Category Archives: Medicine

Learning to Sit Still on a Spinning World

When I was first a mom I was astounded on a daily basis by the experience. Not to mention, exhausted. The now 15 y/o then wanted to nurse constantly.  For hours on end, day and night we would sit together – him happily suckling and me? Well, honestly I was bored. There was a certain low-level trapped feeling; a feeling of being stuck yet again sitting tethered to the little creature. Don’t get me wrong, I loved breast-feeding and we made a great team. It did however, take a while to settle into the experience. That settling came when I learned to enjoy those moments of enforced peace.

There is great beauty to sitting absolutely still and giving into the process of nursing. I had to relax and let the world spin around me – the clothes unwashed, the dinner cold, the business of life unattended to. And in those moments of peace I would often think my clearest thoughts.

Again I find myself forced to sit still on a spinning planet. Forced by an injured leg, to let go of the multitasking productivity the working mother in me prizes. My family laughed at me last night as they scurried around on their good legs and I sat on my hurt bum watching them. They laughed because I mentioned that having my hamstring tendon torn is a lot like breastfeeding. Huh? No one stayed around long enough to hear why; but I kept thinking about this idea. My life is so full of mothering and work. So full of electronic medical records, blogging and Twitter. So filled out by friendship. So full that I lack, almost completely, time for quiet reflection. Now, in a space without the ability to scurry I am left sitting and relaxing. A novel experience? No, but one that is nice to return to.

I am reading Twila Tharp’s book The Creative Habit. She has taught me much about my own developing creative habit. One of the first chapters talks about the squelching effect on creativity of background noise. Noise both literal and figurative. She suggests turning off our computers, our music and skipping the newspaper for a period of time to understand the effect they have on us. That was hard advice to swallow; I have always worked with music playing. I started to drive my 20 min to and from work without the radio. At first the silence was a bit uncomfortable but as the days passed I found that my mind was productively wandering. Bits and pieces of my days were knitting themselves into coherent stories as I drove quietly along.

Breast feeding, healing and silent driving. Less tweeting, less laundry, simpler dinners. Soon I may be positively Zen-like sitting here watching them all run around. Hopefully I will at least, synthesize a few blog ideas while I watch.

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Vulnerability, Becoming a Better Doctor and the Beach.

I like to keep a separation between my workday and my home life. It is created by a walk to my car and a 20 minute drive home. During this time I think, create and often, ask myself how I can be a better doctor tomorrow. Lately, I have been thinking the answer lies not in reading more books or journals, timely license renewal or peer review. The answer it seems, lies in feeling my own vulnerability.

I had a patient this week who was perhaps, a bit challenging. I was overloaded, behind, late. She was not doing what her parent and I needed her to do. Frustration started to enter the room but, as I sensed its arrival I stepped back (literally) and looked at my patient. Then, it hit me. She wasn’t trying to be non-cooperative (that horrid, judgmental, doctor term); she was feeling vulnerable. Scared, hurting, feeling… at a loss. Being ill or hurt makes it hard to be brave, strong and – cooperative. The more time we physicians have the “opportunity” to feel this vulnerability, the more we become able to feel what our patients and their families feel.

Maybe I should not take vacations. I seem to end up worse for the wear after many of them. Hawaii the first time found me in preterm labor and complete bed rest at 20 weeks. Scary then, but now he is 15 and perfectly fine. Hawaii again led to a ruptured appendix and way too much time in a hospital bed. Most recently, a sparkling San Diego day disintegrated into an explosion of pain as my skate slipped on a patch of poorly placed sand. I was left immobilized for a handful of weeks and am now facing a ridiculously long period of rehab. Each of these beach-side mishaps left me stranded, forced to slow down and experience the world as many of my patients have had to. I felt acutely vulnerable. Pain. Needles. Limp. Weak. Dependent. All of this bringing to mind an often quoted passage:

“Did you ever say yes to a pleasure? Oh my friends, then you also said yes to all pain. All things are linked, entwined, in love with one another.”

“What does not kill me, makes me stronger.”

– Friedrich Nietzsche

Yes to vacation? Then risk yes to… learning. For I have found during each stint with vulnerability my skills as a physician do become stronger. But maybe on my next trip (in June with my mother and Godmother in a faraway seaside city) I can take a holiday… not just from daily life and work but from learning?

Pink and Purple Circles

Promoting arts education is crucially important for our kids. Before I leave the background discussion of why I need to address one last point. Arts education is often taken to mean creating and performing art. Art history is also of value. This involves art criticism, the academic study of art with its stylistic and aesthetic context. It gives us the ability to understand the sublime that is art.

Briefly, three ideas for why the contextual study of art should be included in the standard arts education:

  • Understanding what influences the framework that art hangs on allows a more enjoyable connection with it. This is likely better explained with an example. My kids all went to a wonderful parent cooperative preschool. On my workdays there I loved being at the art table. Over the years I became increasingly impressed with the influence the children had on each other’s artistic styles. There might be three kids at the table painting away. One more would join in and start painting say, concentric pink and purple circles. Soon I would notice lots of use of pink and purple and lots of circles appearing across the table. Over time I worked with the teachers to form a yearly art exhibit where we hung the kids art on the fences in the school yard. It was grouped by period and context. It was a joy to see how the kids had developed together! This ripple effect or evolution of style is seen in our study of major schools of art. Artists influence each other and create an ongoing evolution of artistic style.
  • An understanding of the evolution of tastes in art generates acceptance of diversity. Artists through time have often been scorned when they challenged commonly accepted ideals with new approaches. They take a new approach that eventually becomes the accepted norm (think pink and purple circles). Seeing this progression as it has played out repeatedly through time can teach kids an acceptance of new thinking, new looks, innovative approaches. It can help them be less judgmental of differences in those around them.
  • Understanding the mechanics of creating art is valuable. Artists work hard. Really hard. They practice day in and day out in order to produce what can often appear simple. Have you ever looked at a modern painting and thought “I could do that”? Likely, you could not. Professional artwork requires both innate talent and earned skill. Understanding this can encourage and motivate a child in their own persistent efforts.

Art is more sublime when hung on a framework of understanding. You have more fun when you can see where the story behind the pink and purple circles. Then you might be motivated to go home and try some of your own.

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Black and White in Art and Life

I am having a bit of a free association sort of rainy Sunday. Funny about our minds isn’t it? The way we can unconsciously shift through the bits and pieces of what we read or hear during the week to come up with a theme of sorts. What follows is the intersection of learning about the great dance choreographer Twyla Tharp, the painter Caravaggio and thinking about a few failed interactions I have had with patients through the years.

The Calling of Saint Matthew (1599-1600) by Caravaggio

Twyla Tharp explains in her book “The Creative Habit” that she prefers to divide people in her world into two distinct categories: acceptable or not, good or evil, “committed or missing in action”. While I find the book well-written and find myself inspired by her advice, I was bothered by these comments. I recognize that for her this commitment to embracing the extremes rather than the grey zones is artistically motivational but for me, it grates against my own approach to people. I prefer to work in a grey zone embracing the nuances of the personalities I find around me.

Michelangelo Merisi da Caravaggio was an Italian Baroque painter in the late 16th century. He is known for dramatic, dark, richly and realistically depicted paintings of an often religious theme. He is also known for having been a murderer. Good (artist), evil (killer) and yet, to view him fully as one of these extremes we would miss the other side to his story and miss the influence these complex components of his persona have on each other. We would make an error of judgment.

As doctors, we give our best care and make our best diagnoses when our minds are open. I remember a professor in medical school telling me to begin my care for every patient by imagining that the patient’s illness was a tree that I stood at the foot of. A tree full of possibilities. As I tried to figure out their diagnosis I was to consider climbing along a branch chosen after a pruning of other possibilities by listening to their history. The physical exam would allow a deeper cut of the choices, lab tests, xrays and time allowing me if fortunate, to end up on the right twig with the right diagnosis.

I read a blog post today about errors made when “hysterical” E.R. patients’ complaints are dismissed.  Someone loudly and dramatically requesting that they want a certain pain medication in a busy E.R. does tend to get ignored or, written off by the doctors and nurses who care for them. These patients are judged rather than treated in the grey zone of acceptance and this judging can lead to medical errors. This brought me back to two times in the past when such bias crept into my patient care. In both cases I was “warned” before entering the exam room that the patient or parent was difficult in some way causing me to walk into the room seeing a tree with already pruned branches. And indeed, I ended up on the wrong twig at the end of the visit.

Twyla Tharp is a supremely talented artist whose approach to slotting people into good or bad fails me both creatively and humanistically. Caravaggio was a troubled man with a gift; art influenced by his turmoil or, a man of grey shades. Patient care is best done with a clear eye towards the complexity of human nature.

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Connections and Bonus Questions

I just read “18 Stethoscopes, 1 Heart Murmur and Many Missed Connections” a fabulously written article in the New York Times by Madeline Drexler. She tells her story of being a model patient – a person with a medically interesting “finding” who is asked to help teach medical students. These “patients” are examined by small hoards of inexperienced medical students who have little knowledge, little skill and varying degrees of innate bedside manner.

I was fortunate enough to go to a medical school where we began examining patients – real and staged ones – from month one. I still remember many of these people well; more clearly perhaps, than those I cared for in my sleep-deprived haze of residency. As Ms Drexler describes, I am certain that back then, I too was filled with awkwardness and overtaken by my interest in the examination findings at the cost of expressing empathy.

There is one that comes to mind now. He was a model patient for my final exam in a class on physical examination. I think he might have been the bonus “question”. I had studied hard. I was tired. He was in a room behind a door I nervously opened to find the answer to what exactly was different (medically speaking) about him. There in the room, on an exam table sat this young man. He may have been 25 or so. Dark haired, bespectacled and calm. I approached him and began the work of examining his body for a “finding” of sorts. Heart, lungs, abdomen… all depressingly normal. Mouth, neck, ears…getting closer. Then to my joy I found “it” and remember well the thrill when I did. There was a big part of me that wanted to say ” Woo Hoo! I did it”! Ms. Drexler describes this reaction in other students:

“This was a student who is not uncaring or unkind,” Dr. Treadway told the class. “But in that moment she did something all of us do all the time: she was so engaged with the problem that she forgot about the person who had the problem.”

I had a favorite attending doctor in medical school. Everyone else was scared of him. I looked up to him. Sure, he asked the hardest questions and embarrassed me at times. I stood tall with the knowledge he was doing this to make me better. And, when I watched him with patients and parents I saw that all of his sternness evaporated; he became the most caring doctor in the hospital. He asked, as Ms. Drexler reminded us to do, about how it felt to be stuck there as patient or parent. When he was talking with a family it seemed that perhaps, time had stood still. He had no where else to go, nothing else that mattered more than the people in front of him.

I think of this man often. He motivates me still. And, what I know now after all these years, is that I am still learning. Every visit with every patient I strive to become better at listening, interacting, understanding. I reach for the ability to make them feel that time has stood still in that room with them. I am not there yet but – reading Ms Drexler’s words and remembering my attending’s gifts help me feel that I might, just might get there some day.

P.s.: The answer to the bonus question was prosthetic eye.

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The Patient’s Worst Fear or, questions that take my hand off the doorknob

In medicine physicians often talk about the patient concerns that come up in the moment we are leaving the room. The “oh by the ways”. The comments that come when the doctor has a hand on the doorknob, one foot out the door. Mostly, these are simple, quick requests (work notes, PE excuses and the ilk). But every now and then they are real humdingers.  Yesterday I had one of those moments, and it got me thinking about what I do and how I do it.

Work has been busy lately. The clinic is full of kids with colds, earaches, and influenza; lots and lots of sick kids. The volume of patients is pushing us to be very time efficient, very focused in our approaches to care. Yesterday in the afternoon a teenaged patient came in with several separate non-urgent concerns. We worked through the history, examination and plan for each of these and I needed to move on to the next patient. Make that patients – four were waiting. So when, as I was touching the door handle, their parent asked her if they wanted to tell me about another issue I admit that I inwardly groaned. Outwardly I explained that I had four people waiting and that maybe we could schedule an appointment next week to discuss this concern. But something was bugging me about the atmosphere in the room. Some alarm beeping in my head made me stop, take a deep breath and ask if I could on second thought, hear what was worrying them.

It was one of those moments that highlights how much of medicine is an art. Much of being a good doctor involves having an emotional intelligence that helps us know when to take our hand off of the door. I wish that I had never actually reached the door. I wish that I had responded earlier in that visit to the little alarm in my head.

There is lots to read on the internet now about how a patient can prepare for a visit with their doctor. Ideas about advocating for one’s healthcare. Making lists of questions to ask. All often form good advice. I would add this piece of advice for patient interaction with physicians: state your fears upfront. Tell the doctor what your biggest worry is. Tell them what keeps you up at night. Doing so is important for several reasons. We can often calm your worries better if we know what to approach. You are your child’s expert and have input that is valuable to us. We may though, need to schedule another appointment. And, of course if the doctor manages to get out the door without knowing that last “oh by the way” humdinger we may have failed to treat the one medical symptom that actually would have scared us and kept us up at night.

My teen patient will be fine now but they needed that last moment of my attention. Without it they would be very ill today. The other four patients? They waited and understood that I was late because I had been helping another child. They understood that I not been off doing my nails or reading a novel. That is for today.

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For more insight into the approach physicians take to office visits read this excellent outline by BrianVartabedian. It absolutely sums up how I also try to structure a patient visit.

Why February is hard for Pediatricians

It has been rough in the office lately. January is always rough for pediatricians…February is worse. Everyone and their sister is sick, the doctors all get sick too, those of us left standing work extra….Oh well. At least the great thing about pediatrics is that the kids are still cute and make us smile.

Part of what makes the days hard is also that many of the parents who come into our offices are exhausted from lack of sleep and worry. They need our help also. But when so much of the time all we have to offer is the dreaded diagnosis of yet another viral  infection  they feel frustrated. Sure, parents come in for reassurance – they want the piece of mind found in knowing their doctor did not hear a pneumonia or see an ear infection. However, much of the time there is often the hope that they will be handed a medicine that will help their child and get the parent some much-needed rest. I know. I’ve been there; I too have kind of secretly hoped there really was an ear infection to be found because I knew that could be “fixed”.

Too often we can’t offer a fix; we can only offer the diagnosis of “viral infection”. Let’s face it – that is read by the parents in our office as having the subtitles: “I’m back on my own with my sick child” “no sleep tonight” “I wasted my money/time”.  And for us as physicians honestly, handing over the diagnosis that clearly deserves an antibiotic is much easier, much more satisfying than saying yet again… it is “just” a virus (of course this concept of a viral infection being a “just” could take up a whole other blog post).

Then there are the even harder visits when we find an ear infection but need to embark on the discussion of “to treat or not”. Claire McCarthy, M.D. recently posted a wonderful article about this very discussion: Shades of gray: Why medicine isn’t always as clear-cut as we’d like. Her words and perspective have stuck with me through the past rough days at work. They have helped to reassure me and to guide me.

The practice of pediatrics is not unlike the practice of parenthood: full of uncertainty, impossible to understand completely and done best when the child is more important than anything else. We’re coming at it from different places, but we’re in this together.

Thank you.

Lice again? It is nice to know we learn.

Last year I wrote an article for patients at work incorporating the American Academy of Pediatric’s recommendations for the treatment of head lice. Their recommendations and my article we aimed at being calming and reassuring. Lice are indeed gross but – they are not harmful so we mothers need to calm down a bit. As I was writing it I remembered a certain mother’s day I had and changed the article to include this introduction and summary:

Picture this: 0630 Mother’s Day 2008 morning …my dear daughter climbs into bed with me to read a book and snuggles up in the crook of my arm. I decide I will have to do without the dream of sleeping in on mother’s day in order to well, enjoy being a mother. I give into the joy of her good morning love and snuggle in with a nuzzle of the top of her sweet head…only to find….Arrrggghhh! Lice nits! Good grief, what a way to start the day, any day let alone Mother’s Day! So, I did what most mothers would do jumped up and entered into panic/action mode and spent the day (btw that was supposed to be my day) washing, picking nits, combing, doing laundry, vacuuming and cleaning. Let me emphasize the laundry; I totally went overboard with the laundry and did dozens of loads!

And that is really where we need to begin here. So, let’s take a few deep cleansing breaths together (lice tend to reduce the most composed mothers to crazed hyperventilating insane people – me included). Now I know and believe much of what I put my self through that day was unnecessary. We as a nation are too afraid of lice. Yes, they are really, really yucky. Yes, we don’t want them on our children’s heads. However – lice do not hurt our kids (deep breath) and they do not live well or long off of a human head so huge cleaning efforts are unnecessary (deep breath). Having lice is common, does not mean you or your house is dirty and, happens to the best of us (breath).

My Mother’s Day 2008 ended up with a very clean house, 3 slightly traumatized children and 1 exhausted mother. Next time we have lice, and there will likely be a next time, I hope to be able to breathe my way through a more rational response!

So, this week when yet again I was reading and snuggling the very same child and looked below to see…could it really be? Nits? I was able to indeed breathe, relax and not go so overboard. She and I both survived relatively unstressed which made me realize that I too learned in the process of interpreting information for my patients. Glad to know that the deep, subconscious part of my brain that reacts in horror to the idea of bugs on my child was soothed by learning the facts. Education is indeed powerful.

It of course also helped that after a good shampooing the white stuff went away – proving the point that even the “professionals” mistake dandruff for lice!

Why blog re: art/health/parenting? Because Rothko makes my heart sing and mind feel calm.

Why blog about art, parenting and health? Well, I suppose, one blogs what knows. Better yet, one blogs what one is passionate about. Gee, the kids are an easy one but why the art-medicine combo? Here’s my take on that: art is good for our souls, our hearts and brains. Think of the calmness that runs through you when you look at a beautiful landscape, photograph or painting. Think of how you reflexively take a deep breath at the beginning of a beautiful piece of  music. Or how happy you feel when enjoying the artistry of a well presented meal (even better when enjoyed with some warm jazz playing in the background and good friends to laugh with). Beauty calms our souls. Not all art is beautiful; some art disturbs us and makes us think and question. This stretching of our minds also feels good in a deeply fulfilling way.

Happy minds, calm souls = health. The evidence for a mind-body connection is endless and strong. So, find your beauty, find art, be it painting, music or food, that makes your heart sing and stretch.

I have a favorite painter. Not one most people “get”. So, often those friends of mine that are subjected to chatter about art get to hear about Mark Rothko. Inevitably they are puzzled. Rothko is famous for painting large canvases covered with blurry-edged blocks of shimmering colors. They are often vibrant but, later in his life became dark. In the beginning of his career he painted more representational work; things that looked more or less like what they were. Then, as many painters do, he evolved his efforts towards abstract art. He became one of the leading figures in the New York “school” of Abstract Expressionism. In this evolution he had the expressed goal of guiding the viewer of his canvases towards an inner exploration. He intended to transcend their thoughts to a place of meditation of the most basic of human emotions. Famously, he commented that one who thought of his work simply as being studies in color had not seen

people break down and cry when confronted with my pictures shows that I can communicate those basic human emotions . . . The people who weep before my pictures are having the same religious experience I had when I painted them. And if you, as you say, are moved only by their color relationship, then you miss the point.

So, Mark Rothko’s work for me illustrates this connection between art and health. Viewing, listening, experiencing art as a path towards inner strength and calmness that in turn gives us increased health. A gift indeed, to give our children from a young age. And, a reason for writing about the mix of art, health and parenting.

Medicine and art. Art and medicine. A long paired combination but why?

Medicine and art. Art and medicine. A long paired combination but why? Indeed Medicine is termed an art and the influence of studying art on the developing skills of doctors is currently increasingly touted. I have been thinking about this combination and began to write out my thoughts but, while doing so found a beautiful piece to share. The Journal of the American Medical Association features works of art on the cover of every issue. The long-standing cover editor, M. Therese Southgate, MD had the words below to say about why JAMA has kept art so central to its mission. Her words at least in the consideration of the connection between visual art and medicine, are so complete and beautiful they seem to have gotten me out of having to write much more of a post today!

The question I have been most frequently asked during my years with the JAMA covers is: “Why art on the cover of a medical journal? What has medicine to do with art?”

Let’s look at what medicine and art have in common:

First, they share a common goal: to complete what nature has not.

Second, they have a common substrate, the physical, visible world of matter.

More significant, however, are the similar qualities of mind, body, and spirit demanded of the practitioners of each, painter and physician.

Chief among them is an eye: the ability not only to observe, but to observe keenly — to ferret out the tiny detail from the jumble of facts, lines, colors — the tiny detail that unlocks a painting or a patient’s predicament.

Observation demands attention, and this is the key to both art and medicine. Attention is nothing more than a state of receptiveness toward its object, the artist to nature, the viewer to the work of art, the physician to the patient. It is no accident, I believe, that clinicians — or treating physicians, as they are often called — are referred to as “attending physicians.” “Attention” and “attend” are both derived from the same Latin root meaning “to stretch toward.”

Many more “affinities” exist between medicine and the visual arts, but I will close with just one: Medicine is itself an art. It is an art of doing, and if that is so, it must employ the finest tools available — not just the finest in science and technology, but the finest in the knowledge, skills, and character of the physician. Truly, medicine, like art, is a calling.

And so I return to the question I asked at the beginning. What has medicine to do with art?

I answer: Everything.

That’s my opinion. I am Dr. Therese Southgate, Senior Contributing Editor of JAMA.


A Mom First (subtitled: up all night with vomiting 11 y/o)

In the office I am often reassuring parents that there is nothing unusual happening when their kids seem to be “sick all the time”. Primarily they are getting upper respiratory tract infections (URIs)  which are called “common colds”. These are called common for a reason – the AAP  states that children have 8-10 colds in their first two years of life; I usually explain that parents should expect that  their school-aged kids will have 6-10 infections in any given year.  This time of year there is more floating around that the common cold; there are also lot of vomiting and diarrheal illnesses. Of course our little monsters share all these germs making it hard for a household of kids and adults to stay well.

So in new-blog-post #2 I am here to tell you that,  sister, I am right there with you. I fell asleep last night dreaming up another sort of post…it was a lovely one about Alexander Calder and happy art. However, after a night of caring for the third vomiting child in 2 weeks I have changed my mind. I too am left wondering “what the heck”? Since late August (when school started) I am certain there have been no more than a handful of days when all of the 5 of us have been healthy. Colds followed by sinus infections and new colds. Now vomiting mixed with cold after cold. Why is it so hard to stay well? Rationally the doctor in me knows why. Cold viruses are primarily shared by person-to-person contact with contaminated secretions. Meaning that little monster #1 wipes their runny nose and touched the doorknob, the refrigerator, the Lego, the pencil etc and then Monster #2 (or sweet innocent mom) follows behind and touches the same surface. To inoculate themselves they then absent mindedly touch their own nose/eye/mouth. And presto…in 2-3 days a new cold is born. Similar scenario with the throw-ups but with the added bonus that in that case monster #1 may not even be sick but can be shedding virus everywhere they go. Of course, hand-washing helps but – even the fastidious amongst us forget at times.

Okay, back to the real world…laundry load #5 needs to be put in the dryer. See? I’m right here with you!