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Handshakes, Hugs and Cheek Kisses

If you and I were to meet I would likely shake your hand. The next time we crossed paths maybe we would greet each other with a smile and a hug. Perhaps a cheek kiss? Anything but a fist bump. These greetings are situationally and culturally determined.

I work in part, as a physician communication consultant: I help other physicians learn how to better connect with their patients and other colleagues. Often when doing this work I refer to something called the “Four Habits Model.” This model guides physicians through a patient visit and helps them understand ways they can communicate that will ease the interaction with a patient. Riva Greenberg, in a Huffington Post article about this model, explained that:

The model teaches four key habits, or behaviors: 1) Invest in the beginning of the visit and build rapport, 2) Elicit the patient’s perspective, 3) Demonstrate empathy and 4) Involve patients at the end of the visit in designing a treatment plan. The pay off: physicians become more effective and successful in their work and patients get better health outcomes.

I believe in this model of interaction – it works! This success seems to come especially from the very first step: the greeting. “Invest in the Beginning” gives advice for a struggling physician about how to quickly connect with another person: smile, sit down, acknowledge their wait, greet everyone in the room and shake hands – if culturally appropriate.

Ah, but that last bit is hard to get right! How we greet each other – for work or with friends – is more difficult than it appears on the surface. Both inter-culturally and within my own (white, professional, highly educated, middle-aged mother of three.) Many of my colleagues are not “hand shakers.” I am. They seem uncomfortable with the intimacy. I enjoy starting a patient visit with the connection of touch. Perhaps doing so eases the way towards the more intimate or invasive touching that I need to do as a physician with my patients?

Socially and in business settings Americans tend to shake hands with a firm grip and a few firm pumps of the hands. To convey extra warmth, we often use our free hand to cover their shaking hand. In a social setting with friends and families the handshake can evolve into a hug. Or, the handshake can be skipped altogether and replaced directly with a warm embrace. I am a hand shaker and I am also a hugger.

Once at a funeral, a friend whose mother had died spoke. She said that through the weeks surrounding her mother’s death she had learned a few things about life. She had learned how short time was. She had learned that her mother had many friends she’d never met. She learned that she too had a wide group of friends ready to support her. And, she had learned that “Jim Davis is the best hugger ever. When he hugs you it feels like you are safe and loved.” She was right. This friend of ours Jim stands six-foot six and is truly the world’s best hugger. I have learned through him how much a hug can mean. At the end of a dinner it can mean the most genuine of thanks. When my dog was hit by a car it meant that he was hurting with me. When I was frustrated beyond belief by doing taxes for the first time as a 50-year-old, it meant he had my back and knew how to help so – calm down.

All of those messages mean so much. As does the simple “I am so glad to see you” that comes with a big smile and hug as we greet friends. Or, the “I can be trusted and I care about you” that comes from a handshake and a smile when a doctor meets a new patient.

I am at work a hand shaker and in my private life a hugger. Both make me feel more connected to those around me and this connection makes me far happier with my life. Now, I am learning to be a kisser – a cheek kisser. In Europe social greetings involve cheek kissing. In the U.S. at least in major metropolitan areas, a single cheek kiss is becoming more common. Some sophisticated sorts even kiss on each cheek – right then left. Or is it left then right? My attempts to use cheek kissing as a greeting are not meant to mimic European sophistication but rather to bond with my boyfriend’s European friends and siblings.

I have had both many siblings and none. To be clear, I had three step siblings, three half siblings and married into 5. I was however, raised as an only child – usually wishing for some company and always wishing I fit in with all those part-sibs. When I got married it felt like I’d won the lottery but joining that pre-made family did not turn out to be a simple process nor did the marriage last.

Now years later, I have a wonderful relationship with a wonderful man who has two sisters. Meeting them for the first time was nerve-wracking. When I was a child I wanted so much to connect with my father’s three other kids. Before seeing them I would think hard about how I looked and what I wore. I would worry about how I acted and wondered if I was thin enough for them? Surprisingly now, as a normally confident and happy adult I found myself wondering the same things about meeting my boyfriend’s sisters.

He is Swiss, I am decidedly American. Europeans have an odd relationship with Americans. They want to visit our cities and beaches. They want to see our enormous national landscape and to shop in our stores. However, they cringe at our politics, manners, too ready smiles, white socks and sneakers. They think we are cool and… decidedly uncool. When I met his sisters I wanted to fall on the cool side of that spectrum. Clothing-wise I knew I would be fine (I own no tube socks.) I had spent enough time around him to be clear on manners. My politics are in line with theirs. But there was one smaller thing left that worried me.

Greeting people here at home is effortless. Handshakes and smiles around. A one-cheeked kiss with close friends or in big cities. Who thinks much about it? However, I knew in Europe they had a complicated cultural thing about cheek kissing. European women always look so stylish (with perfectly tied scarves) as they warmly greet each other with cheek kisses. No hesitation (right side or left, two or three, noise or no?) and they certainly don’t end up lip-locked. How’s an American gal meant to keep up?

I even went so far as to Google “cheek kissing in Europe” to find no less than 525,000 entries. Turns out there’s even a Wikipedia page explaining the custom. I found numerous blog posts and videos demonstrating how an American could learn this foreign ritual. My research, though, did not really guide me. The number of kisses depends on where you are – not just which country but within each country! Some areas start left, some right. Some make contact and some make noise.

I gave up trying to perfect the local custom. I gave up trying to be sure I fit in and just decided to be terribly American and… smile, shake and hug. The cool part? They did too. They smiled and kissed and laughed at my ineptness. Now, a few years later, he says I am “family” and they make me feel like it is true. They laugh and tease me every time we greet. And I am still not sure, if in the German part of Switzerland, it is two kisses or three.

So, I am at work – a hand shaker. In my social life – a hugger. Now I throw in the occasional cheek kiss – giggles and all.

 

 

 

 

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Cheeky Kisses

I have had both many siblings and none. To be clear, I had three step siblings, three half siblings and married into 5. I was however, raised as an only child – usually wishing for some company and always wishing I fit in with all those part-sibs. When I got married it felt like I’d won the lottery but joining that pre-made family did not turn out to be a simple process nor did the marriage last.

 

Now years later, I have a wonderful relationship with a wonderful man who has two sisters. Meeting them for the first time was nerve-wracking. When I was a child I wanted so much to connect with my father’s three other kids. Before seeing them I would think hard about how I looked and what I wore. I would worry about how I acted and wondered if I was thin enough for them? Surprisingly now, as a normally confident and happy adult I found myself wondering the same things about meeting my boyfriend’s sisters.

 

He is Swiss, I am decidedly American. Europeans have an odd relationship with Americans. They want to visit our cities and beaches. They want to see our enormous national landscape and to shop in our stores. However, they cringe at our politics, manners, too ready smiles, white socks and sneakers. They think we are cool and… decidedly uncool. When I met his sisters I wanted to fall on the cool side of that spectrum. Clothing-wise I knew I would be fine (I own no tube socks.) I had spent enough time around him to be clear on manners. My politics are in line with theirs. But there was one thing left that worried me.

 

Greeting people here at home is effortless. Handshakes and smiles around. A one-cheeked kiss with close friends or in big cities. Who thinks much about it? However, I knew in Europe they had a complicated cultural thing about cheek kissing. European women always look so stylish (with perfectly tied scarves) as they warmly greet each other with cheek kisses. No hesitation (right side or left, two or three, noise or no?) and they certainly don’t end up lip-locked. How’s an American gal meant to keep up?

 

I even went so far as to Google “cheek kissing in Europe” to find no less than 525,000 entries. Turns out there’s even a Wikipedia page explaining the custom. My research, though, did not really guide me. The number of kisses depends on where you are – not just which country but within each country! Some areas start left, some right. Some make contact and some make noise.

 

I gave up trying to perfect the local custom. I gave up trying to be sure I fit in and just decided to be terribly American and… smile. The cool part? They did too. They smiled and kissed and laughed at my ineptness. Now, a few years later, he says I am “family” and they make me feel like it is true. They laugh and tease me every time we greet. And I am still not sure, if in the German part of Switzerland, it is two kisses or three.

 

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Caring for the Butcher, the Baker and the Candlestick maker

I started my current job straight out of residency full of knowledge but short on experience. To bridge that gap I leaned on the experience of my more seasoned colleagues. Day after day I would show up in one of their doorways with a question about  patients I had left waiting in my exam room. The need for this support was humbling and I was glad to find that as time passed largely so did it. Now years later, the cycle has shifted and I enjoy using my built up experience to help our newer physicians.
A few years ago when one of my early mentors was about to retire, I stopped by his office after work to ask one last question.
Before you go is there anything more I need to know?
He was clear:
Get to know your patients and their families. What do they love to do? What are their jobs? What are their struggles? Who are they outside our office?
That one piece of advice has made all the difference for me.
I recently heard of a surgeon who follows this same advice . He pauses before beginning a procedure to tell the OR team about the patient who is lying anesthetized before them on the table:
She is an Iraq veteran, a mother of three, and likes the Bee Gees.
By doing so he humanizes the experience invaluably. If we dig deep to connect with our patients, we form bonds with them that create trust.
This advice has not failed me. I am happier in my work knowing that I am caring for children of firefighters, air traffic controllers, teachers,  a fashion photographer and children of pharmacists, veterinarians,  mothers who love to work at home, and a cookie baker. We become more connected when I learn that, together with their kids, they ski, travel, volunteer, train show dogs and that they sing, model, raise horses and enjoy hip hop. My care benefits from knowing their grandmothers and aunts, and the names of their pets.
So now, as newly hired physicians come to my door to ask me what labs to order, how to reach a specialist or to come to look at a rash with them, I want to add a bit more to my answers. I want to ask them if they know who their patients are, what their patients care about and what makes them smile.
Rub-a-dub-dub,
Three men in a tub,
And who do you think they be?
The butcher, the baker,
The candlestick-maker,
And all of them gone to sea!
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Walking a Labyrinth

There’s a labyrinth outside my window at work. Not a maze of hallways or buildings but, a meditation path. It sits there unused and observed like a work of art.

My friend and I walked it a year or so ago on an especially stressful afternoon. “Let’s take a break, get out of here and go walk around that labyrinth thing” We did walk it – fast. We stomped around the intertwined gravel path complaining about our day at work all the way in and all the way out.

Turns out that’s not the best way to walk a labyrinth. I found a better way at a different labyrinth far away from work on the edge of a desert.

Left my phone on a bench nearby.

Stepped in, breathing timed with each slow step.

Lay my worries, stress, fears behind me in the gravel as I stepped.

Foot, step, crunch, breathe, let go, shift, place a foot, step, crunch, breathe, shift, let go.

Lost by the changing direction of the maze.

Just stepping and breathing, stepping and breathing.

In the middle with a lighter burden, I paused and felt tears (surprised at myself) as I looked over the desert beauty; felt the breeze and sun.

Then I turned to walk out by measured degree.

Foot, step, crunch, breathe, hope, shift, foot, step, crunch, breathe, promise.

Slowly, turning, winding.

At the end one last step out.

Buoyant.

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Choosing to Laugh

I watched another dumb movie recently. I have a penchant for unchallenging, predictable, movies. Best of all? Dumb romantic comedies. In this one a man and woman who are finding that they care about each other, are out at lunch. He invites her “to spend some time getting to know each other better.” As they sit, leaning in to each other, she asks a question about his work. Then another and another. Then one more. We know she is curious and cares to understand him; we can see she is nervous. He answers but, after a bit jests pointedly, that he feels as if he is being interviewed. She stiffens, looks hurt and sits back abruptly.
Even in the best of relationships there pass small moments of friction. Socks on the floor again or toothpaste left in the sink set us on edge. A comment about what the partner is wearing or their hair color that  triggers some deeper insecurity. A word carelessly said. Or not said. Most of these moments should be allowed to pass by; they are not worth making much of. But, so often we chase them down and chew them apart and, in doing so cause unintentional injury.
Often i feel these moments creeping up me, hanging in the air a with sense of tottering balance. I can choose to respond with a not intended vitriol that somehow in these stupid moments can fly out of me. Or, i can choose to let them float by without response and take a deep breath of air full with understanding that the little things are just that. I would wish for a warm humor at those times. An ability to shrug my shoulders and laugh at myself and ask, “why take life so seriously?” Socks on the floor, toothpaste on the sink and questions about hair color are just socks, messes and curiosity. They are not more. 
 
While watching the movie I momentarily held my breath. I could see myself there on the screen, (as the leading lady of my own life) and knew the response to his jest could go one of two ways. I would understand her retreat back into the chair, her stiffened chin and internal kicking of herself for going overboard in her attempt to understand him. I could see myself doing just the same defensive retreat. It was a relief to see her pause, and then laugh and say that “yes, she had a way of going too far when she felt nervous!” What a gift – to accept and lightly laugh at oneself! 
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Halloween Candy is a Learning Opportunity

As @KPKiddoc I posted this recently on Twitter:

Don’t have 2 hand out candy on #Halloween Kids like stickers, pencils & sm toys as much! http://1.usa.gov/1N1HVcC 

Only to get this response from a follower:

#delusional

Beyond guessing this person had not read the study I linked the tweet to, I was sure she was not giving our kids enough credit. Sure, they like candy but, they enjoy toys and non-candy treats. If you allow Halloween to be a “learning opportunity” as the nutritionist Ellyn Satter advises, you will find that they learn to manage their own stash of candy and make wise choices. Those choices may be a cool Halloween pencil over yet another mini candy bar. And, I know this works – for 19 years I have offered both candy and fun non-candy items. The pencils and toys are definitely popular!

 

Before becoming a parent, there were many things I thought I’d never do as a mom. You know, like just wipe off the pacifier and plug it back in. Or, buy them a cell phone. Or, let teens wear sagging jeans. Or, let them eat as much Halloween candy as they want. I have had to eat my words a few times and Halloween is one of those.

 

I enjoy Halloween with its fall colors and crisp air. It has little in the way of obligation or work associated with it and feels for the most part, like pure fun. But as parents and teachers, we worry about the amount of sugar kids get each Halloween. This concern is for good reason. The average child in the U.S. is reported to eat 32 teaspoons of sugar a day.  The Centers for Disease Control tell us that American children eat 16% of their total caloric intake or 442 calories a day from added sugars. We buy nearly 600 million pounds of candy a year for Halloween.

 

Given this, Halloween offers us a chance to educate our kids about sugar, nutrition and exercise. Here are some ideas for how to navigate around these mounds of sugar:

 

  • Tonight at dinner, talk with your kids about sugar, candy, excess and moderation. Is it ok to eat small amounts of candy? Is it important to learn how to stop after one piece? How does eating too much candy make them feel? What can they do with extra candy?
  • Partner with your children’s teacher to teach about nutrition. Kids respond well to the graphics of http://www.choosemyplate.gov/kids/ . Consider using the statistics and articles about sugar consumption cited above.
  • Volunteer to bring a healthy snack to school for Halloween parties. One idea are these seasonal pumpkin muffins.
  • You don’t need to hand out candy on Halloween. Try packs of sugarless gum. A recent studyshowed that kids like getting stickers, pencils and small toys as much as candy!
  • If you hand out candy, give out one small piece per kid.
  • Start off Halloween night with a big, healthy, plant-based dinner. Full kids eat less candy (full grownups too!)

Then, after trick or treating comes the biggest challenge: what do parents do with all the candy? There are many approaches to this and you have to find what works for your family. I suggest that teaching kids moderation is important. Trying to control or prevent all sweet intake can backfire.

  • Some families allow a piece or two a day (many a mom takes one piece for herself each day too!)
  • Some parents “buy back” candy from their kids. For example, a pound of candy can earn a book.
  • Candy can be donated.
  • Show younger kids they can have fun by sorting the candy by color, shape and type. Make graphs of what they got.
  • Do some candy science– there are lots of fun experiments to try!
  • Make trail mix with dried fruits, nuts and small candies.

 

I asked my kids last night at dinner about Halloween candy. I asked why they end up with a pile of uneaten candy each year – rather than chowing down every last grain of sugar? They all felt that it had a lot to do with my unconventional approach. You know those things I said I’d never do as a parent? Well, I do tend to let my kids eat what they want out of their bag of candy. I recognize how crazy that sounds coming from a pediatrician, but – I temper my laid back approach with loads of education. It all comes back to using Halloween as a chance to talk with our kids about health choices, nutrition and exercise.

 

 

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A Sister and the Dog Fur

My kids were wild the other night. Absolutely wild. All the hoopla ended up with the usually calm, easy-going middle child in tears. Her brothers were having fun together  while she was studying for finals but, apparently the fun had gotten out of control. I headed into her room to see quite a mess (it involved a lot of newly brushed out dog fur and her bed… I’ll let your imagination take it from there.) But, more impressive than the disarray was the look of remorse and concern on the boys’ faces. They saw their fun had crossed a line.
This level of sibling conflict is rare around here. Somehow I have raised three kids who like each other. Most of the time. In the office parents often ask me for help with sibling issues. While there is endless advice one could give about not playing favorites and listening well, the first answer I give is always the same and often sufficient.
Way back when my first was 3 and about to have a sister I panicked thinking that life might never be the same again. The new baby would be an intruder into her brother’s world. He would feel cheated, lonely without my undivided attention. He might resent her. About that time, I read some advice for how to avoid sibling rivalry that seems to have worked:
Brainwash ’em.
Tell them from day one how lucky they are to have each other. Tell the big brother that his sis is so lucky to have him in her world. Tell her the flip side. Remind them often, that they will be in each other’s lives forever – through everything life throws at them.
Even dog fur.
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Turning The Summer Slide Into a Ladder Up

After our kids work hard all year-long they are thrilled for the break of summer vacation! I remember well how great those seemingly endless days of sleeping in, playing outdoors and reading books in a sunny spot felt. But now that I am the parent, I worry summer months represent a time for my kids to lose ground academically and as a doctor, I know they can be months of slipping into unhealthy habits. Teachers know they send kids home in June at a certain level of knowledge only to expect them to return in the fall having slid down a bit lower   Summertime with its long, lazy days of freedom is a hallmark of childhood but can be a harm to children’s education and fitness.

There are far-reaching benefits to the free-form days of summer. They can be a time of family connection and exploration – I wrote about this last summer. You can focus together as a family on the value of fitness by heading out for a walk or to the park after dinner each night. Summer can also be a time to develop new skills. And the slide in knowledge base that teachers experience is something parents can help prevent.

Making regular reading part of those summer days at home can help kids avoid losing academic ground. A recent study: “Stories to Stop the Summer Slide: Books to Prevent Summer Learning Loss Among Low-Income Students” demonstrated this. Providing our kids with books (preferably of their choosing), the time and sunny space to read in should be one of our goals each summer.

Ideas to get started with:

  • Does your child have their very own library card? Time to get one! Many libraries have summer reading programs and competitions to motivate young readers.
  • Let your kids choose their books. Comic books? Age-appropriate graphic novels? Say yes!
  • Ask their teachers for ideas that fit well with your child’s current reading level.
  • Check out these reading lists for ideas:
  • Be sure to let your kids see you reading. In this electronically focused age it can be hard for parents to put the phone down and read something paper based. Summer can motivate us to take time to relax with a good book too – let your excuse be acting as a role model for the kids!
  • Consider hosting a beginning-of-summer book swap party.
  • Start a parent-child book group. I have been in one with my daughter and her friends since she was in elementary school and have enjoyed reading their books as a way to bond and understand their world.
  • Choose a book to read as a family. One year we read The Calder Game together. It provided plenty of opportunities for conversation and we even tried making mobiles together!

This year at the start of school maybe our teachers will smile to see that our kids have climbed up a ladder to better reading over the summer! Because as they read this summer, our kids will have grown through the stories they soaked up – those of adventure and laughter, those of mystery and fantasy.

We read fantasy to find the colors again, I think. To taste strong spices and hear the songs the sirens sang. There is something old and true in fantasy that speaks to something deep within us, to the child who dreamt that one day he would hunt the forests of the night, and feast beneath the hollow hills, and find a love to last forever somewhere south of Oz and north of Shangri-La. 

– George R.R. Martin

 

 

Is Your Child Too Sick for School? Or, When Doctor Land’s Kid Threw Up On The Teacher.

It was about 7:30 one morning 10 years ago when, while rushing to clean up breakfast, make lunches, dry my hair and convince three slow kids to move along I heard my son say, “Mom, I don’t feel so good!”

We have all had mornings where we have heard those words but – what do we do next? How do we know when to keep our kids home and when to send them off to school?

Part of our job as parents is to get our kids to school on time everyday. Doing so helps ensure their success in school. We know this and yet, the decision about when a child is too sick for school can be a very difficult one.

While your decision must involve a healthy dose of common sense, here are some basic guidelines to help you:

  • You child should not attend school if they have had a fever over 100.4 in the last 24 hours.
  • If your child is contagious to other kids (some examples are: fever, vomiting, diarrhea, uncontrollable coughing, red and oozing eyes) she should stay home.
  • Keep your child home if they seem too sick to be able to participate actively in school.

Here are more specific examples (each with links to help you know when it is time to see a doctor):

Fever: 

If your child has had a fever in the last 24 hours, the child is likely contagious and does not feel well enough to participate in school.

Vomiting:

While one isolated urp is unlikely to be a reason to keep them home, vomiting right before school or twice within 24 hours should be a cause for staying home under your care. If vomiting is paired with belly pain, fever, decreased urination or an inability to take any liquids, see a doctor.

Diarrhea:

Some kids have chronically loose stools (often from drinking juice) but, if their poops have been watery or bloody or they have had three bowel movements in 24 hours you should consider keeping them home. Diarrhea can be from an infection.

Red eyes:

If the white of the eye is just slightly pink and the discharge is watery, your child should be good to go. However, if the eye is red, hurts or has yellow/green discharge, it is time to see a doctor.

Sore throat:

If a sore throat is accompanied by fever, swollen glands, rash or stomach ache, then you should arrange for a strep throat test. If the sore throat is only paired with a bit of runny nose, the child may be well enough for school.

Rash:

A new rash on a child that does not feel well should be evaluated by a doctor. If the rash is accompanied by a fever, a doctor must see the child.

We know that school-aged kids get sick an average of 6-10 times a year – that’s a lot! There are a few things you can do to keep your child as healthy as possible:

  • Teach them to wash their hands often. Most childhood illnesses are spread through germs shared by touch (one child wipes their runny nose and turns a doorknob and the next child who touches the door knob gets the cooties). Helpful tip: they will do a more effective job of washing if they sing the ABC song twice through while sudsing up!
  • Fully vaccinate your child including the yearly influenza vaccine. Vaccines are safe and effective.

Know that, despite your best efforts sometimes your choice will turn out to be wrong. You may send a sicker-than-you-realized kid off to school and get called by the school office. Or, you may keep your child home, only to be stuck with a way-too-healthy child bouncing around your home! To help avoid repeating that last scenario, I always try to make staying home very unappealing: no TV, no play dates and not too much fun with mom.

Sometimes children begin to try to avoid going to school. This can become a real problem with chronic absences impeding their ability to achieve in school. If you are struggling with a child who often seems to be asking to stay home, check out this toolkit from Attendance Works and this helpful resource on school avoidance from Kaiser Permanente for more guidance.

On that morning that I had a decade ago, I looked at my kiddo and said: “You have no fever, you aren’t throwing up or coughing, you look good enough to me so – hop into the car!” Off we went. Then, 3 hours later the school called me – the poor kid had thrown up. All over his teacher’s shoes. My son is in college now but – I’m guessing I will never live that one down!

 

 

S.T.O.P.ing at The Exam Room Door

I was at a work meeting recently. One meant to address physician “wellness”, but held ironically at my kids’ dinner and bedtime. We were given a stack of Post-it notes and asked to write down things that made us happy during our work days. I wrote:

  • laughing 6-month old babies
  • having time to get to know patients’ families
  • choosing stickers with my patients

The doctor next to me wrote:

  • no shows

Well, there is that. What doctor doesn’t dream of the occasional break in the schedule created by a patient not keeping their appointment?

One morning recently, I saw the name on my schedule of a patient that led me to spend the rest of the day hoping for a smile-inducing no show. When the patient arrived, I sighed a deep sigh but, then decided to test out some of the mindfulness-in-the-workplace practices I have spent the past few months learning. As I headed to the room, I thought to myself:

S for stop what you are doing (hand on doorknob, poised to enter into the room and

Take a breath. Stop thinking of the name on the schedule that brings you stress. Put aside the last phone call. Put aside worrying that the dog stuck at home alone might be eating the trash and the kids need rides to practice and that you need to be home on time tonight. Stop and

Observe how you feel. Yes, your jaw is, as usual, tense. Your leg hurts. Loosen those. Let go of the stress. Ask yourself what you can offer this family. What do they need from you? What can you bring to the exam room behind the door; what can you be open to? And then,

Proceed – open the door.

I have known this family that makes me hope for a no-show for many years and through several children. On that day though, somehow, we connected. I asked first how their ill father was feeling. I asked about their financial struggles. I asked how school was. Then I turned to the reason for the visit. It felt softer and easier to work together. We left with smiles and, for the first time in ages, they left without an antibiotic prescription.

I do not find this physician wellness, mindfulness stuff easy. All the deep breathing tends to send me off for a nap. But on that day, giving it a try worked well. I’ll be S.T.O.P.ing again.

 

 

 

 

 

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Full Spoons at Medicine X

I heard a few people talking about spoons on Friday morning at Stanford’s Medicine X conference . They were wondering why artist-in-residence Rachel Stork Stoltz, had asked us all to bring a spoon to the conference? After listening in a bit, I leaned over and tried to answer their questions. The spoon theory was created by Christine Miserandino and is a powerful way of explaining to a healthy person what it feels like to live with a chronic illness. You start the day with a finite amount of energy and as you move through the day you use quanta of energy (spoons) with even the smallest tasks of daily living. You count your spoons and may find you do not have enough spoons (energy) left to do what you want or need to that day because of the demands of your illness.

At its best moments Med X was a masterpiece of collaboration. It was a bringing together of patients, physicians, thought leaders and innovators to work together to discuss the future of medicine. Our recursive efforts mirrored and repeated each others’ in a way that built a powerful basis of understanding to move forward with.

Pamela Ressler opened her panel discussion on communicating the experience of illness in the digital age with a stunning quote from Susan Sontag:
Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.
Using an understanding of this commonality allowed us to enter into a dynamic dialog. I left the Med X space with more questions than answers. The questions are in themselves powerful motivators.
  • How will I recognize the daily efforts of patients in the days of their lives not in my office?
  • How will I be as caring as an old-school physician and as vital as a fully connected 2.0 MD.
  • How will I allow a space of communication about patient’s emotional challenges (as well as those physical)?
  • How will I shape my efforts to motivate health change through social media?
We did bring spoons to Med X and used them to create a sparkly, swirling tower of energy. We were each asked to think of what saps our energy and what refills our spoon count. I paused between lectures on Saturday and stood in the sunny afternoon decorating my spoon with wire and beads and copper. I tried to think as I worked not only of my own energy but of the more carefully counted energy of patients with chronic illness and hoped that they too felt a renewed spoon count from the connections forged at Med X.
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Rachel Stork Stoltz and our spoons
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MedX Day One – Going The Extra Mile

After this, the first day of Stanford’s  Medicine X conference, my mind is blown and my heart is full.

This word cloud of tweets today from @tmlfox Symplur.com analytics sums it all up well. BwyU7q0CYAAhFoo (1)“Patients” are at the center and are surrounded by “empathy”, “team”, “livestream” and “care. We see “relationships”, “mind” and “stories.” All are the spirit of MedX. All represent why I attend this amazing conference. There is the pure fun of the technology: tweeting, scanning our neighbor’s barcodes and using an app to request blanket deliveries. There are the people – each more inspiring than the next. The food is great and, have you met @therealzoechu?

At the end of the day though, none of that is really to the point. Instead, what matters is that I am left here pausing, quietly asking myself how I can be as caring a doctor as medical historian Barron Lerner’s physician father. He was a doctor of another generation. A generation of men faulted now for practicing paternalistic protection of their patients but praised for giving all to their work. They took call 24/7, they took every opportunity to reach out when needed, they went the extra mile.

In this era of technological involvement and focus, in this time of schedules and hurry, how do I go that extra mile? How do I pause and turn towards the person in front of me  take the opportunity to reach out and care?

Thanks @MedX.

 

 

 

Summertime And The Livin’ is Easy – If You Think Like a Kid!

Everyone loves summertime, right? Books, songs and movies speak poetically about the long, lazy days this time of year. We remember our own summers fondly. But I talk with many parents who have a less rosy view of summertime. Kids are home underfoot and rattling around complaining about being bored. Or, kids are home alone while parents go to work distracted by worry about the kids.

I experienced this worry one recent morning as I left my three to head to the office. I left them a hopeful note with chores for each (little brother: put away all the dishes and reload the washer, sister in the middle: mow the grass, big brother: sort the laundry). I reminded them of all the healthy leftovers in the fridge to munch on. In a feeble attempt to keep them away from too much screen time, I added reading suggestions. As I drove away I envisioned a Utopian day filled with cleaning, reading and sibling harmony. Instead by the end of the day I was reminded of Erma Bombeck’s humor:

Being a child at home alone in the summer is a high-risk occupation. If you call your mother at work thirteen times an hour, she can hurt you.

So what’s a parent to do? Throughout the school year, our kids learn about fitness and nutrition. They work their minds and bodies. How do we keep our kids active and healthy during the summertime? I find it helps me to think like a child; it helps to think back to what I enjoyed in the summer as a kid. Here are some ideas (inspired by my childhood memories of summertime) that my family has enjoyed this summer:

  1. Swing. The other evening, I was watching TV with my youngest child. In one scene, a character was swinging her child at the park. I remarked to my son that I missed swinging. He paused the show, looked at me and said “Let’s go!” So we did! Remember the floating feeling of swinging? Head to the park and try it with your kids.
  2. Play outdoor games. What games did you play as a kid? I needed to look up the rules to some but, we have found the old-fashioned ones are still a hit. Try kick the can or can of sardines. My favorite as a child was ghost in the graveyard. Can your kids teach you how to play flashlight tag?
  3. Grow. Kids love to grow a garden and we like to see them eat their veggies. It’s a match made in heaven that most parents can facilitate. Even in the smallest backyard you can grow some food. Try radishes first – they are fast and fun! In a city kitchen you can grow some sprouts for salads.
  4. Cook. Head to the kitchen to cook inspired by your garden harvest. It makes for a great chance to talk about what foods are healthy for us and which ones should be eaten in moderation. If you find that your garden produced too many zucchini, here’s a great recipe for zucchini bread. Or try these fun smoothies and let your kids choose what to throw in the blender.
  5. Fly. When I was a kid, my dad and I made a box kite once. It was an elaborate and fragile thing made of paper and balsa wood. This summer, my son and I tried this far easier version of a simple kite made of things you already have at home. Then we had fun for days flying it. Took a lot of running to get that kite up!
  6. Watch. After running that kite for a while, my son and I collapsed in the grass and lay there watching the clouds. As we did a rabbit, a scary big-jawed fish and a palm tree floated by.
  7. Create. There are endless art projects to enjoy in the summer. One we have had fun with was making mobiles. The kids and I read The Calder Game by Blue Balliett then looked up information about the artist Alexander Calder. Inspired by his art, we searched at the park for things to balance for our own mobiles.
  8. Imagine. Reminiscing about my childhood summer times inspired my son to imagine the future. He is building a time capsule; a box filled with tidbits from our time to bury for people to dig up one day in the future.
  9. Build. Take all the blankets stored for winter and let the kids use them to make a blanket fort. If it is hot outside make it under a table. Nice day? Tie them to a tree branch. Then sneak a few healthy snacks and books under the edge and let your kids relax.
  10. Hunt. Not for deer. Make your kids a scavenger hunt using a list of things found at the park or in your house or yard. Or better yet, have them make one for each other.

The summers of my memories were endless days of exploration and fun. I remember eating summer veggies from the garden and drinking lemonade. I roamed and read. I think I was bored but my mother had the wisdom to let that boredom be the opportunity for me to create my own fun. It is indeed wise to let our kids relax into their summertime to find their own adventures. It is also fun to join in and fly a kite or sit under a blanket fort with them!

 

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Zucchini Hiding

It’s that time of year again. The time of year when I get sneaky.

I have a passion for cooking and a love of gardening. An interest in nutrition and, a love for my children. Combined, these had me convinced that if kids were given the chance to grow their own food in their backyard or patio garden they would eat just about anything they grew.

My garden space is small but full and in July it is full of zucchini. But, it turns out that zucchini is not my kids’ idea of good food. Even if they did grow it. Funny thing that I can’t remember this in May when I put in the seedlings.

So, every year, this time of year, I am forced to hide zucchini everywhere in order to use it up. I have the most fun sneaking the truly huge, two foot-long zucchinis (that seem to grow ignored under those big leaves) in my neighbor’s beds. I sneak over when they have headed out to walk the dog and place, like the tooth fairy but different, a big zucchini under their pillows. Hee, hee.

Then, I turn to cooking up the more manageable fruits. For dinner there is no better choice than the recipe found in Barbara Kingsolver’s book Animal, Vegetable, Mineral for Disappearing Zucchini Orzo. It is a perfect way to hide three large ones. Hee, hee, hee!

Then for breakfast I whip up zucchini bread from a recipe I have tuned and tweaked for the past 18 years of feeding children. It is a perfect way to thin the crop and a fabulous way to trick reluctant youngsters into eating their veggies.

Ingredients

3 eggs

1/2 cup canola oil

1 cup granulated sugar

1 teaspoon vanilla

2-3 cups grated zucchini (or a mix of zucchini, yellow summer squash and carrots)

1 cup white flour

1 cup whole wheat pastry flour)

2 teaspoons baking soda

1 teaspoon baking powder

1/2 teaspoon salt

1 teaspoon cinnamon

1 teaspoon cloves

1 cup chopped walnuts

Preheat oven to 350 degrees. Grease a 9 x 5 loaf pan.

Beat eggs, oil, sugar, vanilla until light. Mix in zucchini.

Whisk together dry ingredients then fold into wet. Stir in walnuts.

Pour into pan and cook for 1 hour and 15 minutes or until center springs back and tester comes out clean.

Cool for 10 min then turn onto cooling rack.

When asked, don’t tell them what the green flecks are just let them try it first!

 

 

 

 

 

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Frozen

I have learned a new trick. On a busy day of seeing patients it is easy to run from exam room to office desk and off to the next exam room at a frenzied pace. The charts, the orders even the patients can blur a bit. It is not a way to move through my day.

Now before entering the next exam room, I put my hand on the doorknob and pause. I take a moment to notice how I feel, take a deep breath and let it go. I let go of what ever might be distracting me from what is behind the door. Then I turn the handle and focus more fully on the person inside waiting to see me.

One day last week when I opened the door there was some fun waiting for me. A boy had a wart that needed freezing with liquid nitrogen. It is a simple procedure that he had done before and he and I settled in to chat while I worked. Also in the room was his much younger sister – maybe five years old. This girl was wearing a dress and holding a rose. She was smiling and excitedly hopping from foot to foot but – not saying a word obviously trying hard to be polite and wait for me to finish up.

Now, this clinic day was as busy a day as could be.  But when my wart treatment was done and the bouncy little sister finally got her turn to talk, I listened. She said:

Please freeze it.

And smash it!

And so we did. I dipped her rose in the liquid nitrogen and handed it to her. With great joyful enthusiasm she smashed that rose into tiny fragrant icy pieces!

Then with wide smiles we said goodbye. She and her brother got their stickers. I went on, placed my hand on the next door knob and fully focused, went to the next patient.

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Media and Your Teen: Ask Them to Decide

The American Academy of Pediatrics has clear words for parents seeking advice about screen time limits for children. No screen time for kids under 2 and no more that 2 hours a day for kids over 2. Less is better and content matters.

While I find these guidelines challenging in my office and in my home, my mother would have had no trouble enforcing these guidelines with me – for most of my childhood we did not have a television. I remember mornings in junior high school as being rough. Not only those mornings too early, cold (N.Y. State in winter is COLD) but once I made it to school everyone around me was discussing last night’s episode of this or that show. I tried to look casual and preoccupied while they sounded so…. cool.

As a Pediatrician, I understand the social power that being up to date with the latest show, game  or video has. Being connected on each of the latest social media tools be they Instagram, Vine or Snapchat, matters on today’s Monday mornings.

However, I want my teens and my teen patients to turn off their screens more. I know that doing so will broaden their horizons and shrink their waistlines. They also on some level, get this. It is though, hard to translate advice and understanding into action. Teens especially do not like to accept rules made for them without their input and buy in. At my house I always begin change with a discussion around the dinner table. It is a perfect chance to ask and listen.
It is perhaps ironic that I found some words to inspire teens to turn off their screens from a recent episode of Grey’s Anatomy. They have just the right touch of inspirational simplicity that appeals to the Pinterest set:

Decide .

We are all going to die. We don’t get to decide where or when.

But we do get to decide how we are going to live. So do it.

Decide.

Is this the life you want to live? Is this the person you want to love?

Is this the best you can be? Can you be stronger, kinder, more compassionate?

Decide.

Breathe in, breathe out and decide.

When you put it this way, few kids would choose to spend their time in front of a screen. And definitely not the average of seven hours a day on entertainment media, including televisions, computers, phones and other electronic devices that our kids are currently spending. Tonight at dinner, ask your kids to Decide. And then come up with a plan together for media use in your home.

For ideas about how to decrease your family’s media use read this blog post by Corinn Cross, MD or see the AAP parent’s web page healthychildren.org .

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Hoofing it to School “Old-Style”

Research is mounting; the evidence is weighing in on the side of the health benefits of having kids walk or bike to school. This is termed active school transportation or, AST. The benefit to our children of getting to school in an active way is clear: increased aerobic activity leading to healthier, leaner bodies. There are additional benefits to our environment of fewer cars and to our neighborhoods of greater social cohesion.

Even given that actively moving to school would make our kids healthier more and more kids are driven by parents every day. In 1970 42% of kids actively got to school. Today? Closer to 13%. Changing these numbers can change our kid’s health.

When asked why their kids are not actively getting to school parent express concern about street safety, weather and distance. I understand these concerns. As a mom of three kids I have driven miles (in small ant-like circles around town) carting my kids to school, music and sports practices. However, my kids for the most part ride their bikes to school. Their elementary school is a 6.5 mile round trip which my youngest asked to do on his bike first in fourth grade. To calm my maternal concern I spent a good deal of time traveling with him to teach the ways of the roads and bike lanes and equipped him with a cell phone much earlier than his sibs were given one. Even now, a few years later I worry about his journey – is he safe? is it too long is he cold or too hot? For the most part though, I know that encouraging him to ride helps him: his body is stronger and he is more mature.

Deciding to chauffeur less can seem challenging. Here are some ideas to get you started:

  • Consider starting a neighborhood “walking school bus.” Neighbors and friends can take turns walking groups of children from “bus stops” to school.
  • If you plan to have your child start biking spend some time teaching them the ways of the road. Then bike with them until you are convinced they are ready to roll solo.
  • Some parents fear that their children may be intentionally harmed by others as the child walks to and from school. To help protect your child read my post on safety around strangers.

Above all rules, the one I have been strictest about is the helmet rule. When on anything with wheels they have to wear a well-fitting helmet. And it has to be strapped! To enforce this rule I used the “it takes a village” concept and have told all of my friends to notify me if they see one of my kids without a helmet. The kids know that they will be fined $25 dollars for the first time and that fine will be doubled with each “offense.” Years of safe bike riding had gone by when last spring I got a text from a friend saying she just saw my child without a helmet. I quickly fired of a text:

You owe me $25.

I immediately got the answer:

Wait Mom! My helmet is broken!

He biked in 5 minutes later looking worried and holding his helmet – in nearly two pieces. He had fallen and it had saved his brain. Fine revoked.

Active school transportation is an important step towards a healthier community of children. It is worth trying for your child! In a commentary written for the journal Pediatrics Dr.s Liu and Mendoza sum this all up well:

We recognize the many societal changes that have led to more students being driven to school. As parents, we empathize with families who worry about dangerous streets, distracted drivers, and challenging weather conditions that give pause to even letter carriers. When viewed through the eyes of child health, AST is an ‘old school’ form of physical activity that more children should adopt to make the daily trek to and from school.

 

 

 

 

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Daily Tile

We are becoming increasingly aware that our children are in many cases, over scheduled, over stressed, over involved. As parents we feel overwhelmed by time pressures. The American Academy of Pediatrics has published several recent articles on how to help families with these challenges. One discussed the importance of play for kids themselves and also for us as parents. Play helps us maintain strong bonds with our kids.

As my kids are getting older I am increasingly listening to the little voice in my head telling me that they won’t be young for long. Now, when they ask to play or read I have begun dropping everything on my to-do list to jump up and join them. Rarer even than these requests for my time are pickup games of ball. Who just plays ball these days? Rarer still? Pickup games of kelpball on the beach at sunset.

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Birthdays, Beets and Baby Carrots

I heard once that my influence over my kids’ final outcome ended when they turned five. By age five they had soaked up all the manners, values and habits they ever would from me. Now, on the occasion of my first child’s sixteenth birthday I find myself wondering if perhaps I have become dispensable.

His manners are for the most part lovely. Check. He is usually kind and generous. Check. He is clean and well dressed. Hmmm …clean – check. But do the pants around the buttocks count as well dressed? (before having kids there were several silly things I said in the category of “I’ll never”. “I’ll never let my boys wear their pants sagging” was one). He works hard in school – yes, and room to grow. He has commonsense. Um…. not always. This was demonstrated this week when he donated blood in the middle of lacrosse season and then wondered why he was so winded while running. Sigh. He understands the importance of physical fitness. Check! He understands the importance of good nutrition…. Uh oh. Wait, yes, I am sure he understands. This is where I see the wisdom of the five-year old rule.

As a mother there are household chores that I do happily, there are others that drive me slowly insane day after day. Making lunches leads the list of things making my hair go gray. One recent afternoon on the way to his lacrosse practice, my son asked if we could stop by his school locker to pick up something too big to carry on his bike. Indeed, the sack of old lunches filling his locker was big. And smelly. Turns out he wasn’t eating much of what I had packed. The carefully cut veggies, the fresh fruit, the whole grain bread all…moldy. Later that night I had one of those “Look out: Mom’s head is spinning!” moments that all children should see occasionally. Now I no longer make lunch, they do. I made some rules: each lunch must have a fruit, a veggie and some protein. It has worked well for the most part. Those were rules they knew by age five, right?

Yesterday my friend told me a story. She was at the grocery store during the high school lunch hour and happened to see our sons there. She quietly watched them go through the checkout aisle. My son had a 2 liter bottle of Mountain Dew. Her son, a family sized bag of Cheetos and their friend had a bag of Oreos. Well, I guess that explains the lunches in the locker. Why eat vegetables when you can eat your Cheetos with Mountain Dew? So, by age five he knew the food pyramid well enough to scold me when I crept up too high on it, but by age sixteen he is apparently very comfortable at its apex.

Now, I am left both looking back and hoping I taught him enough and gazing forward and hoping that the knowledge will resurface in time. His recent choice of a birthday dinner reflects this split in a way. He requested steak (“to replace the iron lost from donating blood this week so I can run better”), potatoes and … a vegetable. Great! Which one? Asparagus?

Ew, no.

Beets?

Are you kidding Mom?

How about roasted broccoli?

No mom, just carrots.

The endless stream of baby carrots was part of what made me hate making lunches so much. Maybe if I show him this article about how eating beets can make you run significantly faster he’ll change his mind? ©