. 

Back in the saddle again

It is almost the end of the school year, my kids are tired of school, it is hard to get out of bed, hard to remember to pack a lunch, annoying to do homework. This is a tough time of year and this has been a tough year besides. Starting over is nice, starting over is a gift of childhood. They will have summer adventures, have a re-set and start the school year over again in the fall. But first we have to get through this. Just a couple more weeks!

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Local theatre company is doing Shakespeare in Love and I’m going to see it this weekend. I’m very excited. I hope it’s good. Result: it was passable local theatre, free and at a neat outside amphitheatre. We took the dog. He had fun!

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I’m almost done with a burst of steroids to help treat my hearing. It has been 2 weeks of high doses and now I’m doing about a week of a taper. The meds have been a mixed bag - some of the usual side effects were not present but I slept like crap and now that I’m tapering down the dose, I’m getting symptoms again - headaches, fatigue, appetite changes. I ate like a starving animal today and I have no idea why. And as the anti-inflammatory benefits wean, there are changes to my hearing & my tinnitus that are annoying and tiring.

Tinnitus is a tough condition to deal with. I was used to the frequency & sensation of my tinnitus but it has changed this week, maybe due to the new hearing aid but probably due to the steroids. I’m spending a lot of mental effort getting re-acclimated to my tinnitus. There are mindfulness and distraction activities that you can practice that help train your brain to either ignore or not be distressed by the constant whine coming from one side of your head. And as you are getting there, it is cause for headaches (different from the steroid headaches) and fatigue. For me, it is hard to concentrate on writing and creative tasks (some of which I have with my current role) when I’m struggling with tinnitus management.

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I got a hearing aid! I’m still getting used to it and I had to get it turned WAY down after a couple of days. I took today off from it to give myself some time to adjust to the tinnitus changes and to recover from the higher volume setting. Apparently getting a hearing aid is more like learning to drive than getting a pair of glasses. It takes your brain some time to be able to make sense of the sounds again. I don’t know that I will ever be able to tolerate a fully compensated volume but the fact that I can hear more now is amazing. Listening to my own voice is one of the interesting changes, I am singing with the radio more now. I was overwhelmed by the return of the hearing, I didn’t realize how much I had lost. Now I’m just trying to get to a new normal.

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I’m getting ready to go back to residency. It is an interesting if somewhat nerve-wracking experience. My program continues to be amazing and innovative and we are talking about how to structure my return to maximize success. Since I’m going to have to take extra time anyway now, we are working on building in some cushion so I can single-parent effectively and still reliably meet obligations to my co-workers and my training. I’ve also been thinking a lot about how to come back mindfully so that my co-workers can be honest about the time I’ve been gone and what it’s meant for them. It is going to be a several weeks process.

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The relevant people have been consulted and notified, specifically my children and the other residents, and it has been officially announced - I’m going back to work on June 10th. I continue to be so grateful for the space and time to take care of my family and myself. I’m a little apprehensive about going back - it’s a bit like choosing to go for a walk in gale force winds. But as soon as I made the decision to go back, I started feeling better about things. This is still what I want to do, still what I am most excited about.

I don't know. It's a Mystery

My favorite scene from Shakespeare in Love:

A: The natural condition is one of insurmountable obstacles on the road to imminent disaster.

B: So what do we do?

A: Nothing. Strangely enough, it all turns out well.”

B: How?

A: I don’t know. It’s a mystery.

This always makes me think of my dear friend Keith. He often sent me this clip as a reminder to have faith, that living is a Mystery and even when things are hard, strangely enough, it all turns out well.

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I’m struggling with letting go of the high touch, interventionist parenting that I’ve been doing for the last couple of months. Action comforts me, distracts me. Now we’re all in a place where my action is not the action that is needed to get anyone where they need to be. The action needs to be theirs. Which means they do things their way. Which is not my way. And sitting back and allowing my kids to do things their way is hard when I don’t have my own things to do to fill the space. I’m waking them up in the morning but then backing off and letting them get ready for school without my intervention. Which means they scramble at the last minute and rush out the door. Which is a very teenagerly way of doing things. And probably what they did for a year and a half while I wasn’t looking. It works for them, the unease is all my problem. So I’m working on sitting with it. 

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I read an article that said that 50 year olds who did 15 minutes of meditation a day had the grey matter in their brains equivalent to that of a 25 year old. Given the cognitive demands of my training and my profession, I’m happy that I already have a robust meditation habit. At some point I realized that sitting with discomfort was something that I could interpret as an “action” for the sake of my own coping mechanisms. Sitting and noticing how a situation makes me feel or what it makes me think is an action I can take. It didn’t used to feel like DOING something, but it does now.

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I’m going to bring my kids to the Mahec OB residency graduation this June before they go off for the summer. I want them to see the people who have worked harder this spring so I could be here to take care of them. It is strange to spend more time with my colleagues than I do my kids and have my kids not really know them at all. They need to see what a big deal residency graduation is, they need to know that there have been people affected by this windfall they’ve had.

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As someone who Gets Things Done, I’ve developed a surgical ability to jump right over the “emotional reaction” to a crisis and move right into action mode. This is very good for my job, for parenting through crises and for being able to take care of myself and the people I love.


My problem has been that once the crisis winds down, I find myself still having feelings (UGH so annoying!) even though the problems are in the past. It is hard to gain access to feelings of fear, sadness, loss, worry without triggering second guessing, self-blame, spinning my mind’s wheels trying to think of some ACTION I can take to mitigate the feelings I don’t even realize I have. It is usually only while talking to a friend or a therapist that the emotions come out. I’m working on identifying my cover behaviors so I can slow down and find those emotions on my own.


This week I had a bought of “they’re both better now, it’s safe to be sad & scared” in response to my kids’ challenges since about October. That’s 7 months of TCB, of pushing the fear away and just keeping moving. It turns out, I was also terrified about and so very sad for their pain. I’m profoundly grateful for the healing place at which my children have arrived but given what I know about both their family tree and the world, this destination was not the easiest or even the most likely for them.

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I’m having a scary exacerbation of my hearing loss this week. I woke up 2 days ago thinking there was something off with my head but didn’t realize what it was until being at my desk for a while. Around 9:30 I realized that it felt like I was talking to the right of where I was sitting, the dial tone on the phone was hardly audible and I couldn’t hear my fingers rub together at my left ear at all. I went to get an urgent audiogram (mad props to my new audiologist for having an appointment for me 15 minutes after I called!) and was found to have about a 15% reduction in my hearing from the audiogram I had done about 4 weeks ago.


My hearing condition is both cyclic and progressive hearing loss, meaning this big dip will likely be temporary but the general trajectory of my hearing is to decline. I’m getting into profound enough hearing loss that these 10-15dB changes in my hearing are very notable to me. Not being able to localize my own voice really freaked me out.


After some back and forth with my neurotologist in Charlotte, I got a prescription for high dose steroids for 2 weeks and then a 2 week taper. It sucks. I feel lousy and my hearing and tinnitus continue to fluctuate. The tinnitus was so bad this AM I actually called in sick to work. I can’t strain to hear and try to ignore this constant whine in my ear and think at the same time. I put drops in my ear. I took a nap. I gave myself a day with no obligations beyond keeping the dog from making messes on the floor and taking my kid where they needed to be (was a therapy day unfortunately). I feel better now than I did this AM but I’m a little worried what 2 weeks on this dose of prednisone is going to do to me!

I'm tired of being vague about things

This weekend we cleaned the house, which shouldn’t have been as big a deal as it was, but it was and so I’m feeling very accomplished and proud of my kids. We swept, swiffered, vacuumed, dusted, de-cluttered and cleaned bathrooms. We also rearranged the living room, at the request of my son, into an arrangement that solves the problem of flow into the sitting area and has the happy coincidence of being easier for us to play fetch with the dog!

My physical therapy is making progress, which is good but it is also not complete which is making me impatient. Being well enough to actually do the cleaning that was necessary was progress, but I did have to watch the amount of stair-climbing I did and was sore for a couple of days afterward anyway. I’m still swimming a couple of times a week and am more limited by my availability & boredom than by my pain now. I’m getting another steroid injection in my worse knee and that will help a lot. Soon I might even be able to do weight bearing exercises!

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I’ve now passed the 2 year mark since I left my marriage, though the divorce was finalized months later. As happens with the passage of time, the edges of the pain are softening and life is looking, in many ways, better than it ever has. I’m exploring my own sense of self, wants and needs with patience in the safe space of independence. I’m enjoying dating and connecting with people on all sorts of levels, though I still miss many of my far flung friends. One of my co-workers told me months ago about her dating adventures and how she went on many dates after a big break up. I remember the story making me sad and overwhelmed, now I believe that it was actually as fun as she said it was.

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I’m trying to stay engaged in Ob/Gyn medicine while I’m on this hiatus from residency so I’m not completely rusty when I go back. I’m finding as many excuses as I can to read practice bulletins and even reading the main academic journal we have (the one we get paper copies of as residents). I have issues and issues stacked up, unexplored. I decided to start with 2019 and read some of them. I’m also continuing to think about surgery, imagining the steps and the sensations of the common procedures I do - cesareans, hysterectomies, etc. I want to spend some time with the laparoscopic trainer in the sim lab but it is going to have to wait until my duties at home are a little less time consuming. I’m hoping that after spring break I’ll be able to work a regular in-office schedule instead of having to work from home sometimes. Everyone needs to get used to me having obligations outside of parenting so we can ease back into residency.

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I have this chronic health condition that I have alluded to here but not spelled out. I have something called endolymph hydrops in my left ear. The medical eponym is Meniere’s disease, which is a term I hate. In part because it is more of a syndrome than a disease and in part because I hate eponyms.

I started having symptoms in the 2nd year of med school, whether it was just onset of the hydrops or if I had an infection in the ear after which the consequence was hydrops, we’ll never know. I believe it was the latter. The most limiting symptom of this condition is episodes of debilitating vertigo. Fortunately I have had very few of these and not for nearly three years. However, it does also have symptoms of progressive but waxing & waning hearing loss and tinnitus. Also the process of losing hearing is not painless, at least for me. It is accompanied by pain and fullness in my inner ear that causes headaches and fatigue.

I’ve got some triggers that I avoid or manage to reduce symptoms and I’ve recently learned that I clench my jaw a lot and have TMJ pain as well that is causing some of my symptoms and is not related to the hydrops. A bite guard helps so I’m splurging for a custom one so I can sleep a little easier. The cheap one I have now is already helping. I take a low dose diuretic that has absolutely no data to support it (Never seen such an empty review from the Cochrane database!). Some doctors tell me it will help the fullness, others say it is really only for the vertigo. So I may not need to take it but I think it helps so I am going to keep taking it. I’m limited in dose by my very low blood pressure so this is as much effect as I’m going to get.

There are also times that the tinnitus & hearing just get worse and I don’t know why. Right now is one of those times. It may get better again, but it is pretty bad right now. I have profound hearing loss in low frequencies and mild hearing loss in higher (conversational) frequencies. I have a REALLY hard time localizing sound right now (recently thought my kids were in the bathroom together, which they would never do!) My new ear doctor says that I definitely qualify for a hearing aid at this point. Whether or not I can tolerate one will be another question. Hearing loss sometimes causes paradoxical noise sensitivity and I’ve got that. Also insurance doesn’t cover hearing aids or accompanying visits at all.

Right now I have this low steady tinnitus that is constant, but better than it has been the last few days (bite guard!). There have been moments this week where the tinnitus is so distracting, I have trouble thinking, I talk loudly, or I just have to go to my room and put glycerine drops in my ear and lay down (the drops put pressure against my eardrum and into my cochlea, they are soothing). Interestingly, I have another tone of tinnitus that comes when certain muscles in my back & neck are tensed. In a quiet room, I can tell when that tone is present and if I relax the muscles, it goes right away. I’m regularly wowed by this little experiment on my 8th cranial nerve.

The changes to my reality with this syndrome now include that I don’t drink alcohol (I already didn’t drink caffeine but that would have been another change to make), I endeavor to eat a low sodium diet (I fail miserably often), I have an earplug that I can use if I want to be social someplace loud (any bar, restaurant or public gathering place, even movies sometimes), and sometimes I can’t bear to be in any of those places at all. I can’t go see live music without days of repercussions so it has to be good to make it worth it. Even during this leave of absence when I’m able to think about my food more and get enough sleep (obviously fatigue is also a trigger), I’m still very tense and stressed (I want to go back to work, but the timing of that is very much out of my control, not something I cope well with). Couple all that with a rising pollen count (nothing like living in Oregon at least), and I’ve been pretty symptomatic recently.

This too shall pass.

Medical middle man syndrome

My mom and I were talking about dinner table conversation and I mentioned that I had the idea to get some conversation starters for us to use because frankly I run out of energy & inspiration trying to engage my teenagers. So she found a list of nearly 100 questions (we took out the Jesus ones), we printed them out and she cut them into strips and we put them in a vase to use as conversation starters at dinner tonight. They were a big hit! Each kid picked several, prompted me and Grandma to pick and we talked and joked about our answers. And we got to tell some family stories and talk about relatives and that was very heartwarming.

When the kids were little there was a parenting strategy to get them to complete tasks quickly that involved setting a timer and letting the timer be the “bad guy” instead of the parent. It sounded ridiculous to me, that a kid would not be able to connect the person to the timer. But it mostly worked! I think this new dinner table conversation approach is very similar. There’s something empowering in them picking out their own question instead of me asking/interrogating them. All in all it made for a very pleasant meal.

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I started my new job about 2 weeks ago. Shortly after which, the woman who is training me announced that she is leaving. So the person who was filling in on the QI duties is going to be gone at the end of March and the job has been vacant for some time. In steps this now well-rested resident, experienced in program management and interested in quality improvement, to help out. Serendipity. I honestly do not believe that the Universe navigates itself to provide these sorts of opportunities for people. The Universe is chaotic and random, and sometimes things just work out. Whether this opportunity is provided by the cold randomness of existence or because of The Secret & the “law of attraction” (insert eyeroll emoji here), I am grateful and engaged in doing the very best for the organization that I can while I’m here.

One of my recent tasks was looking over phone triage protocols for a new service we are starting that adds a layer of evaluation & support over the phone before patients get sent to the resident pager. In order for the nurses at the triage service to take the calls, we need to approve, add and amend protocols that they will use to address some simple concerns. I was able to review this with the clinical manager so that instead of asking a very busy attending to create it, she was able to take a proposal to them and ask for revisions/approval.

I’m also going to be running an every other week 90 minute meeting about quality improvement initiatives at our practice. I’ll write more later about why these QI measures are important to clinical care anc clinic operations. I just wanted to get started blogging about the new job and now it is time to get some sleep.

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Children are like a gas - they will fill up any space you allow them to occupy. This is not a good or bad thing, it just is. My children have very quickly gotten used to having me around more. They are taking up more space; there are requests for things that they can very easily accomplish on their own (Can I have some milk? Will you go get my __?). Sometimes I oblige them, sometimes I make them do it themselves. Usually the former is met with appreciation, the latter with resignation. Also, they have lost the ability to get themselves up and out the door in the mornings. There is oversleeping, forgetting to set alarms (okay, I’m guilty of that one too), some unfortunate cases where the bus comes much earlier than expected. After a whole school year of up and at ‘em, they are now decidedly slacking. I’ve decided that is okay for now. I will wean them back to the harsh reality of getting their acts together when we are all ready for me to go back to work.

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Some of the scariest moments of my life have been filled with worry about my children. Fortunately these days, mostly I’m feeling moments of joy, peace and an unclenching of my heart as my kids demonstrate resiliency and emotional fluency they are mastering in the process of recovering from the first real moments where their lives went sideways. Not that there haven’t been hardships in their lives, but the divorce and relocation were the first big “oh shit” moments they’ve experienced, where their lives unfolded in drastically unexpected ways. They’re both learning to deal with disappointment and not to let a bad moment ruin their entire day. They are better able to communicate their needs and are more open and loving people than the angry (albeit justifiably) and resentful people they were at the beginning of this big change. Bittersweet indeed that just as they develop these nuanced personalities, they are nearly done being my full-time responsibility. I swear, they were toddlers & preschoolers like 20 minutes ago, where has the time gone?!?

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One of the dizzying things about this temporary job I’ve got is that it is squarely in the “other half” of the health care system from where I have been situated as a resident. Instead of seeing patients and learning clinical decision making, I’m dealing with a lot of administration, billing, health information management, insurance (private & public) and practice management issues. These are real and important issues and it is amazing how divorced they are from the day to day work of taking care of patients. We have a whole office of billing & HIM people who retrieve & send out records and submit and manage reimbursements. This is a very necessary part of the current structure of our delivery of health care. Granted, I think Medicare for all is the way to go, but DAMN there is going to be some serious unemployment that we will have to deal with if that ever were to become the way things work. There are so many middle men in medicine, I can’t even accurately convey the scope of it.

Wherein life goes on

I’m calling this next phase of my life “Making Lemonade.” I’m trying VERY hard not to be petulant and self-pitying, because I’m not really in a pitiable situation. I’m just not in the situation I *planned* to be in.

It’s hard for me to wrap my brain around the idea that I’m not going to labor & delivery tomorrow. I’m going to have a conference call instead, to learn more about the first undertaking in my new role. 40 hours a week seems like hardly working at all to me at this moment, though I know that is not so.

I have been given a rare gift, and I’m abundantly grateful for it. I know that my children need more high touch parenting right now, that they are processing grief surrounding abandonment and that the only antidote to that right now is connection and presence. And soon enough, I will be done with full time parenting and this brief moment is going to be so precious to me.

Brain weasels abound, despite my best efforts to remain positive. The only thing to do is notice them and let them skate on by (Weasels on skates, at least the imagery is entertaining). Yes, I remember that I don’t like to be a stay at home parent. Thanks for the reminder, but that’s not what’s happening. Just keep skating. I know, this isn’t helping my feeling of not belonging but those are feelings, not reality. Keep gliding through. Yeah, it is easy to see how, through a certain, warped lens, this could be considered a failure. Carry on. Other people are indeed being inconvenienced by this, you’re right, Weasels. I don’t like that and I wish it weren’t so. Let’s all notice that for a moment and then you can be on your way again.

Let’s just say I’m getting my money’s worth from the Headspace app this week.

I’m so grateful for this opportunity, despite the brain weasels, and I’m looking forward to my new role. I’m starting tomorrow, in part to save some of my PTO but also because the new job is interesting and I’m going to enjoy it.

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I’m having what I interpret as a “lazy day,” which is quite judgemental I know and probably still an incomplete interpretation of what is going on. I can’t seem to get out of bed. I’m hungry, I have shit to do. I just can’t muster the ganas to move. I have clean, dry hair, I could fix my roots. I have a leaking toilet, I could run to ACE hardware. I could do more research for my lit review. I could do a craft project or go to yoga. I could do yoga here. I could walk my dog. I could straighten the house. I could pay bills. I could fix myself some food.

Why don’t I want to do anything? I’ve lost my forward momentum and I’m not sure where it went. I think I’m suffering from the loss of my delayed gratification. Instead of living for the moment in the future when I get what I am working toward, I’m actually living IN a moment and it is surprisingly unfulfilling. This is an opportunity to slow down, which nearly every OB/GYN resident wants, right? Our lives run at a breakneck pace and it is exhausting. We have all fantasized about slowing down in some way - becoming a fitness instructor, working at Starbucks, laying on a beach. These are all fantasies my fellow co-residents have espoused. Where I find myself now - working a decent schedule for a decent wage with 2 kids at home - is a more practical, mid-life version of that fantasy. And here I am, unsurprisingly, feeling a little empty without the drive, the rush toward something, propelling me forward.

This is going to happen every time I slow down, because the energy that gets you to the goal is not the same energy that keeps you going once you’ve gotten there. I’m an incredibly driven, competent person who is sorely ill equipped to cope with a life that is filled with things that make me happy NOW. I don’t know how to be content. I don’t know how to live without unrelenting obligation. I don’t know how to fill space with just...myself. It feels exhausting to try.

My plan is to allow myself this morning of stillness, to remove that label of “lazy” from my behavior. To notice the feelings that are accompanying the lack of drive to act. To allow them space to exist in me. I will have to get up soon, because I still have obligations, despite the relative ease of my new arrangement. I will try to allow these feelings to have space even when I move, give them some air and allow them to shift, as feelings always do when left to their own devices. Let’s see what they become.

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There’s an expression, “May you live in interesting times.” (It is purported to be a Chinese curse but it is not actually so, the trail of the quote ends at British colonizers, attributing it to the Chinese) Whatever the origin, I love the backhanded nature of that curse. I have often thought that a similar curse could be “May you have stubborn daughters.” I say “daughters” and not “children” only because my daughter is the most stubborn person I know. Besides me, perhaps. Parenting stubborn is ungratifying and tiring. Getting a stubborn person to adopt a behavior change is particularly exhausting. I’m learning a lot about not being co-dependent by parenting teenagers. They are a special kind of self-centered that actually might be good for me to interact with. I’m needing a lot of the same emotional stability in the face of chaos that I found myself needing when they were toddlers. Whoever compared preschool development with adolescence was Spot. On. Brains are weird.

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The one-two punch of entering my forties and starting medical school in the context of the specific stressors of my life has resulted in my body being in the worst shape it has EVER been in. Including compared to the days immediately postpartum when I had no pelvic floor tone and had not shed more than the weight of my children and their uterine accessories.

In related news, I started physical therapy today. I lovehate the way that PTs can evaluate a person’s body and then give them a series of TEENY TINY exercises that don’t seem like a big deal except they hurt like lava when you do them. I’m an exceptionally compliant PT patient, and I’ve seen great results the times I’ve needed PT in the past. I was recently diagnosed with arthritis in both my knees and I’m certain this is not a new finding, only that the deconditioning of the last 5 years has brought it to light. Seriously, I was cruel to my knees. For decades. I had this coming. I’ve been waiting for it. And I’m young and the arthritis isn’t that bad, so there are significant lifestyle modifications that I can do that I anticipate helping a lot. Overall, I’m hopeful.

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My mom has been visiting and I feel a little like a bad host because mostly we sit around and watch interesting National Geographic shows and read books and hang out. I feel like I should be showing her the town or something. It is amazingly nice to have another cook (who makes more than Trader Joe’s Orange Chicken and frozen pizzas) and seriously great to have an adult here to roll their eyes with me when my kids respond to my outrageous demands that they do chores. I’m surrounded by adolescents. An adult lifeline is sanity.

Is Life a Highway?

Life is a journey, not just a destination.

As an aspiring physician, I was focused, goal-directed and hard working. There were times that things didn’t go my way but I found hunkering down, working harder, working different, staying focused on my goal was enough to get me where I needed to go. As a resident, I find myself surrounded by hard working, focused people with similar temperaments who like to solve problems and who work really damn hard. The road we are on is an Interstate, speed limit 75, no sleep til Brooklyn.

As a parent, putting my shoulder to the grindstone doesn’t yield quite the same result. Working harder as a parent doesn’t necessarily get you anything. And it isn’t just your work that matters. As my kids get older, I have less and less control over anything. And that is so frustrating for the hard-working, goal-directed Interstate driver in me. This is more like being on a city bus that’s going to the general part of town I want to be in but maybe not exactly where I want to go and makes who knows how many stops! I don’t always know what the right thing to do is, I can simply do my best and LOVE my children through whatever life throws at us.

According to my plans, this second year in Asheville was supposed to be an easier year for our family. The kids were going back to a school they’d been to before, they had made it ALL school year last year without missing the bus, now it would be even easier. This would leave space for me to be more focused on my residency, which would be harder than last year.

Make plans and the Gods laugh, right?

This year has NOT been an easier year for my kids. They’ve both had some problems that many of my friends probably already know about but I’m not putting on the internet. Teens have their own stories that they control and my blog isn’t the place for me to talk about them.

In my residency program there are only 11 other people who can do my job. At home there’s only one. And that job has become a job that cannot be done by the many surrogates and supporters I have. It can’t be outsourced, it can’t be done over the phone or by text. I have to be here, putting in the face time, navigating daily life with them. There are good days, where they are doing well and don’t seem to need me much, but there are bad days too, where a high-touch parenting approach is needed.

The unpredictable nature of good days vs bad days, and the crucialness of my presence on those bad days, makes me a terrible team member for those other 11 people (and the 4 interns who do important work, just not my job yet). They deserve to have a reliable team. I’ve been working very hard to try to be all things to all people but I just can’t do it.

I can’t do it. As much as I want to. As hard as I’ve tried. Some things can’t be accomplished with grit and hard work.

So, for the next little while, I’m going to stop pulling myself apart. I'm going to stop being a resident, for just a little while. I have the most amazingly supportive residency program, they are going to hire me to use my MPH and my clinical skills together to do research. As a single mother, I need my salary and working a 40 hour work week will seem like half a job (it will be about half the hours I was working before!). With flexibility to work from home sometimes and no nights or weekends, I can be the parent I need to be right now.

One of the people I sought advice from this week while figuring all this stuff out gave me some great advice: Think about what difference this choice will make in 5 days, 5 months and 5 years. In just the last few days of being more accessible, I can see my kids unfolding and coping better. In 5 months I hope that their lives will be stable again. Maybe I’ll be able to use this time to take care of myself as well - to exercise, socialize and get some regular therapy. I still have a bit of healing from my divorce and resettlement process that could benefit from some time to reflect. In 5 years, everyone I’m inconveniencing will be finished with residency, so will I. They will have made it through the Larissa-sized hole I’m putting in their lives. It won’t matter as much to me that I didn’t get to graduate with the class I started with, that my residency will be finished in October or November instead of July like nearly all residents everywhere. My little ego bumps and their big scheduling nightmares will be over.

Sometimes the road of life has unexpected curves in it. It still gets you where you are going, but you’re going to have to slow down, take the corners carefully, maybe stop and get gas or a bite to eat off the beaten path.

Life is more than a destination.

These can't be Still Life because I never stop moving. How about Blurry Snapshots?

That Teen Whiplash is hitting me again, but the other way - my kids are incredible humans. They are strong, resilient, emotionally intelligent, compassionate, well attached to their loved ones (including each other) and are all around awesome human beings. Between them, they made dinner 3 times this week, once at my request and twice just to be nice to me. Explicitly because they wanted to do something nice for me. These amazing humans.

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I did the better part of a vaginal hysterectomy this week. It was spectacular. Some of the things I really like gyn surgery: it is fascinating to work in the pelvis - getting a uterus out without messing up the bladder, the ureters, the rectum or the clitoris is a technical challenge that requires solid technique and knowledge of anatomy. At the same time, it is not all consuming - there are surgeries that general & other specialist surgeons do that last many many hours. Most of our cases are a couple of hours long. I have no desire to test the limits of my physical endurance by operating for 5 or 6 hours in a row if I can ever help it.

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I have 2 and a half days off in a row this weekend - half day b/c I spent most of today taking an annual Ob/Gyn resident exam, 2 because I also get MLK Jr day off! We take turns getting these bank holidays off (also 4th of July, Labor day, Memorial day). Four residents in each class, four bank holidays. I’m really grateful to get a couple days where I get to sleep in to the limits of my distorted circadian rhythm. I’ll be up early by most standards, but the peace & quiet of a cup of tea and no place to be is just as restorative for me now as sleeping until noon used to be. (Edit: I ended up sleeping until nearly 11 am and both kids were up before me! So much for peace and quiet, but it felt good!)

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There are a number of things that I think about during the day and think “I should write about that” and then when I get home I have forgotten that there was minutia in my day that I wanted to explore. I need to make some sort of notes about it but I always think, “Naw, I’ll remember! This is really interesting!” (Edit: still haven't worked out a system yet)

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I had occasion to be on Peds this week, just meeting a co-worker who was seeing a patient there, not seeing someone myself. But it was the first time I’ve been on that unit since my son was a patient there. It was hard and I had to do some work to shove it down and move on with my day and then some more work to dig it back out again and look at it. Things are better now, but they were pretty scary that weekend.

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I am at the phase in my rehab that the exercises are working, my knee feels better and then I do something really nutty like putter around the house for a half a day and then it hurts more the next day. I hate this phase. I’m actually a pretty good PT patient. I do my exercises, I don’t over do it, I don’t try to get back to working out too soon. But I’m really bad at remembering that I can’t do basic life things. Yesterday I hung pictures, I put away clothes & did laundry, I spiffied up my room a little - fixed a broken picture frame, got rid of some junk. Unfortunately, I have a multiple story home and I went up and down stairs and I walked around Target & the grocery stores. Today was a day of rest - the most vigorous thing I did was go to a movie with D (we saw Glass - it was good, which you never know given M. Night Shyamalan’s track record, still haven’t forgiven him for The Last Airbender). I’m hoping that some RICE treatment will make tomorrow a better day but we’ll see. And now my room looks nice & D has some pictures up so there’s that.

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I seem to have done something spasm-y to my back. Throughout today on the left very low it has been painful and tight, to the point of taking my breath away and making me nauseated. I spent many hours with a heating pad on it. That seems to help. I am not used to back problems. It makes me feel helpless and old and decrepit and irritated. I want to help my mental and physical health by working out and I can’t even effing stand or walk.

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Nothing like working nearly every weekend, being sleep deprived, isolated, exhausted and injured to really cheer you up. Calgon take me away!

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I have used all the advice I could muster and managed to minimize a rather debilitating back spasm in less than a week. I’m still a little sore but feeling better enough that I almost forget to do the stretches that are helping. I was a bit worried about how my 24 on Friday night would impact my back but other than some stiffness from sitting to do notes for too long, I think being awake and moving all night (no napping this time unfortunately) actually kept it from getting too stiff.

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I really want a hobby but I am having a hard time mustering energy for anything. I have yarn, hooks and patterns for crocheting amigurumi, a simple DIY embroidery project kit I bought and have completed about 25% of, coloring books, markers & pencils, and of course I still have roving and felting supplies. I have a couple great books, a cool graphic novel and some around the house things I want to do. I’m not depressed, I want to be clear. I don’t have anhedonia, I have exhaustion. It is very boring.

Not glamorous

This week I deeply felt whatever it is that fundamentally altruistic people who go into medicine but end up not practicing altruistically feel that makes them not do so. I’m tired, physically, existentially. I’m sick of delaying gratification and waiting for the time I can do the things I want to do. I want to travel, read books, do crafts, travel, fix up a house (just a little, not like Money Pit style), walk my dog, oh and travel. I can see why private practice life has such a siren song to those folks who started med school thinking they’d end up on a reservation or in the inner city or rural hospital or at an FQHC. I don’t think it is going to fundamentally change my plans, but I can see why we have a crisis of distribution in medicine.

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Today I was reminded that days of constant pain are exhausting and emotionally stressful. And that pain relief brings with it the sleep of the innocent. I mean, I knew those things before, but today I experienced them again. I got a steroid shot in my L knee. Long standing issues, my L knee has. Missing a part, kind of unstable, makes trouble for the neighbor joints. In the 30 years I have struggled with this knee, I have developed solid strategies for dealing with the pain & injury when it comes up (off the top of my head, I thought of 7 times but there are probably more that weren’t as emotionally charged and therefore memorable). Unfortunately those strategies involve rest, proper exercise, regular pain meds (hold on, forgot my nightly ibuprofen…), icing & probably physical therapy. I cannot rest, I don’t have time or access to a pool for swimming, time or extra cash for PT, regular pain meds & icing are the best I can accomplish. Unfortunately dosing q6h is a bit challenging to my memory, even if I carry ibuprofen everywhere with me.

So, steroid shot. With lidocaine. Which has worn off by now but still it feels so much better. But more full of fluid than I’ve ever had it. Residency is a very deconditioning event, especially in middle age. If residency were designed for 40 year olds, it would take longer but be less time consuming from moment to moment. People in their 40s are not is the same hurry that people in their 20s are in. There is a sort of existential urgency that slows over time. Like the escape velocity from childhood is still driving them forward. Telling a person in their 20s that it is okay to take a year off, go a little slower, don’t worry about getting there just yet, is like speaking to them in a way they literally cannot understand. “Why the old lady suddenly talkin’ in word salad?” they think to themselves.

I don’t begrudge them the urgency at all. I had it when I was their age. I remember feeling absolutely justified in the decisions that my urgency inspired: marriage, graduate school, home purchase, childbearing, job changes, religious pursuits. I **needed** to do those things RIGHT NOW. I don’t regret those decisions, I just realize that I’m making my plans with a different background velocity these days and it is hard for me to muster the same sense of urgency that many of my peers show about life.

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Parenting teens subjects One to a regular whiplash. I have gone from feeling horribly desperate on Tuesday to feeling a bit more put together and calm on Thursday. Feeling like my children were suffering, I was not fixing it, I had no idea how to fix it and dear sweet ever loving Honey God, how was I ever going to find the time to deal with All. These. Things.

Turns out that my kids were having a hard time, but it was mostly transient (I need to reflect on how they spend their vacations and how it impacts their overall well being going forward). The things I was doing WERE helping, and I thought of some new stuff and got that on board as well. But I still don’t know either who this Honey God is I’ve suddenly discovered or how I’m going to find time to deal with everything. One bite at a time, I suppose. And I was instructed to pursue treatment for my stupid knee by someone I trust and respect. And she was right. Because being in pain makes everything harder. Now I will just try to do the next right thing, and the next right thing and the next.

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I’m now 1 week post-steroid shot in my knee and 3 days into some simple PT rehab exercises. I’m a highly adherent PT patient. They hurt so bad the first day, I could only do 4 of the 10+ exercises in the regimen. And the second day I honestly considered skipping bc I was worried the pain would be too bad. But it was better, and today was even better. Ainsley & I have joined a kickboxing gym (called 9 Rounds, it’s like Curves but with punching & kicking. I’m very excited). She’s gone twice now and I haven’t been able to work out yet (the registration was a really good deal so I just went for it, even though I know it will be a couple more weeks until I can workout).

Happy New Year

I’m really grateful for my dog. And my friends. Who help with my dog. But mostly my dog. He’s sweet and loves me and makes me laugh. I mean he’s the kids’ dog but I’m really grateful that he stays here with me when they go away. He’s very snuggly.

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Do you ever have those days where you’re just in a foul mood? I’m having a stretch of them right now. I know that it is temporary, but it still sucks. Some of it is because of the time of year. Some of it is burnout. Some of it is because of the day I had. Some of it is because of adulting life stuff. None of it is world-ending, but taken together they are pretty crushing at the moment. I’m fantasizing about holing up in bed for days on end, my appetite is shot. I really wish I could sleep in or nap. Probably both. Let’s break it down one by one.

1. Time of year: In this instance I don’t mean December or “the holidays” I mean time of year in the resident calendar. With the “new year” being July 1st, I’m in my 2nd year hump time right now. It’s been a hard year, I know that I am getting better at my job but I haven’t had a chance to really demonstrate mastery yet. I have done a LOT of nights and weekend call and it is exhausting and I still have 6 months left. BUT. It will get better. The second half of the year is reallyreallyreally nice. I remember thinking the second half of last year was lots better and people generally agreed that for all years of residency, the second half of the year is a great time. 
2. Burnout: One of the hard things about this schedule with lots of days in a row and lots of weeks of nights is the quantity of time I have to ON. I am craving a few days to just lay around in my pajamas and watch crap TV. I want to not have to decide things. I want to have some fun and relaxation. But my kids will be back in 2 days and in 4 we are going to NYC for vacation and I’m so very much looking forward to that. 
3. Ugh my day: I wrote before about delivering a preterm baby that had died and I remarked that in my anxiety and focus about taking good medical care of my patient, I somehow forgot to FEEL any kind of way about the experience. I postulated that when I was more comfortable with the role, perhaps I would feel more. Well, today, unfortunately, I can report that to be in fact what happens. Few things are more tragic than a fetal demise except maybe a fetal demise at Christmastime. I felt all kinds of ways about this today. It was harder than last time, for lots of reasons. 
4. Adulting: You know, this is a really unrelenting part of life that I look forward to being able to outsource in the future. I’m going to have people, minions, assistants, something. People to clean things, wash and fold and walk dogs and pick up poop for me. I’m going to be less stressed about paying bills and I’m going to feel safe and secure enough in my financial status to be able to use autopay more than I do now (too many years of living hand to mouth with a very unstable income have left me scarred). Being an adult is so tiresome. 

I’m not prone to ennui, depression or self-defeating attitudes. I know this will pass. I’m sure there are more reasons than these for me to feel existentially tired. But it will pass. I largely define my self-image as a Woman Who Takes Care of Things. Every once in a while I need to let myself feel this fatigue. I’ll get bored of it very soon. But right now, it is making me feel heavy.

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I just finished my last shift of the Stretch of DOOM. I will now be off of work until next weekend. I have very many observations and lessons from this stretch of time that I need and want to put down on the page but tomorrow the kids & I are going to NYC to see friends and visit the city for their first time. The alarm goes off in too few hours for me to get settled into writing. More later…

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The kids & I are in NYC, Brooklyn specifically. We are staying with friends and having a fantastic time. We’ve explored Brooklyn, gone to the Met, seen the High Line, shopped at some amazing place called Century 21. Tomorrow we’ll see Book of Mormon and explore a little bit more (D was promised an arcade and A was promised the NYC public library). I’m not taking pictures because I don’t want to look like a dork and it makes my kids roll their eyes. Also it is cold. My friend got some nice pictures of D climbing scaffolding with the Empire State Building in the background. I’ve got one kid who is loving NYC and another who isn’t really, aside from the shopping. I mean it is hard to not be impressed by the Metropolitan Museum of Art but if anyone could do it, it would be a teenager, right?

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Part of what has made this vacation nice is the lack of plan. I didn’t have time to set an agenda and we’ve decided to be pretty organic about what we are doing. Which means some sleeping in, some laying around in the evenings, and long lazy rides on the subway home. After just 2 days of reduced responsibility and increased sleep, I felt ready to study again. It only took a teeny tiny break for me to be interested in work again. I love my job. I can totally listen to CREOG topic podcasts and compose op notes in my head while I’m on the subway. Decision fatigue has hit me hard with the latest string of work. I’m glad to have a break.

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I am a supporter of out of hospital birth. I am a supporter of midwifery care. I am a supporter of delayed cord clamping, water birth, low intervention, unmedicated labors and even of lotus birth. I’m pretty grossed out by placenta encapsulation from a food handling and meat preservation perspective but I’m not opposed to it out of hand.

In addition to all these things, I’m also a supporter of trustworthy prenatal care, appropriate scope of practice, timely referral to higher levels of care as needed and respectful transfers between home and hospital (with respect going both ways).

As safety net providers, we often see patients who are home birth transfers, at varying stages in their care - prenatally, intrapartum and postpartum. When we care for these patients, I am full of empathy and respect for their choices, things haven’t gone how they’d hoped if they are with me, but that doesn’t mean it has to be a bad day. I sometimes have less respect for the providers who set us up as slice-happy demons, hospitals as dens of horror and worst-case scenarios, who’s propaganda indoctrinates patients to make choices that can harm their and their child’s health. I have little patience for out of hospital providers, doulas, childbirth educators or anyone who sees their role as protector, with a chip on their shoulder, who prefers to foment conflict. It doesn’t help anyone - not your patient/client, not you, not your reputation, not your profession.