Physicians, Burnout and Rust

When asked last week to write an article about physician burnout I had to laugh. Really, laughter was the only choice. After all, laughter is indeed good medicine. You see, lately I have been feeling an increased affinity for the 38% percent of practicing physicians reported to be burnt out, according to the most recent issue of the Archives of Internal Medicine.

A sad number isn’t it? Burnout is a syndrome described by a triad of emotional exhaustion, detachment or cynicism,  and a low sense of accomplishment. The authors, Shanafelt, et al. used the gold standard Maslach Burnout Inventory to assess burnout in over 7000 American doctors.  Try these numbers on for size:

  • 46% of all physicians reported at least 1 symptom of burnout
  • 37% felt their work schedule did not leave  enough time for personal or family life
  • 38% of US physicians had high emotional exhaustion, 30% had high depersonalization, and 12% had a low sense of personal accomplishment.

All of this brings me back to a conversation I had a few years back. I was out of residency and had been working for Kaiser for some time. Long enough for the penny to seem a bit less shiny. I was enjoying a glass of wine with friends around my old backyard table. One of them, a pilot and I started talking about work. Our careers, which we had long dreamed of having, and for which we had worked incredibly hard, were in ways somehow lacking.  As cool as being a doctor or a pilot sounds when one dreams it up, in the end what you have is a job that has long hours, enormous stress and may not fully pay your bills. Too cynical? Maybe.

As I read about physician burnout for this article, it occurred to me that perhaps we were making too much of ourselves. The Pub Med search entry “physician burnout” yields no less than 1,233 articles. Are we really that much worse off than the rest of the population? Well, yes we are. The Shanafelt study compares our rate of burnout to that of population-matched controls and  suggests that

the experience of burnout among physicians
does not simply mirror larger societal trends.

And, burnout in physicians has disturbing consequences. This study also measured the rates of depression and suicidal ideation amongst doctors, both found at alarming levels. Emotionally detached doctors are less likely to be empathetic and more likely to make errors. They are more likely to leave the profession altogether.

I met with my financial planner yesterday for a regular review. We talked about this issue of burnout for a while. I learned that he has been concerned by the increasing numbers of physicians sitting before him to ask how they can afford to get out of the field. Pauline Chen in this week’s NY Times writes that this trend

has serious repercussions in a system already facing a severe doctor shortage as it attempts to expand coverage to 30 million or more currently uninsured Americans.

So what do we do about this? I read a good dozen articles on burnout. Each offered a similar list of platitudinous suggestions for the suffering colleague. Exercise more. Spend more time with loved ones. Consider a change. Set limits at work. Only this recent article by Shanafelt et al. delves into a discussion about the need for evidenced based recommendations and system-wide change.

Most of the available literature focuses on
individual interventions centered on stress reduction
training rather than organizational interventions designed to address the system factors that result in high burnout rates…Given the evidence that burnout
may adversely affect quality of care and negatively affect physician health, additional research is needed to identify personal, organizational, and societal interventions to address this problem.

As to my own fight against the  burnout triad (loss of enthusiasm for work, cynicism and a low sense of personal accomplishment), I am on most days winning. I do find that the best approach is humor. My patients make me smile. I find enjoying the bond with my patients and their families can get me through even the hardest days. I do not tend to be cynical by nature so when this mood hits me it can truly seem comical – as if I am doing a bad imitation of a cranky doctor. To maintain a sense of pride in my work I try to continue to challenge myself by aggressively reading about any new patient diagnosis or diagnostic dilemma. Outside work, by taking on jobs that challenge me in new ways like writing, bike repair and learning German. I do this to avoid the apparent alternative to burnout presented first by President Millard Fillmore and later, Neil Young: rust.

And, when I have a vacation I work hard to follow the Dalai Lama’s teaching:

In dealing with those who are undergoing great suffering, if you feel “burnout” setting in, if you feel demoralized and exhausted, it is best, for the sake of everyone, to withdraw and restore yourself. The point is to have a long-term perspective.

Vacations do not involve using the electronic medical record, email, Twitter or my cell phone. But these steps are only stop-gap measures while I and nearly half of the physicians in this country await more research and, perhaps more importantly, system-wide changes.

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Reunions and Poetry

Sometimes I find my self paralyzed here before the keyboard. I am paused by concern that my thoughts are mundane or trite; that anything I say will have been said before. And better. Ah well,  sometimes that which has been said before is worth saying again. And perhaps, again.

I went to my 30th high school reunion recently. I was ambivalent about attending; my life now seems so remote from those days of the past. I am here, they are there. I am not who I thought I would be. I have family, friends, career…an identity that seems to have little to do with then. There were though, reasons to go, places to revisit, people to embrace, relationships to nurture. So off I went.

I was moved and surprised. Sure, it was fun. Unexpectedly, stay up-til-3AM-two-nights-in-a-row kind of fun. Sure, there were people who I was surprised by. I found more people than not unchanged; we slipped back into easy conversation. It was as much fun to watch who looked the same as they always had as it was to see who had satisfyingly evolved (not sure where I fell exactly). Sure, it was interesting to see what had come of old flames.

The real magic though was not so simple to explain. I have since, been coming here to this keyboard to write, only to pull away, in a struggle to explain something different. I found my voice through remembering the words of Elizabeth Barret Browning quoted by a classmate as she warmly led us in a remembrance for the too many that we have lost:

What I do and what I dream include thee, as the wine
Must taste of its own grapes.

The people we knew in our youth, the people of our growing years shaped us. They have defined us in ways hard to account for. I was embraced by a warm air of recognition, understanding and support by those many faces from the past. We all move forward into our lives and, the people we become? They are in large part shaped by our relationships of the past. I found this especially poignant and reassuring. I have next to no family of my own left; I have lost many. Yet I know well that they are with me, they are in me. Even so, I was surprised to see how strongly even small acquaintances of the past were a part of who I am today.

As we re-encountered each other we asked and, answered over again, the same set of questions. Where do you live? What do you do? Married? Divorced? So sorry. Children? These were our descriptors used to define us. But just as easily, the questions to define us upon meeting could be: Where were you from? Who was your first kiss? Who taught you art? What were the trees like there in the summer? Which friends motivated you? Who do you love still? What did your high school look like? Who still intimidates you? Who do you miss?

What I do and what I dream include thee, as the wine
Must taste of its own grapes.

Indeed. I am shaped by my past. I taste it.

Manifestos For Art

A friend of mine sent me this yesterday. He had read a print version of my post Art for the 99% and immediately knew what I was saying had been said by others before me. And well. And in the year 1984!

Manifestos written to present the intersection of art and politics are not new; the list of them is long. I especially enjoy Claus Oldenberg’s

“I am for an art that is political-erotical-mystical, that does something other than sit on its ass in a museum.
I am for an art that grows up not knowing it is art at all, an art given the chance of having a staring point of zero… “

Then there is the Stuckist Manifesto which ends, confusingly in this way:

Stuckism embraces all that it denounces. We only denounce that which stops at the starting point — Stuckism starts at the stopping point!

The Stuckists define themselves as being anti-anti-art or against anti-art and for art. Huh? Simpler to understand is what my friend sent me. Enjoy!

How to Resist Chocolate (or, using art for appetite control)

Yesterday my chickens again woke me up too early; they seem hell-bent on making me into a morning person. And grudgingly, I will admit I enjoyed the chance to have my coffee and catch up on my reading alone. I picked up the latest issues of Nutrition Action Newsletter and Bon Appétit. What I found to read was too fun to not share.

Apparently some researchers in Zurich (Appetite 58:1109) are looking into the effect of subtle food related cues around us as we eat. What things in the space around us cause us eat more or less? Well, right up my alley, these wise Swiss researchers examined the effect of different works of art on one’s appetite for what else? Chocolate. If the study subjects were given free access to those fabulous Swiss chocolates while in a room where a screen portrayed images of skinny Giacometti sculptures they ate less than if the screen portrayed Rothkos. How cool!

In the same magazine, there was an article discussing the need for people to eat fewer calories per day after age 50 in order to maintain the same weight. Depressingly, as we age our metabolism slows no matter how much hard exercise we get each day. Now putting the two articles together in my mind made for some fun. What works of art should I put over my kitchen table? The Giacomettis might send the wrong message to my soon to be a teenaged daughter. The Rothkos are too expensive (one sold earlier this month at Christies for nearly 87 million). What else then? Carravagio’s David with the Head of Goliath could slow even my 16-year-old son’s appetite and might help decrease the food bill a bit. What would our appetites do under a Bruce Nauman neon sculpture? The Wedding Feast of Cana by Veronese might upstage my cooking (this enormous painting is most notable in my mind for thoroughly upstaging the Mona Lisa at the Louvre, if you are ever able, go to the Louvre, stand in front of the Mona Lisa with the crowd then, turn around and look at this magnificent piece to see what I mean). We might eat more fruit under a Cezanne. More soup under a Warhol? Would I hang a Rubens to warn my subconsciousness of the consequences of eating those chocolates? No, more likely when redecorating my kitchen I would just throw wisdom about calorie restriction to the wind, let my sweet tooth take over and happily hang a Thiebaud.

After daydreaming in this way with my cup of coffee growing cool, I opened the Bon Appétit. It featured a yummy looking recipe for Roast Chickens with Pistachio Salsa, Peppers, and Corn. I may not be able to afford the Rothko but… I know where to get the chickens. Cheep.

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Happiness, Tesselations and Tangled Hair (or, it is truly all in how you look at it)

Some art is beautiful and moving. Some art just makes me think. The dutch graphic artist M.C. Escher’s intricate woodcuts and lithographs are examples of the kind of academic, exacting art that moves me little but inspires me lots. His works

feature impossible constructions, explorations of infinity, architecture, and tessellations.

They are studies of perspective. His work Relativity shows figures walking up stairs that are upside down and others walking down stairs who should be falling off into space. Our minds struggle to adjust. It is truly all in how you look at it.

I was out with a friend Tuesday night and got a frantic string of texts from my daughter. Here is the transcription:

Hi Mom, I got a comb stuck in my hair….WHAT DO I DO?

MOM?

HELP!!!!!!!?

See Mom:

Oh my. As I gave her my advice of using a bucket of conditioner and slowly trying to work the hair free, I could hear her brothers in the background. They were apparently “helping”. I then had to ask

Honey, are you crying or laughing?

The answer is a study in perspective that shows like Escher’s works, that life is often all in how you look at things. Ensnared and frantic though she was, her whole-hearted response was: “I’m laughing Mom. This is hilarious!”

This ability to see the stairs as right-side up and rising is such a gift! She has the ability to use perspective to her advantage. Currently this very skill is being widely studied and often touted as the key to happiness. As happiness has become a subject of study (an Amazon search of books on happiness yields no less than 24,170 results) we are collectively being told to adjust our thinking in order to be more content. In her book The Happiness Project, Gretchen Rubin repeatedly finds that if she acts the way she wants to feel, she feels the way she wanted to – be it happier or more energetic. She cites studies that show making yourself smile can boost your mood. In a recent lecture by Dr. David Sobel he advised us to pursue happiness. He pointed out that

stress is produced by the stories we tell ourselves … optimists who tell themselves more positive, empowering stories tend to be healthier, live longer and enjoy life more.

Ah indeed, the old “cup is half full” advice. Or the stairs are right side up. Or the tangled hair is funny. I find myself (though more naturally a the-cup-is-half-full-AND-half-empty kid of person) – inspired.

©

P.s.: My daughter’s story and picture were published with her permission. As fits her positive perspective, she thought being blogged about would be a hoot!

Son, Eating Your Beets Will Make You Run Faster

I heard once some time ago that my influence over my kids’ final outcome ended when they turned five. That by age five they had soaked up all the manners, values and habits they ever would from me. I have thought about this snippet of trivia often. Is my role as family educator done? Did I squeeze enough knowledge into them before they left for kindergarten? Now, on the occasion of my first child’s sixteenth birthday I find myself again 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. Check, and room to grow. He has commonsense. Um, not always as 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. But this point 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 wholegrain bread all…moldy. That was IT. 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 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. Hers 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 it’s 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 recent article about how eating beets before running can make you run significantly faster he’ll change his mind? ©

Fun with Spring Fevers and March Madness

Last year I wrote about Why February is Hard for Pediatricians. I think, today it is time for Why March is Fun for Pediatricians. Why? The air is warmer, the flowers are bursting forth, I put my veggie garden in…the fava beans are getting tall. Spring is indeed here. But these aren’t my answers.

In medical school we were all faced with the challenge of choosing our specialty. Some of us knew from the beginning, some struggled with the decision. For me there was never any choice but Pediatrics. My reasons were a mix of meaningful and perhaps less so. Besides finding a field of medicine that is interesting and exciting, to choose well you also have to consider what social issue you are willing to confront. I found it much easier to help people parent than to help the same people confront their smoking and drinking habits.  I would rather be a child advocate than work to repair years of self-inflicted health damage.  The less weighty reasons for choosing Pediatrics? Easy: kids smell better. And, they make me laugh.

So in this month of spring fever and madness it seems that the sillies have come out in my patients! Enjoying their antics has made me very happy with the choice I made!

  • Last Tuesday one of my patients didn’t say much to me, didn’t answer my questions and drooled constantly; she spent our entire time together sucking on her toe.
  • As one little 5 y/o left I said to him “Bye, handsome!” He turned to his dad and said “see Dad, all the girls think I’m handsome!”
  • I had a well child check up with a 6 month old who giggled so incessantly every time I touched him that his parents and I started laughing with him; we laughed so hard we all had tears and I had to sit on my stool and take a break before I could focus on his exam again.
  • Yesterday, one of my patients was too busy to let me examine her. she had taken out my entire herd of plastic dinos and a book on dinos and was matching the plastic ones to the paper ones page by page. It took a while.
  • One father was irritated at his son who refused to let me look in his ears. The blackboard needed erasing…every single tiny bit of chalk needed to go. It was a slow process so, I gave up and got down on the floor to erase with him. When we were done we stayed there to deal with the ears.

What adult medicine doctor has this much fun with their patients? Then, there were some other kids….

  • One girl on Thursday decked me full-fisted in the nose when I tried to look in her ears.
  • Last week when I opened a boy’s diaper to examine him he looked me straight in the eye, smiled and peed full-stream ahead all over me.

Oh well, at least they smelled good?

A Can of Beans

http://www.tate.org.uk/home/copyright.htm
Black Bean 1968 Andy Warhol

Something difficult has unfolded around here lately and when news got out a dear friend came by with a gift of a story. She told us about a day years ago when one neighbor heard the other had breast cancer. The well neighbor was shocked and saddened. She was at a loss and wanted to help; wanted to do something but, what? In a daze but motivated none the less, she grabbed a can of beans from her cupboard (perhaps we should imagine she was reaching for the chocolates?) and headed to her friend’s house. She rang the bell and as the door opened she felt suddenly a bit silly but, with a warm embrace she greeted her friend and said “I have brought you something.”

When those around us are suffering, when the news is bad, we often feel at a loss for words.  Or worry we will say the wrong things. And, all too often we do. I sat by the fire Sunday night talking about what people say and do in these moments. Some feel compelled to tell you their story.  When my brother-in-law committed suicide a few years back his brother had to endure story after story of other similar deaths. How painful for him to have to stand there suddenly supporting rather than being supported! Or, people would say how horrible it was that his brother had done this to him. Rather than lamenting how much pain his brother must have had to quietly suffer before death! When I shared my recent news with an acquaintance  she blurted out a question that was so absurd as to deserve my favorite of all snap comebacks: “Oh my! You actually said that out loud! You must be so embarrassed.” I of course did not think that fast and simply answered the hurtful question. Another friend of mine recently lost both of her beloved grandparents in the same month. She received many comments about how they had lived a long life implying perhaps that it was okay that they had died. Instead for her, the loss was stark and biting – not easier somehow because she had lived all these years with their love.

These examples brought me to think of an article I read last summer. In “You Look Great and Other Lies” Bruce Feiler writes well of “Six Things You Should Never Say to a Friend (or Relative or Colleague) Who’s Sick. And Four Things You Can Always Say..” It is absolutely worth a read. The tip that most sticks in my mind (perhaps because it seemed such a natural thing to say) is that it is hurtful to hear “You Look Great!” As if it is all about looks?

In the spirit of Mr. Feiler’s article and in the spirit of knowing that all of us mean well and want to say the right words let me add a few tips:

  • Learn to be comfortable with a moment of silence. As a physician and as a person who likes to gab I have had to cultivate this skill. When confronting uncomfortable topics many of us have a tendency to start talking – immediately and fast. Instead, pause, breathe and count to ten. While you do, you can gather your thoughts and the person you are with may have a chance to tell you more.
  • Simplicity is best. The briefest responses are often the most powerful. Try “My heart goes out to you” or “I love you and wish you did not have to face this.” Best yet for me was “I have faith in you.”

And, don’t forget Feiler’s tip: don’t ask “How can I help?” There are few people who want to ask for help and in a crisis, few who know what help they need. Instead – just figure out how to help on your own. Bring dinner. Call on your way to the grocery store to ask for their shopping list. Send a note. Or, if all else fails you… bring a can of beans. Your support will be priceless.

Art For the 99%

A recent Sunday  N.Y. Times article “Show of Hands Please, Who Can Buy Art?” described the current art auction season in Manhattan where

despite trouble outside, life in the art bubble remained effervescent.

In part it asked the reader to consider the contrast between the extreme wealth of those actually buying art and the other 99% of our country. A stark contrast indeed; one that raises the question of who art is meant to be for?

The rising prominence of street art speaks to this question. Through time art has been largely subsidized by the wealthy. Caravaggio and Rembrandt both had their patrons. Ed Ruscha (whose Strange Catch For a Fresh Water Fish sold this fall in auction for $3.8 million) has had numerous commissions from wealthy supporters for paintings, t-shirt series and even a painted private jet. Art generated by wealthy grants can remain cloistered in the world of the rich or upper middle class but, surely art itself is the great leveler? Created from the passion and drive of an individual and meant to move the soul of everyman.

We have watched graffiti with increasing acceptance as it has evolved from simple, defacing tagging to being in some magical cases, art. I find graffiti sprayed on trains often forms just such magic. The pairing of this art form (meant to be temporary and fleeting) painted on trains that move through time and space with their roving art exhibits can often be quite spectacular!

Now there are increasingly other forms of art to be found on the streets. This is termed post-graffiti or street art and is separate from the potentially vandalizing nature of graffiti or corporate-sponsored works. The art itself ranges far from aerosol paints to mosaics, ceramics, stickers and yarn.The works are fun, startling and sneaky; you may see a window painted into a wall, a tree with a crocheted trunk and branches or, a ceramic man rising, seemingly formed out of a mud puddle. “Yarn bombing” in particular seems to be urging us to take life less seriously; to smile as we walk by. Some works make us think; one wheat paste applied poster proclaimed “Let’s fall in love like both our parent’s aren’t divorced” asks us to consider the effect of our family story on our current loves.

Protestors far and wide are occupying in an attempt to question the increasingly unequal financial conditions of this time. The artists of our world, ever a forward-thinking lot, have been quietly occupying our streets for years. Their work reaches beyond the grasp of those in the rich art bubble and straight to the heart and minds of those of us in the other 99%.  Enjoy!

Falling Back and Cleaning Desks

I have been feeling a wee bit overloaded these days. Overloaded in the happy-all-these-cool-opportunities are on my plate kind of way. But, also overloaded in the I-can’t-find-the-time-to-get-the-little-stuff-done kind of way. I am certain all of you know this feeling . My desk is more disheveled than I like. The winter garden (think fava beans) is not completely in. My pile of laundry needing to be folded is reaching epic proportions.

So on Sunday morning I woke up early to try to get a head start on my day. Maybe I was inspired by my European friend for whom daylight savings time started last week. He thought it was some how an inconvenience. I suffered pangs of jealousy.

Spring forward, fall back….

For me that falling backwards has been a mixed experience. In medical school and residency it was really quite the drag. At 2400 instead of being done with that calendar day of call, we had to start the hour over again. As a parent I am quite fond of gaining that extra hour of time. Now it represents a quiet house; an hour of uninterrupted catching up on the small stuff.

This Sunday I created my own falling back by getting up early and used the time to paint a really grubby bathroom. Ceiling done, wall edged, I was starting on the trim – happily painting away and listening to an NPR podcast on my iPod. I was also thinking about how great it was that to have this small piece of time and how nice fall daylight savings is. Maybe in a utopian world we could have a Parent Savings Day when all the children of the world slept for 24 hours while we parents got caught up. Then my reverie was broken by a sound outside the door and I opened it a crack. There was my lovely middle child with a huge happy-to-see me grin. I was deep into  my falling back and getting it done zone and all I could think was “Seriously?” Apparently I said it also.Oops.  #notgreatparentingmoments

p.s. : That podcast I was listening to was a collection of interviews called Desktop Diary reporting on

going into scientists or creative thinker’s workspaces and seeing how they work and what their desk looks like. The idea is that maybe some of the desks can tell us a little bit about the person.

It included the rather irritating desk of physicist Brian Greene who seems to think one thinks better with a clean desk. Hmmph. Now I need another early Sunday. Or, maybe I’ll emulate another physicist, Michio Kaku who said:

it’s pointless to have a nice clean desk, because it means you’re not doing anything.

Now, that’s more like it.

Bobbleheads, Packaging and Wise Career Choices

Sometimes life presents you with unexpected learning opportunities doesn’t it?

Last Thursday I went with my 12 daughter to see k.d. lang in concert. She needed to write a report for her band class on observations made while seeing a live music performance. We looked around for a local show and stumbled across the listing for k.d. lang’s show. It seemed perfect to me – my daughter could get her report done and I could enjoy some good music.

My daughter’s report had to list the instruments played, comment on sets and costumes.  Critique the music itself. She had to watch the mannerisms of the musicians (apparently some of the trumpet players in band move like bobble heads with each breath).

I hoped that there would be another lesson presented to her that night. A lesson of acceptance. In a review of k.d. lang’s singing, The Times of London declared:

It’s a quirk of the music industry that one of the sexiest, most sensual voices in all of pop music comes not from some raven-tressed siren in a glitter-dress but a middle-aged woman with a utility haircut and a penchant for male tailoring.

Exactly. I wanted my daughter to see that talent and success, wisdom and sexuality present themselves in all kinds of packages. Each worthy of her attention. I felt vaguely guilty for “using” k.d.’s concert as a teaching moment  rather than just an opportunity to listen to fabulous music but – so be it, off we went.

Turns out there was a better lesson waiting for us that night. As I watched k.d. on stage it struck me that although she gives this very same performance night after night it has not grown dull for her. Her songs soar, her feet skip and she smiles. A smile described in the NY Times as being the size of Montana, forms an invitation for us to join in the fun.

The next morning at work I was reminded that my job as pediatrician has some of the same fun worked into the routine. One 9 month old smiled so continuously and contagiously at me that I had to apologize to his mother for my own grin. An autistic boy with an uncontrollable fit of ticklish giggling while I was examining his belly made me give in to the giggles with him. How lucky k.d. and I are! And, what better lesson than showing my daughter that one’s work should feel at least in part, fun?

Lessons learned? Don’t be a bobble head.  Impressive people come in many packages. And careers should be fun. Choose well dear girl!

Two Patients: Trusting Intuition in Medicine and Life

Sick or not sick? This is the snap judgment all physicians make in the second they first view a patient. This is what they ask as they open the exam room door or pull back the curtain around the gurney. “Is this patient in front of me sick (in a way that means I need to act now to save their life) or not sick (ill but, someone I can patch up in some way and send home)?” Much of residency training is aimed at making sure young doctors leave with this skill finely honed. But, is it a skill or an innate talent that is hard to teach?

At the end of a recent clinic day I had just two patients left. I walked into the first room and inwardly groaned. This one was sick. However after hearing the history I started second guessing myself; it all sounded very reassuring. And, as we are also taught in medical school – the history is 90% of the diagnosis. Maybe I could treat and send this one home for the night? However, I had a gut sense, a hunch, that home was the wrong place for this child. That snap decision of sick won me over and I was right. The child was sick.

The next exam room held a child who I immediately felt was fine; not sick. But, the more I listened to their story the more I worried. There was some real potential for hidden danger. Then I was left wondering – how much of a workup should be done on this well-appearing child? Since the history had given me cause for worry, labs and a CT were done to prove that this child was indeed, not sick.

Later I commented to a friend on this sick vs. not sick judgment we make. He pointed out to me that likely this is based less in instinct and more in hard facts that are processed by our minds before we notice the processing. He felt that in a blink of an eye, on a subconscious level, I connected the dots I observed:  reassuring history or not this patient was sick!

Perhaps but, I have met well-trained, intelligent doctors who struggle with this talent of intuition. In medicine the hard facts are obviously of tantamount importance but, our instincts need to complement our intelligence. Malcolm Gladwell wrote in his book Blink: The Power of Thinking Without Thinking:

 The key to good decision making is not knowledge. It is understanding. We are swimming in the former. We are desperately lacking in the latter.

Another friend of mine is in the process of making a life-changing decision. His sister challenged him by asking how he could make such a choice with barely any evidence of it being right? He explained that it felt right, that his gut told him it was right, that to make this choice made him feel like he was returning to home. Gladwell might say to his sister that:

our world requires that decisions be sourced and footnoted, and if we say how we feel, we must also be prepared to elaborate on why we feel that way…We need to respect the fact that it is possible to know without knowing why we know and accept that – sometimes – we’re better off that way.

In his 2005 commencement address at Stanford, Steve Jobs spoke in large part about trusting one’s intuition both in career and in love.

you can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future. You have to trust in something — your gut, destiny, life, karma, whatever.

I wonder what Jobs would make of this concept of the balance of science and intuition that physicians face with every patient?  In our personal lives it is clear he felt trusting our gut was the way to go. He left those Stanford graduates with wise words:

have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

 

Sublime and Surreal; A Birthday Vocabulary Lesson.

I walked to my car a few nights ago on my birthday and was stopped in my tracks by something in the atmosphere there on the street. It was twilight; the sky an electric blue and the trees and houses nearly black silhouettes against the sky. The street light stood as a golden guardian. The only sound out there in those few moments was a rustling of the leaves in those dark trees caused by a gentle breeze.

It was distinctly dreamlike. Surreal even. It was exactly as if I were standing in Magritte’s painting The Empire of Light II.

Earlier in the day I had been hiking on the bluffs over the ocean with two friends. At one point along the trail we paused. They were chatting, I was breathing. I looked up to see the most fabulous sky. There is no other way to put it but to say it was “sky blue”. That bright light blue that can be bought in a tube. There were fluffy clouds in cartoon-character shapes floating by. Standing there I again felt I could  have been standing in a painting: Magritte’s The False Mirror. It transformed my hike into a sublime experience.

These moments began a vocabulary lesson at dinner last night.

Surreal:

marked by the intense irrational reality of a dream

Sublime:

of such excellence, grandeur, or beauty as to inspire great admiration or awe

The rest of my birthday weekend continued the theme. A spa massage: sublime. Practicing the massage techniques I had “learned” on my 10 year old and savoring the feel of his strong little body: sublime. Apricot almond birthday cake: sublime. Fighting an hour-long, block-wide nerf war, girls against boys, with my kids and their friends: surreal.

Yes, having the ultra-pacifist mom shoot her kids repeatedly aiming to “kill” was indeed surreal. But, it was also such a sublimely fun hour capping off an at times dreamlike weekend.

An Accident, an Artist and a Poster

Several years ago I was driving along the north coast of California. As I rounded a sharp, cliff-lined bend I came upon an accident scene. A girl in her early 20s had been riding her bike and was hit by a semi-truck. The truck was long gone but a gaggle of well-meaning good Samaritans was at the scene. I joined them reluctantly (not wanting to stall my journey and put my own kids at risk as they waited by the roadside). As I walked up and assessed the scene I hoped to see that all was well and that I could quietly leave. But that wasn’t to be, I was needed. When I saw this I told the small group that I was a doctor and remember now the relief this brought to all of them. Imagine their fear, there on the coast with this wounded girl and help a long time coming.

The girl ultimately did well and, is not the point of this story. Instead her accident formed for me the basis of a happy accident of acquaintance.

Every year on Labor Day weekend my family travels that same coast road and in the town we stay in is a yearly art show. The year after the accident I was touring the show, which is held in multiple studios, homes and galleries. As I walked into the seaside home of one painter I was surprised to be greeted by her with a gushing of enthusiastic greetings and thanks. She had been there at the scene of the accident the previous year,  and remembered me. From this serendipitous meeting has come a nice acquaintance based on yearly trips to see her and her art.

This year on the usual day that I tour the show, I was tired and feeling a bit more introverted than usual. I was tempted to walk by her house and out to the beach to sit alone. Instead, I talked myself into heading in and by doing so, reaped the benefits of making the effort. Her art is astoundingly beautiful. Her plein air paintings have evolved to be increasingly and delightfully abstract. They show planes of space defined by thickly laid paint and a powerful use of color. For me they are as if Rothko has come back with a palette knife to paint landscapes. She and I enjoyed a long conversation about art started off by my asking who she is most influenced by. We looked at books of hers and discussed style, color and method.

Our conversation brought to mind a word that has come to mind several times lately: process.  In the sense of it being:

a natural phenomenon marked by gradual changes that lead toward a particular result – the process of growth

One of the paintings my friend showed me connects to this sense of appreciating process. It was by Paul Wonner, depicting two men sitting together. There is great feeling in the abstract strokes of color that blurs their faces but, leaves feeling intact. Perfect in a way. And yet, Wonner chose to leave obvious drips of paint across the canvas, even on one man’s face. Obvious imperfections decisively left. Why?

Process used in a psychological sense can mean taking the time to work towards becoming a better version of our selves. To generate this evolution though one needs enough self-reflection to be able to say “Look! This is how I did it – this is how I changed!” In viewing Paul Wonner’s painting of the two men it seems the drips were left as an indication of his process. They are leading us to see the gestures, the spaces, the feeling. He is saying “Look! This is how I did it – see my broad brush strokes, see my drips?” He was perhaps, asking us to look at how his beautiful painting evolved. He may have been asking us to see that the drips on his painting are part of the process that generated the emotional meaning held in its planes.

I saw a poster on a city street this week that said:

“art is not a moment; it is a process”

Indeed. Art like life, is best when it involves a process of evolution and observation.

Nutritional Soundbite #2: You Serve, They Choose.

One day when I was a resident in Pediatrics I was assigned to work in the gastroenterology clinic. There were not many children to be seen that day.  As I waited for a small person with a stomach issue to arrive I picked a book off the shelf and started reading. It was small, had a friendly cover and looked approachable. Indeed, it was a gem. I passed my time that morning reading and the words I soaked up then have stuck with me as I have mothered my three and as I have talked with scores of parents through the years.

The words from this book by childhood nutrition guru Ellyn Satter form the basis of Soundbite #2.

There is an important division of labor in feeding children. Their adults should choose what food they are served. The children choose what to eat and how much. At times parents find it very hard to trust in nature: children are built for success, if trusted they will eat the right amount of food for their bodies. Only the child knows when she is hungry.

Your child will get hungry, eat, get filled up, and stop eating (even in the middle of a bowl of ice cream). Whether your child needs a lot or a little, she instinctively eats as much as she needs. If you follow the division of responsibility with feeding she will automatically eat the right amount of food to grow and be as active as is right for her.

However, if we as parents interfere with this natural rhythm we risk raising children who are either too heavy or too thin for what nature intended. Imagine how confusing it may be to a young child when on one hand her brain knows they are not hungry but their parent is telling them to eat more! Repeat this enough times and the child no longer listens to her body but eats beyond hunger and fills with unneeded calories.

So, fill her plate with good choices. You are obviously not offering soda, chips and sugary cereal all day long. Instead lay out fruits, veggies, cheese, yogurt, milk and whole grains. Then sit back, relax, and trust your very smart child. ©

What I Learned From a Patient Yesterday and a Tree Today

As an addendum to my post: Why Make Art? A New Answer Arises, Stitch by Stitch, I want to let you in on what the crocheted tree made me think about.

First though, I need to start with a really cute three year-old. She came to see me yesterday with her mom and big brother. He was actually the patient, in for an earache or rash or… something. But when I opened the exam room door his sister completely stole the show. She had big blond bouncy ringlets, gorgeous blue eyes and a great smile. She was very proud of herself, and for good reason! She had chosen absolutely the most stunning (blindingly?) outfit I have seen in a month. It was a great sundress with polkadots and flowers in one color palette and twisty hair ribbons in another. The shoes, obviously, were pink. Her ensemble made me smile and it made us both happy.

What we wear has power. We’ve discussed this concept often in my house. Several years ago we had a good friend whose teenage son chose to dress in goth (or emo) attire. Black everything, lots of piercings, unusual hair. My kids found him scary-looking.

I encouraged them to be open-minded and non-judgemental. After all, how you dress is nowhere near as important as how you act, right? If he avoided drugs and alcohol (check), if his grades were good (check), if he treated the people around him with respect (check) then, what did it matter what he wore?

But we decided around the dinner table that how we dress does matter. It can either open or close doors. Dressing in a way that closes figurative doors does not seem wise for a kid headed to college or to the workforce. An obvious point, or perhaps a bit of parental brainwashing on my part.

Another point came to mind today. How we dress also affects the feelings and mood of those around us. Dr. Brain Vartabedian makes this point in part, in his blog post Doctors with Purple Hair:

The argument is always the same: ‘I can be a good doctor with purple hair.’ Of course you can.  But this isn’t about you. …A career built on the privileged relationships shared with patients requires consideration of what will make them most comfortable.

In my closet today I surveyed the muted array of clothing colors with a certain sense of boredom. No happy polka dots and clashing ribbons for me. Sure, I could dress to make the parents of my young patients trust me. But where was the happy-inducing outfit? I stood there wondering why adults can’t dress more like three-year old children. Why couldn’t we dress like crocheted trees, decked out in cheerful stripes from head to toe? And in doing so make everyone around us a bit better off. Think of all the happiness that would follow us around through the day!

And, if I dressed as a tree at least my patients would approve. Maybe I need to go shopping. ©

Why Make Art? A New Answer Arises, Stitch by Stitch.

Art makes me think. It has happened before and it is happening now. Funny thing is that I am not just set to thinking by the big, important art but also by art that takes itself less seriously.  I am certain that Rodin’s The Thinker has never made me think. But Calder’s whimsical Performing Seal has.

There is art afoot, art about towns today that is making me smile. And yes, think. Is it Art? What is art? Why make art? A new answer arises: to make us smile again. Maybe at times that is all we really need from art.

Have fun looking and oh yes, definitely show your kids!

http://ht.ly/61VST  Scroll two down, click under the tree on more information to find “Yarn Bombing / Guerrilla Crochet – A Collection”.

Nutritional Soundbite #1: Make Snacks Count

Young children often need to snack frequently as they go through the day. They have small tummies and high energy needs. Big kids need lots of healthy food to keep up with their incredibly rapid growth through the teen years (you should see my 15 y/o athlete eat).  It may at times seem hard to get all the nutrients that are needed into your child! Many parents feel that it is a challenge to get their child to eat all of the recommended servings of fruits, veggies and whole grains.  You can use your child’s need to snack to help you meet his nutritional goals. In other words, make snacks count!

Ways to do this are to provide snacks that are healthy and fun. Make sure that snacks you offer are not junk or processed food but, good, simple, real food. Some examples include:

  • Celery sticks with a side of cream cheese and raisins – young kids can create “ants on a log” and eat them!
  • Apples and peanut butter-tofu dip (1/2 cup tofu, 1/2 cottage cheese, 3 TBS peanut butter, 1TBS honey, 1TSP vanilla – processed till smooth)
  • Tortilla chips and salsa
  • Dried fruit
  • Pretzels and small chunks of cheese – they can form building units by sticking the pretzels into the cheese before popping them in his mouth
  • Popcorn (preferably what you pop yourself in canola or other healthy oil or low-fat microwave popcorn).
  • Cut up fresh seasonal fruit
  • Carrots, snap peas, cucumbers and a little low-fat ranch dressing for dipping
  • Applesauce or yogurt (look for lower sugar versions, try greek yogurt for extra protein)
  • Smoothies made of yogurt, frozen bananas, a little orange juice and berries.
  • banana bread, zucchini bread or pumpkin muffins

Children love to help you in the kitchen – they also think it is fun to eat what they cook! So, you can use this willingness as a tool to help them get some healthy snacks in. For example, bake some pumpkin mini-muffins or zucchini bread (use 1/2 whole wheat flour, use canola oil and add some flax meal to up the nutritional worth) together and enjoy some together with a glass of skim milk. Try adding pureed white beans to your favorite cookie recipe to add protein and fiber.  Then if you have made a double batch, you can freeze some and stick them in his school lunches.

Using these baked treats as snack can help address the issue of forbidden foods. I discussed this in my post “Sugary Cereal, Cornchips and S’Mores or, Moderation in All Things” – if we occasionally allow our kids to eat foods we view as nutritionally unsound for regular intake then they crave them less. Research has shown that they in the end, eat less of these forbidden foods. So, if you occasionally greet them after school with a plate of chocolate chip cookies they will be better off for it. And who’s to know that the cookies are high fiber?

When you do let them watch TV use that as a good snacking opportunity. Hand your child a bowl filled with an assortment of fresh fruits and veggies. Try carrot pieces, strawberries, black olives, bell peppers and cucumbers. It is amazing how much  they will devour without even noticing!

One last word, while young kids do often need a snack, some days they don’t. Children do not grow as much some days as they do on other days – therefore their appetite changes. Your job is to offer the healthy snacks and his job is to decide if he is hungry enough to eat it. If not – it is okay, he will want some another day. Which perfectly introduces my nutritional soundbite #2 …

My Top 10 Nutritional Soundbites

  1. make snacks count
  2. you serve, they choose
  3. limit drinks that taste sweet
  4. don’t worry
  5. don’t be a short order chef
  6. go with their strong suits; average nutrition over a week or month
  7. talk with your kids about nutrition
  8. allow treats
  9. raise cooks
  10. family meals

What’s a parent to do? The news is so full of nutritional advice it can seem impossible to know where to begin an attempt to feed children well. Sugar is increasingly viewed as a dietary mistake. Fiber is fantastic for preventing constipation, irritable bowel syndrome and is linked to a reduction in colon cancer. Blueberries and walnuts have antioxidants, salmon and tuna have vitamin D and omega-3 fatty acids. Too much tuna has too much mercury. Too much cow’s milk can lead to iron-deficiency anemia. Too much soy milk is risky as well. How does a parent put all of this advice into action?

My patients’ parents often ask questions about nutrition. I offer them a collection of nutritional advice soundbites. Over the next few days I will share details of my top 10 of these soundbites. Please, comment and join in with yours!

Sugary Cereal, Cornchips and S’Mores or, Moderation in All Things

What’s a parent to do? The news is so full of nutritional advice it can seem impossible to know where to begin an attempt to feed children well. Sugar is increasingly viewed as dietary suicide. Fiber is fantastic for preventing constipation, irritable bowel syndrome and is linked to a reduction in colon cancer. Blueberries and walnuts have antioxidants, salmon and tuna have vitamin D and omega-3 fatty acids. Too much tuna has too much mercury. Too much cow’s milk can lead to iron-deficiency anemia. Too much soy milk is risky as well. How does a parent put all of this advice into action?

My patients’ parents often ask questions about nutrition. I offer them a collection of nutritional advice soundbites; the top ten of which may form my next blog posts. One bit of “wisdom” I have always put out there is this: “Make snacks count”. Snacks are a great chance to get in the foods we most want our kids to eat. As a mom of 15, 12 and 10 year old kids I certainly try to practice what I preach. Sometimes though, I fail. It struck me today as I watched the 12 year old gleefully eat her bowl of very sugary cereal complete with colored marshmallow bits,  that there is something about summer vacation that seems programmed to allow these failures.

My childhood summer vacations were spent on the beaches of Virginia, North and South Carolina, in the woods around my grandparents home on the Chesapeake bay and on a lake in the Blue Ridge Mountains. They were formed of long days of freedom, swimming, exploring and happiness. Sand and heat, mosquitoes, crabs and fireflies, lemonade and Fritos formed the texture of the days.

Fritos? Yes. Now looking back on those days I realize how much of my summertime memories center around foods enjoyed only then. Some of course were healthy summertime treats, some were not. S’mores, Fritos and the occasional bowl of sugary cereal were a wonderful break from the extremely healthy diet my mother usually fed me. Now I realize that I have programmed my own children to expect the same sort of nutritional holiday. Sugary cereal never enters my house and to their credit, the kids don’t ask for it either. They know though, that on vacation away from home they are allowed to get a box of the junkiest cereal their little hearts desire. It seems to me that this kind of holiday has a place in their lives.

I may have benefited from being allowed to lie in a sunny spot on a houseboat with my bowl of chips. How? It taught me moderation. As the Roman writer Petronius said:

moderation in all things, including moderation.

Perhaps if we allow our kids the occasional nutritional holiday they will crave the junk less regularly. Outright prohibition doesn’t seem to work well, for adults or for children.  Allowing junk food holidays at times provides us an opportunity to discuss why it is usually not allowed. Maybe they will appreciate it more. I do know for certain that as I sit here now I am certainly enjoying my bowl of Fritos.