Monday, April 29, 2013

I Love Being a Working Mom...I Think

Recently I happened upon this article, and it got me thinking.  I admire the author's dedication to her profession and her desire to make a change AND to instill that desire in her child.  Yet, it really didn't hit home with me, and not just because I will never be flown to the Netherlands to do a TED talk or any other sort of public speaking.  I feel like she missed the real-life, day-to-day reality of being a working mother and how awesome that can be. In fact, I think she missed the boat entirely.  I think her viewpoint is definitely doctor-centric, and I don't think it speaks to women in other lines of work.  Being a working mother, for me, has little to do with charging my child with social responsibility and is in no way connected to what I actually do for a living; it has everything to do with providing me with the balance that I need.  I suppose my outlook could be considered selfish, but I believe raising a healthy child starts with being a healthy parent.

As working parents, we miss out on some things.  Asher is one of two kids in his mommy-and-me class who attend with a nanny.  Lately, he has been singing a color song to the tune of "Twinkle, Twinkle Little Star", unbeknownst to me.  For days I thought he was just singing gibberish until Becca joined in the other afternoon.  Mostly I feel gut-wrenchingly awful about this.  It's hard enough knowing that your child spends most of his day with another person, but it's even worse when you have clear evidence that someone else understands your kid better than you do.  On top of that, I worry about judgment from the stay-at-home parents in Asher's classes.  I would love to meet his friends' moms, but I honestly worry about what they'll think of me, the absentee mother who lets a nanny do all the dirty work.  The secret of working moms that a lot of stay-at-home moms don't know is that we see them as a higher order of mother in some ways--part of us wishes that we could do that ourselves, but the reality is that we know that we couldn't be kid-focused all day long--and we're pretty sure they look down on us.

On the other hand, I know that I am a better parent because I'm not parenting every minute of every day.  At work, at least to a certain extent, the part of my brain that is fixated on scheduling and enforcing rules and, essentially, trying to create order out of chaos turns off.  I can focus.  I can think.  I can have adult conversations.  I get to learn about what's going on in the world around me.  These are things that only happen at naptime when I'm home, and I notice that when I go too long without turning off the parenting part of my brain, the caring, loving, fun mommy part of my brain starts checking out.  In order to be the emotionally connected parent I want to be, I need to not be a parent for a good part of the day.  I need to have the freedom to connect to other parts of myself.

That said, there is a fine line between working enough to stay in touch with those parts of my brain and working too much.  Earlier this year, my work schedule had changed so that I was working fewer days but those days were each unbearably busy.  I came home exhausted and checked-out.  It's a matter of finding a way to giving enough time to each part of me without any part taking over.  When I notice one part dominating at the expense of the others, I know it's time to change things.

 Being working parents certainly teaches our children a lot about the world and their role in it.  I like to think that, by seeing his mommy work as a physician and his daddy run a web development company, Asher will learn the value of hard work and not take what we have for granted, that he will learn how to work ethically and treat people (clients, patients, colleagues) with respect, and that by seeing what we do professionally and how it evolves with time, his mind will be opened opportunities that aren't necessarily the 9-to-5 cubicle grind.  More importantly, though, I expect that he will learn to take care of himself in a more holistic way.  He will see the struggles we have to keep a balance between work and family and the mindfulness it takes to realize when balance is lost.  He will also learn the importance of understanding and respecting his own needs.  He will understand that in order to care for others, he first must care for himself.

These are all lessons it has taken me years to learn, and I constantly have re-examine myself and adjust things accordingly.  The hardest and most important lesson is that no one can really "have it all" in the more traditional sense, and trying to do so just brings pain.  You must identify what's important to you and what you need to be happy, and then you must work to make those things a reality.  Then you will have it all, and so will your kids.  It really doesn't matter one bit what your employment status is.

Sunday, April 28, 2013

The Perfect Day

Spring is always so busy for us, and this year has been no exception.  Between trips across the country to visit family and birthday parties and holidays, it seems like there is something planned every weekend.  Add to that me being on call every six weekends or so, and there just isn't much time left.  I try to plan just one big thing every weekend so that we aren't totally frazzled.  This weekend I made an exception, and I am really glad I did.

As I mentioned in my last post, we have all been crazy busy.  Crockett has been stressed with work piling up, and he expressed a need for some time this weekend.  We had plans on Saturday to spend the evening with some close friends to celebrate the impending arrival of a new baby boy, and normally this would mean an unscheduled Sunday.  But because I knew Crockett needed quiet time, I decided that Asher and I would have the first "Mommy-Ashie Adventure Day" in a while and go to Gilroy Gardens, a toddler-oriented amusement park about an hour from our house.  We had heard great things about it and had bought a season pass sight-unseen when they went on sale at Costco, so I was anxious to go.  I had doubts this morning when Asher woke at 6:20 after a restless night, but I decided to throw caution to the wind, and at 9:30, we were off.

My grand plan involved a nap in the car on the way there, and that didn't happen until 5 minutes before we reached the parking lot, so I was pretty sure we were screwed.  I was going to just wait it out, but it was 10:30 and sunny and getting rather hot, so I took a reckless course once again and decided that if Asher needed to sleep, he could do it in the stroller.  Come Hell or high water, we were going to do this thing.  Of course, he woke up immediately, and we were off.  First stop, the carousel for rides on several different horses.  Next, a ride on a swinging strawberry.  All were enjoyed with an ear-to-ear smile throughout.  Pizza lunch up next, and then the train, more rides, a run under the waterfall, a hot dog, another trip the carousel before we left.  Smiles and laughs all around.  The best day ever.

The funny thing is that if you dissect the day, you probably wouldn't understand how it was perfect in any way.  I forgot to put a pull-up on Asher before we got in the car, and, for the first time in ages, he had an accident during his short nap on our way there.  There were brooms and dustpans in every bathroom, which he always wanted to play with, and there was a small amount of screaming when I led him away every time.  Lunch took half an hour to eat, most of which was spent spacing out and counting trash cans.  He was trying to be so naughty while in line for the train, and yet, there was just enough going on to distract him into submission.  I almost had a panic attack on the ferris wheel (not a fan of heights), and then Asher tried to take a nap on the seat as the attendant came to let us out of our cabin.  The hot dog request came completely out of the blue, less than two hours after lunch, and was revealed on a whim as we were passing by a restaurant that does not serve hot dogs; I had to walk nearly the entire park to find the damn hot dog--there is only one restaurant that serves them--but we got it, and life was good.  Last, but not least, on the final carousel ride, I was told to "LEAVE!!!" by this increasingly independent child (unfortunately for him, he isn't tall enough to ride alone).  Such love.  And then I had to fight a little to get off the carousel; he wanted to try a horse in every color.  During the five minutes it took at the end of the day to convert our Costco voucher into a real season pass, the few remaining bits of hot dog went flying, a protest for taking away the fun.  On our way out of the parking lot, a pitiful, exhausted utterance, "Back in....Back in...."

That's the most amazing part of living these experiences: there is nothing particularly wonderful about any of it, and yet it is all wonderful.  There is some sort of magic chemistry that makes it perfect.  How often do you spend eight hours with a two-year-old and not get frustrated?  Almost never.  This was one of those rare days.

But I know life is short and childhood even shorter.  His yearning for independence is a blatant reminder.  I feel a need to commemorate it all.  I'm usually the one behind the camera, trying to preserve the memory.  I tried to capture the moments, the smiles, the laughs.  However, unlike most outings, on this one, I had no back-up, and my only camera was my phone.  I became more aware of how I usually miss the full experience of the moment by trying to preserve it somehow.   In the process of accepting my limitations, I became more whole.  Contrary to what I expected at the start of the day, by not being able to record it audio-visually, our outing became better recorded emotionally.  I was more there, and because of that, I will never forget it.

It was the perfect day with the perfect iPhone self-portrait to prove it.

Saturday, April 27, 2013

24+ Hours of Mommy Fails

The last 24 hours have been tough around our house.  I am exhausted after two nearly-sleepless nights in a week.  Asher has been discombobulated by my absence and more baby-sitter time than usual, and he has been busy all week with activities.  Crockett is stressed about a lot of exciting but work-intensive projects.  It should come as no surprise that this all takes a toll at some point.

It all became apparent last night.  Asher and I took a shower, and while I was straightening up afterward, I let him run around naked for a while.  As I came out of my room, I saw him proudly peeing on the hall carpet saying, "Clean up!  Spray soap!"  Ugh--the downside of having a kid who loves to clean and is obsessed with spray bottles.  Needless to say, he did not fish his wish.  Instead, we soaked up what we could with a towel, and then I declared an early bed time.  I stuck to my guns with the usual three stories in the chair, one story on the potty, and then to bed.  I thought I was so smart.  On the webcam, I could watch him rolling around, sipping on his water bottle and getting settled in bed.  I was sure he'd be asleep any minute.  Then 20 minutes later, shrieking.  Eventually, I went in, rubbed his back and reminded him that it was time to sleep, and when he seemed nice and calm, I left.  Another few minutes of silence, and then more shrieking.  Finally, about an hour after we had first said goodnight, I caved.  I got him out of the crib, sat back down in the chair, and held him until he fell asleep, something I hadn't done in ages.

This morning he woke up about 20 minutes earlier than usual, and he was cranky.  We made it through the first part of the morning without too much trouble, and at 8:00, I handed a seemingly happy kid off to the nanny before I headed off to an appointment.  A couple of hours later, I had planned to meet them at the children's museum, where they had a playdate scheduled with one of Asher's friends and her nanny.  There was a large school group on a fieldtrip there, so the nannies decided they would rather go elsewhere.  I wanted to squeeze a workout in before heading to the office for an afternoon full of appointments, so I took Asher back to the car and said goodbye.  Apparently, I underestimated the effect my brief appearance would have.  By the time he got home, he was tired and frustrated and upset that I hadn't been there.  Oops.

I eventually had to head to work, again leaving behind a seemingly contented kid.  Little did I know that a volcano was about to erupt.  Nanny leaves around 4:00.  At 4:20, I got several calls to my cell phone, which I could hear from the exam room where I was talking with a patient.  Finally I decided something must be wrong, so I went out an answered.  Crockett wanted to know where I was, forgetting that I had to work that afternoon even though Thursday is usually my day off.  Asher was a mess, crying and fussy and inconsolable.  Apparently he had been like that for a while.

When I finally got home, Daddy and Asher were both exhausted and vegging out in front of some A-B-C youtube videos.  We had dinner and planned an early bedtime for the little guy.  Normal bedtime routine, and again, the shrieking.  Again, Mommy held Ashie until he fell asleep.  Goodbye, sleep training.

Weeks like this, lots of thoughts, mostly self-critical ones, enter my mind, ranging from doubt about my understanding of my own child and wondering if stay-at-home moms have a better sense of what to do to frustration with myself for not sticking to the cry-it-out method of sleep training that we've used for months and concern that I've ruined his ability to self-soothe permanently with the last two nights.  This time, I even wondered if my assumption that we have successfully potty-trained him--something I have been so sure and proud of--was premature.  I wish I could see the glass as half full: my child loves me; he misses me when I'm gone; despite having a working mother, he has secure attachment.  While it's normal for a mother to worry about her child, and I suppose it's healthy to examine your parenting behaviors, I think it's sad that we hold ourselves to an imaginary standard of perfection.  We all struggle.  We all have bad days.  We all have moments when we misinterpret our children's needs.  We all cave from time to time.  But few of us are willing to admit it.  The good news is that our kids are resilient, and so are we. 

Besides, it feels damn good to snuggle up together in that big chair. 

Thursday, April 25, 2013

The Toddler Ten

You've heard about the "Freshman Fifteen," that weight gain young women often undergo when they leave for college due to an over-consumption pizza and beer, right?  I'm coining a new term: the Toddler Ten.  For a lot of women with young children, weight is a big issue, and I am convinced that in most cases, the kid is to blame.  I am living proof.  No, I don't want anyone to give their two-year-old a hard time about this.  What I mean is that a lot of aspects of having a little kid in your life that not only make it more difficult to lose weight but also probably contribute to weight gain.  Until you identify how these factors play into your lifestyle, you will never be able to make the changes necessary to stop gaining weight and, hopefully, start losing.

I know that most of you who know me in person are rolling your eyes and groaning right now.  True, as an adult, I have always been thin and haven't had to think much about my weight. Even trying to gain weight during pregnancy, I only managed to pack on 15 pounds.  Yet, I realized something was wrong when I looked at some pictures of myself about eight months ago.  To my horror, I discovered that I still looked pregnant.  The scale said the same thing.  Though I was down to my pre-pregnancy weight about six months after delivery, I didn't stay there. What was happening?

Pondering the changes in my lifestyle and eating habits, I realized that it was all the little man's fault. Here's why and how I changed things for the better:

1. Lack of time for exercise.  Especially for those of us who work, there is little flexibility in our schedules to carve out time to exercise.  I used to be able to get up super early in the morning to get my workout in, but when you're waking up at night to care for a baby or toddler, any extra sleep you can squeeze in is important.  For those who don't work, unless you can do everything--exercise, clean, cook, etc.--during naptime, you need a sitter for you to get some exercise, and most don't have that luxury.  Joining a gym with childcare might be an option, but with all the kid expenses, that might not be in the budget either.  Things get even harder as your baby become a toddler and cuts back from two naps to one (and on bad days, none).  And not to burst anyone's bubble, as tiring as it can be, chasing a toddler around the house does not count as exercise from a fitness or weight loss standpoint.

I  had grand plans before I delivered.  Somehow I was under the delusion that I would have a kid who would love to ride in the jogging stroller while I ran every day.  I think the folks at my office suffered from the same delusion because they gave me a BOB stroller at my shower.  As it turns out, I actually fear running with my antsy kid because I'm pretty sure he will lose his mind two miles away from the car, and I'll have to find some way to get us both back there without losing my mind as well.  I needed an alternative.

The reality is that your child needs you to be healthy to care for him, so you need to find a way to take care of yourself.  In my case, solo runs are great, but only if I don't have to spend a lot of time driving to my starting point.  Unfortunately, my house is at the top of a big hill, and my legs simply can't tolerate running that hill day in and day out, so the hubby and I started looking into home exercise programs.  "Insanity" was as hard as the name implies, but I could do it at home without any special equipment, so I could do it easily during kiddo's naps.  Recently, I also rearranged my office schedule so that I have time at lunch to squeeze in a run on the flat land near my office at a time when I already have childcare.  Hubby does the same thing.  On the weekends, we each take shifts so that the other can exercise or do whatever else is important at the moment.  We might not get out as much as some families whose weekends are packed with activites, but we're healthier for it.

2. Toddler snacks.  Little kids like to eat a lot of starchy, fatty, sugary foods.  So do adults.  The difference is that kids actually need fat and calories in these foods; you and I do not.  If your pantry is full of cheese crackers, fruit snacks, and worse, it's natural to be tempted by these things.  The easiest way to avoid this stuff not to buy it in the first place.  Your child can still have plenty of tasty, easy snacks.  Try cheese, fruit, toast with peanut butter, cereal with milk.  There are a lot of ways to provide good snacks without tempting yourself.  My kid eats hummus with a spoon. He loves my healthy creamed spinach.  Toddlers aren't biased the way we are.  They are naturally drawn to a lot of foods that we dub "health foods" as adults.  Let your kid eat health food (just don't limit his fat and natural sugar intake).  Get the junk out of the pantry.  If your child is older and protests when the chips and cookies disappear, be strong; you are the adult and get to call the shots.  Remember that teaching your children to appreciate healthy food is helping them make better choices later in life.  If you show them that eating well is important, they will carry on your legacy.

3. Dinner time.  Many studies show that families who share meals produce healthier, happier kids in the long run.  From an adult diet standpoint, eating as a family is easy when babies are eating purees; once they can handle table food, it's a whole new ballgame.  I found myself trying to find meals that my boy would/could eat (his teeth have been slow to come in and at nearly two, he is just starting to get his canines and still needs a set of molars), and they all revolved around a starch--mac and cheese, spaghetti, fried rice.  I'm not anti-starch, but it's hard to get really full on a meal of mac and cheese without eating way more calories than you actually need.  I started thinking about things a new way: prepare and serve what the adults eat and let the kid learn to eat that way too.  Now we have a more balanced meal.  Lots of veggies and protein in addition to the starches. I try to make sure that all of our meals have some component that he will eat, but I don't make the meal revolve around his preferred diet.

[Note: studies show that it can take at least 20 tries for a child to willingly eat a new food, so if your kid protests at first, try again!]

4. The tempting tray.  We ALL start snacking off our kids' plates at some point.  I'm not sure why this is.  We probably serve bigger portions than a child can eat and don't want to see so much waste.  We are also serving our kids foods with more starch, sugar, and fat than we generally allow ourselves, so there is a huge temptation to eat the leftovers.  I have never seen a parent who doesn't do it, though some patients deny it.  If you want to get rid of those extra pounds, stop eating your kid's food, or at least factor that into your own daily intake.  This is especially important if you don't eat your meals together.  Because I know I'll probably finish my son's dinner for him, I serve myself a lot less than I used to, and as absurd as it sounds, there are times that I literally talk myself out of "tasting" what's left on the tray.

5. Starving yourself.  If you aren't eating throughout the day, your child's food is going to look especially tempting.  You'll eat fewer calories and more healthfully if you keep up with your meals and snacks.  When I'm at home, I feed myself when I feed Asher.  At work, I stick to the same schedule.  This reduces the chance that I will overeat because I'm not starving when I am around food.  Also, your internal clock knows when it is used to eating and will tell you your hungry at certain times of the day, even if you've just had a high calorie meal.  I know a lot of people who will eat a big breakfast on the weekend and say they'll skip lunch.  Not sure how well that works for them, but I personally am always hungry when lunchtime rolls around.  If you're anything like me, it helps to keep your meal and snack times relatively consistent. 

6. Not doing unto yourself....  We all take better care of our families than we do of ourselves.  How many moms spend a good chunk of time each week packing lunches for their kids but rely on a run to the closest fast food joint for their own lunch?  I always make sure we have plenty of cut up veggies and fruits for the little guy to snack on when I'm away.  One day I caught myself thinking that I should bring a snack to work but not wanting to take "Asher's food."  Weird, right?  It occurred to me a second later that I was spending a lot of time on food prep every week but didn't personally benefit from all that work.  Increasing the number of peppers and cucumbers I cut up each week took minimal effort, but now there was plenty for the whole family to enjoy.  Now Asher has veggies for his snacks, and we have veggies to throw into salads to take for lunch.

7. Stress with a capital S.  Moms and dads are stressed people.  We have a lot more responsibility and worries than childless people. Stress contributes to weight gain.  Whether it's because of hormonal changes triggered by stress or simply the over-eating for comfort that stress promotes, I'm not sure--I'm guessing the latter because despite a lot of stress in college and med school, I was always under-weight due to not eating as a coping mechanism.  Either way, a lot of people gain when stressed, so if only from a weight perspective, it is important to find an outlet. Exercise is a great one, but if that doesn't do it for you, try meditation, journaling, baking...whatever gives you a moment to breathe.

I'm not saying that any of this is easy--it is serious work--but before you start calorie counting, think about where those calories come from and the barriers that are preventing you from burning them off.  Consider the little changes you can make to your current routine that might make a big difference.  Do this before you try the newest fad diet or ask your doctor for a weight-loss pill.  Your children will learn from you and will be healthier and happier people for a lifetime, and so will you.

Tuesday, April 23, 2013

What's in a Name?

When I was a resident, I had a very interesting and unusual patient, CH.  She had very little wrong with her medically, but she needed a lot of medical care, and there were days that I honestly dreaded being her care-giver.  I was reminded of her today when I received a message from a patient that included the comment that my name was M-D, MD, "Cute."  CH was the only other patient who has ever mentioned that to me.  Immediately, I flashed back nine years.

I first met CH during my first year of residency.  She had become a regular patient of one of my senior residents, Dr. T.  At time she was homeless and without resources.  He happened to be working in the Gyn ER when she turned there looking for help for a minor medical problem.  They connected, and he started letting her stay there when she was in need and the place wasn't busy.  Eventually, her life got a bit more stable, but she was stuck to him like white on rice.  I worked with him for several months out of my first year, and so, inevitably, I became acquainted with her but had little real contact.  She needed him for support, and not the kind of support that physicians in training, who are focused on the medical side of everything, usually have on the mind.

And then, like all residents, Dr. T. graduated.  As his graduation approached, he warned her that she would need to pick a new doctor and gave her a list of the people with whom he had worked and thought she might like.  She looked at my name and decided that "M-D, MD" must be a sign and chose me.  I was not excited about this.  She was notorious for showing up unannounced anywhere Dr. T. happened to be working.  I was busy and focused and didn't need the extra work.

Our first few meetings were awkward.  I couldn't figure out what her actual medical problems might be, and I couldn't figure out why she needed to be seen so frequently.  To make matters worse, though she had an appointment for the first visit or two, soon thereafter, she started to show up every afternoon I was in clinic and create a stir by demanding to see me.  I admired Dr. T. and wanted to do right by him but couldn't bear the thought of seeing this woman.

My dedication to Dr. T. won out and I kept seeing her.  Eventually, the clinic staff just knew that she was coming and didn't argue.  I had at least twelve patients booked every clinic afternoon and adjusted my practice to get them seen and still have enough time to talk to CH for a while, usually half an hour or more.  I eventually set some boundaries and got her to come later in the day so that I could get most of my work done before she arrived.

I learned a lot about her in the three years that I was her doctor, and very little of it had anything to do with her medical history.  I learned about her childhood and younger adulthood. I learned about the challenges she faced throughout life.  I learned about how she had become homeless, and I watched her slowly climb out of homelessness.  I learned about her love for literature and writing and her desire to go back to school and get a masters in fine arts.  I learned about the difficulty acquiring Chapter 9 housing so that she could move out of the shelters.  Later, I learned about her hatred for the kind of life she was living in Chapter 9 housing.  I learned about the frustration of the public medical system when all you need is dentures to replace the teeth that were pulled because of damage from your history of binging and purging and it takes years to get them.  I learned about the trials of taking the bus from Long Beach to the East Side of LA every week to see your doctor.  

Above all, I learned from her how to be a better doctor.  I learned to set side my curiosity about how I could help from a medical standpoint because she helped me understand that sometimes helping doesn't always mean doing something.  In fact, I did almost nothing medically to help her.  Over three years, I managed to work the system to get her bone density checked and kept her up-to-date with her pap smears and mammograms.  Other than that, I was just a sounding board, an empathetic listener at times when there was no one else.

When it was time for my own graduation, saying goodbye was hard.  I wouldn't miss the stress of trying to cram so much work into so little time in order to create space to talk to CH every week, and yet, I cried a little.  We had a connection.  Moving ahead with my new life, I thought about her a lot at first but less as time moved on.

Fast-forward to 2011: letter arrives in the mail shortly after I return from maternity leave.  An update from CH.  She has completed her MFA.  She is doing well.  Life is good.  So much has changed for both of us.

It would probably come as a surprise to all of my friends from residency for me to say that my time with CH was one of the most valuable parts of my training, but six years later, I truly believe that.  She taught me so much about the importance of listening and empathy, and she forced me to learn how to provide that kind of attention while at the same time providing quality care to other patients.  Largely because of her, I can stop the business-as-usual of medicine and be present for a patient with other needs and then re-engage to provide the medical care other patients need and still stay--at least relatively--on schedule.  Most importantly, I have learned when to stop being such a "doctor" and start being a "supporter."

Who knew having this name would get me here?

Sunday, April 21, 2013

Travelin' (Wo)Man

This evening I am leaving for my first business trip in over two years. In fact, it's my first solo trip of any kind in the last couple of years.  It's a quick flight to Denver to observe surgery tomorrow, and I'll be home tomorrow night, but I am dreading it.  It's not my first night away from home since Asher was born--as you might imagine, there are some nights that I just don't make it home because L&D is busy--and there are even more nights that I'm home to sleep but miss Asher's bedtime and wake-up, but somehow having to go on a plane and planning to sleep in another bed makes feel more "away."  Mommy is not handling things well. 

Being a physician in private practice generally means staying close to home.  Whereas some docs travel a lot to conferences and training gigs, those of us in private practice don't get out much.  It's one thing when your employer pays for these kinds of trips and doesn't dock your salary.  Unfortunately, I don't pay myself for time out of the office, so most of my continuing education comes from reading and local meetings.  Honestly, it's what I prefer.  I am definitely a homebody.  I've never wanted a job that would acquaint me with airports all over the world.  My fear of flying might have something to do with that.  I am happiest in my own space, with my own stuff, and surrounded by my own people, even moreso now that "my people" means my little family.

I left the house much earlier than necessary.  I could have carpooled with someone, but that would mean leaving the house right at dinnertime.  Certainly not an ideal time for me to say goodbye.  But I think I realized that the longer the day wore on, the harder it would be for me to leave.  We tried to explain to Asher about my trip and how I would be home to see him in a couple of mornings.  The fantastic thing about two-year-olds is that he really didn't need an explanation.  Tomorrow he will be surrounded by people who love him--Daddy and Nanny Becca--and though he might think about me a lot, it won't really occur to him too much that I'm gone.   Most of me was hoping for a panicked, tearful goodbye from him.  Only a small part of me can acknowledge that this kind of goodbye was better for all involved.

So here I sit in the San Jose airport, about 3 hours before my flight is actually going to leave (an hour far).  The few belongings I need for this whirlwind trip are packed into the diaper bag I no longer need since it's the only bag I have that is remotely the correct size.  I realize now that it's been ages since I've traveled so light, and the bag is a not-so-subtle reminder of the 25-pound cargo I left back home.  I feel self-conscious about it all, feeling like I don't fit in with the rest of the Silicon Valley business travelers for whom today is just like any other Sunday.  Unlike the other travelers, I've got a super cute cuddle bug to spy on via webcam while he sleeps tonight.  Can't wait for bedtime!

Saturday, April 20, 2013

The B Word

No, not THAT one.  In fact, with Asher's love of the ABC's, my life is full of a lot of B words right now.  But the one on my mind at the moment is BREASTFEEDING.  It came up a few times at work this week, which reminded me that it was one of topics I most wanted to talk about here because I think (or at least hope) that my input has helped a lot of my patients keep their sanity.  However, I have to admit that I'm a bit nervous to post this publicly because breastfeeding is such an emotionally-charged subject these days.

So that none of you miss the take-home message of what I'm about to say, it's this: Breastfeeding is best, but for some of us, it's hard, and although breastfeeding has a bazillion benefits over formula, the most important thing for your child is having a sane mother.

First of all, I am totally pro-breastmilk.  Aside from being cheap, convenient (no supermarket runs at midnight when you run out), and safe (no need to worry about contaminants in the water), it delivers immunoglobulins and other substances that even the best formula can't and apparently even boosts your kid's IQ.  Nursing has even more benefits: bonding time for mom and baby and even more convenience.  Plus, there are long-term health benefits for mom as well, including, but not limited to, increased calorie-burning = postpartum weight loss, decrease in the risk of postpartum depression, and decrease in the risk of breast cancer.  When breastfeeding goes well, it is a great experience for mother and baby, or at least that's what I've been told.

My experience was not so great.  My kid latched almost as soon as he was placed on me in the recovery room.  I thought it would be a breeze.  Then the actual nursing started.  Latch was good, but for some reason, day after day, my little guy lost weight.  By day 3, he had lost 12 ounces of his whopping 5 pound, 5.5 ounce birth weight.  Finally the pediatricians admitted that something wasn't right.  That's when the pump came out.  I was instructed by lactation consultants to nurse him for as long as he wanted, then pump and give him by bottle whatever I got out.  Then they left the room.  And left me all alone with a starving newborn.

My first word of advice is that if your kid is hungry and there is no milk available, give formula.  Fortunately, I had a pacifier (taboo, I know) with me, so I shoved that in his mouth to keep him "pacified" while I pumped. I quickly realized that at some point, I was going to have to pump a little extra in order to get ahead so that there wasn't a delay in getting him a bottle after our attempt at nursing.  With my milk just barely coming in and feeding every 2 hours, that wasn't an easy task.  I finally got around to that the following day.  In the meantime, every feeding was a bit of a nightmare for all involved, but I was determined not to give evil formula!

And so it went on.  Every 2 to 3 hours, nursing, bottle-feeding, pumping.  The whole routine took about an hour.  With a baby who was barely sleeping, this meant almost no sleep for me either.  Meanwhile, he was growing in size and appetite.  He was fussy and crying.  The amount of milk I actually pumped was pathetic, just 1-2 ounces total after half an hour.  Finally my husband convinced me to let him open the formula canister.  I felt like a total failure, but I was exhausted and had started to realize that Asher was getting almost all of his calories from the bottle and not from nursing.

At that point, I decided to do an experiment and skip the nursing part of the feeding altogether, just to see how much he needed to become satisfied.  Immediately it became apparent that he was probably getting nothing from the breast.  As I was slowly losing my mind from chronic sleep deprivation, I realized that if I was going to give him breast milk, I was going to have to be an "exclusive pumper."

It turns out that the exclusive-pumping club is not as exclusive as one might assume from the name, but the membership roster is short because very few can stick with it for long.  A lot of my patients have latch issues; eventually their nipples are torn to shreds, and they resort to pumping for a while to let themselves heal.  For a few weeks, it seems like pumping is an easier alternative than trying to get their babies to latch properly.  But in order to make it work well, you have to pump at least 10 times a day, which also means getting up in the middle of the night.  Any less than that, your supply won't come in and stay in. Add that to the nighttime feedings and playtime, and you are only getting a couple of hours of interrupted sleep each night.  Even with a supportive partner helping you out at night, it's exhausting.

Those were my nights.  Crockett took the early shift, from about 9-1; my shift was the second part of the night, though I still had to set an alarm to get up at some point during his shift to pump.  It was easier during his shift because all I had to do was pump.  My shift was harder.  I would get up with the baby, but if he didn't go to sleep after his bottle, I was up trying to entertain him while also trying to pump for 30 minutes.  Many nights I was hooked up to the pump while bouncing him around--thank goodness for those pumping bustiers--and trying to make sure I didn't spill any milk.  A lot of milk got spilled, and there were a lot of tears.  Very little sleep happened.  I continued to lose my mind, and my milk still didn't come in as planned, despite pumping 12 times a day and taking fenugreek religiously and staying nourished and hydrated.  I was incredibly frustrated and exhausted and cried a lot.  I loved Asher dearly but sometimes wondered if I had made a terrible mistake.  So much time was spent attached to the pump that I couldn't enjoy the newborn stuff as much as usual, and in some ways, it was a sad time.

A little over three weeks into it, my brother got married, and amid the stress of preparing to spend a weekend in a hotel for the first time with our newborn, I realized that I could not continue down this road.  A new experiment: what would happen if I pumped less often?  Amazingly, I produced as much milk over the course of the day but with much less effort.  And so I embarked on a new normal: pumping about 6 times a day and supplementing with formula as needed, which was about 50% at that point.  Asher continued to grow and thrive.

When Asher was 7 weeks and 6 days old, I returned to work.  Being self-employed has its benefits, and some flexibility in my schedule is one of them.  I don't have an office of my own, so I would shut myself in one of the exam rooms while I was pumping and charting.  Eventually the medical assistants learned that if the exam room door was closed before office hours or at lunchtime, I was pumping and they should just leave me alone.  Every activity was planned around my pumping schedule, and a pump went with me basically everywhere I went.  I even rented a hospital-grade pump to leave at work, and I bought enough extra pump supplies so that I only had to wash them once a day.

However, by the third month, my supply had begun to dwindle.  The day before we were supposed to leave on our first cross-country flight with Asher, I came home from work with only one ounce of milk to show for a total of an hour pumping.  I made the decision to stop.  It was one of the hardest decisions I ever made, but I realized that the stress of scheduling life around pumping was doing me in, and it just wasn't worth it anymore.  I cried as I bottle-fed Asher that last ounce.

And so started a period of shame.  I felt like not breastfeeding was my first failing as a mother.  I was depriving my son of the number one best thing I could give him.  I had trouble cutting myself slack and wouldn't give myself credit for trying as hard as I could and using every trick in the book.  I also felt like I was a hypocrite and terrible doctor.  How was I in any way equipped to counsel women about breastfeeding when I couldn't do it successfully myself?

Gradually, I began to see that I wasn't alone, and I realized that I was able to use my challenging experience to help my patients not just be more successful with breastfeeding but also be more forgiving of themselves when they were struggling.  I was also able to see when it was truly ruining a woman's experience with her newborn and felt more qualified to give her "permission" to supplement with formula or to stop nursing entirely.  I had a distinctly new sort of empathy.

It turns out that no matter how much you know about breastfeeding, there are some factors that are beyond your control to some extent, including your baby's cooperation and your supply.  And even if you have all the support in the world and follow all of the recommendations, sometimes it just doesn't work out.  That can be a very hard thing to accept as a new mother.  It seems like the most dire problem at the time, but in the grand scheme of things, it's a minor point.  A lot of us were formula fed and turned out pretty awesome (my brother and I were both formula-fed, and we both turned out OK).  What really screws kids up is having absentee parents or parents who are too stressed to connect.  Making yourself physically and emotionally available for that connection is far more important than what you feed your child.  It's easy to see now in retrospect but was difficult to understand in the moment.

When my incredibly bright child snuggles up with me to drink his sippy cup of milk (now, cow's milk), I know I did OK.

Thursday, April 18, 2013

The Easy Way Out?

The elective cesarean section.  At some point along the way, it occurs to a lot women that just having a c-section and getting it over with might be the best way to go.  No muss, no fuss.  You schedule things and just go to the hospital and get the baby out.  Perfect for the type-A personalities out there, right?  Wrong.

I'm here to say that there is NO EASY WAY  to have a baby.  I was reminded of this today while I was on call.  I spent the entire night pushing with a patient (for real, the entire night; EIGHT hours of pushing--a new record for me).  She, of course, questioned whether she should have just chosen a c-section from the start.  However, she ultimately delivered vaginally a vigorous baby girl.  The question becomes, is a vaginal delivery after a 38-hour induction and incredible physical, mental, and emotional fatigue the best way to accomplish things?  That, of course, completely depends on your perspective. 

An important disclaimer here is that I personally had an elective cesarean section, and I do elective c-sections when that's what my patients ultimately decide they prefer.  My point here is not to say it's the wrong thing to do, just that it is not an easier way to go.  When I discuss this issue with patients, I give them the pros and the cons and let them decide.  This is one place I know that personal experience has made me a better doctor.

A lot of people, especially those who have had uneventful vaginal deliveries in the past, wonder why any of us would have elective surgery.  The reasons vary: fear of trauma to the nether-regions, concern for fetal well-being, worry about pain, anxiety about the unknown, shame about pooping while pushing.  In my case, the reason was all of the above, but the over-riding fact was that I knew I would be overly anxious about labor.  I knew I would have to be induced because of some complications (at first, just a history of high blood pressure; later on, the list of issues grew), which I knew would be a long process, and I knew that I would be watching the fetal heart rate the entire time and would ask to go to the operating room with the first abnormality, no matter how mild.  Some of my colleagues just ask to put the heart rate monitor outside the room; that is not something I can conceive.  I guess I'm a bit of a control freak.  Anyway, it just made more sense for me to nip it in the bud and just go to the OR from the start.  But that decision was made, of course, with a very clear understanding of the down-sides of having a c-section.

 Although the data show that a planned cesarean section is probably not any more dangerous for mom and baby than a vaginal delivery, there are some real disadvantages.  The biggest ones are postoperative pain and physical limitations.  I always tell people that you get pain on one side or the other--either during the labor itself (few women get their epidurals so early in the process that it's not at all painful) or afterward.  Vaginal deliveries often result in a sore bottom for a few days, but it's nothing like the pain of an abdominal incision, which takes weeks to heal.  You don't realize how much you use your abs until you've had surgery.  Hard enough with just a newborn to deal with, but so much harder with the second (or third, fourth, etc.) baby, when you have older children to care for.  If you're not supposed to lift over 20 pounds, how are you going to manage your 2-year-old?  Then there's the additional day or two in the hospital.

Then there are longer-term effects: the once-a-c-section-always-a-c-section reality in many communities (including mine), the scar tissue caused by surgery that makes any abdominal surgery in the future more difficult, the lingering numbness and tenderness of the incision years later.  More serious issues include the higher risk of serious complications in subsequent pregnancies, particularly an increased risk uterine rupture (when the scar on the uterus tears open and can result in stillbirth if the baby isn't delivered immediately) and of placenta accreta (when the placenta grows into the uterine wall and usually results in an emergency hysterectomy at the time of delivery).  Not minor issues.

Time will tell how today's patient feels about her delivery in the long-run.  All things considered, I still feel that an elective cesarean was the right decision for me, and I'm still open about that fact when discussing with my patients.  But my circumstances were very different from most women's, and I definitely had deeper understanding of the risks when making that call.  From my perspective, I am also very glad that my patient this morning stuck with it and had a successful vaginal delivery.

And when baby Elizabeth is older, I'll be sure she knows how much thanks she owes her mom!

Tuesday, April 16, 2013

To Circ or Not to Circ...

Coming out of residency, I never anticipated the number of baby- (as opposed to fetus-) related questions I would get in the course of routine prenatal care.  This came to mind the other day when, for the first time ever, I was asked for advice regarding ear-piercing for a baby girl.  I've always felt like parents of girls got off easy because the biggest issue for those of us destined to have boys is the circumcision question. It comes up at least as often as "who do you recommend as a pediatrician?" 

That said, it's not an easy decision to make, nor should it be.  You are deciding whether or not to do elective surgery on your newborn.  It's a big freaking deal! 

Unfortunately, there is no definitive answer on the subject.  Most men who are uncircumcised do just fine; a few require the procedure to be done later for medical reasons, which is requires anesthesia and entails a more painful recovery.  There is now evidence that men who are circumcised contract fewer sexually transmitted infections and are less likely to pass those on to their partners, but, seriously, who wants to think about a newborn's future sex life?  On the flip side, as with any surgical procedure, there's a risk of complications: infections, damage to the tissue, bleeding.

So what do I actually advise?  Look at the guys around you (figuratively, most likely).  You want your son to look like his father and other male relatives and close friends (and their kids)--the ones who are going to shape his idea of what is "normal" for a man during his first few years.

How did we decide what to do?  Exactly that.  The circumcision itself was done by our pediatrician and was no big deal at all.  Much more traumatic for the parents than for the kids.

Will you question decision?  Absolutely!  As you will about every other decision you make as a parent.  Having never cared for a healing circ before, I had no idea what to expect and was hyper-vigilant about complications--any fussiness or hint of redness, I was certain I had made a terrible choice.  First episode of mommy guilt...first of many.

Take home lesson: as a parent, there is little black-and-white.  You use your love and the best information available to make a decision for your child.  And that is ALWAYS the RIGHT decision!

Moving Day Madness

Yesterday was a big day in my office: we grew!  More precisely, "we" had grown over the course of a couple of years from five docs to seven, without adding any office space.  Quarters were tight, and everyone's office hours were cut back so that we could share the exam rooms.  Yesterday our physical space grew.  And I was the lucky girl who got to work in that space.

You realize at times like this that you take for granted the systems you have in place.  Where does the medical assistant put charts to indicate that a patient is roomed and ready?  Which computer do I use?  How do I call my assistant in to help with an exam (for now, it's just a shout out the door, so I'm a bit hoarse from screaming, "ANGELA!!!" all day long--it turns out the new office space is quite large)?  And I got quite a workout running back to the main office to gather all the little things that I use throughout the day.  Then there was the grumpy guy putting in the phone lines who was yelling at his assistants too.

All of this led to some serious mental chaos.  This was my "desk" AFTER cleaning up.  Note the open purse spilling all over the place, charts strewn about, the stool that is way too low for the counter height.
Good thing it was a slowish day for me because not much work got done.  Not a single afternoon chart note got written.  Between the mess and the grumpy phone guy yelling in the background, I simply could not concentrate.

I couldn't wait for the day to end, but if you look, you can almost always find something positive amid the madness.  I see at least four lessons in all of this that definitely apply to real life.

1. Messes slow mental function and disrupt concentration.  Have you ever seen your kid over-stimulated?  If not, you haven't been paying attention!  We try to stick to one big rule in our house: before you get out a new toy, you put the last one away.   We don't always stick to it, but I've noticed the less mess on the floor, the less frantic the boy's behavior.  This rule applies other places as well.  For example, the fewer morsels of food we put on his plate at a time, the more he eats in the long run.  Simple, calm, and tidy always gets us better results.

2. We all thrive on routine.  I definitely felt out-of-whack yesterday.  Today back in my normal environment (the docs in the office rotate between different work areas), I'm back on track.  Yesterday one of my patients commented that she has been stressed out because her grandsons, ages six and seven, have recently moved in with her and they are "bad kids."  They've never had a stable home and haven't been taught basic manners and rules.  Children need consistency to learn and grow.  My least favorite part of parenthood is having to enforce the rules I've made, but it is vitally important.  Rules and expectations make kids feel respected and loved.  Likewise, never underestimate the value of a bedtime routine, meal schedule, or reading and re-reading a favorite book.  Having a rules and a system for things is comforting.

3. Change is hard, even when it's a change for the better.  For me, more office space means more time available to see patients, which in turn means that I can schedule more down-time into my day.  This is all good.  But living through the change is difficult.  You might even mourn the loss of the old way a little--I definitely felt that way yesterday.  This is true whether the change is a new exercise program or a new bedtime routine.  It's important to acknowledge the difficulty but also remember why you made the change in the first place.  Sometimes you have to work to get the life you want.

4. Change is exciting.  Despite all of the stress and frustration, part of me can't wait to work in that part of the office again.  It's new and different and interesting.  It reminds me of the excitement we had as kids eating breakfast for dinner or spending the night in our sleeping bags on the family room floor rather than in bed.  You've got to balance the routine with the thrill of the unexpected!

Sunday, April 14, 2013


I had just sat down to start writing and wasn't sure what topic to start with--full of ideas for my new blog--when I was interrupted by Asher waking up from a nap, and the topic became clear. Previously, this was generally a serene event, which involved a lot of rolling around with his blankets, drinking some water, and reading some books to himself. That all changed about two months ago with potty training. Now he wakes with a full bladder and plaintive cries to urinate. Part of me really misses those gradual, peaceful wake-ups. Most of me loves being diaper-free.

 I know what you're thinking, "He's so young!" Yes, he is young. We got rid of diapers at 20 months. That said, no, I am not concerned about him having any sort of Freudian issues. For the record, back in the day, they used to strap kids to the potty and hold them down until they went. For hours. Seriously. Kids at any age would have issues after that. We took a more natural, less pressured approach. It worked, and though he probably will have a million other issues related to his upbringing, I don't think any of them will be scatological. 

So why a blog post about this? As with all families, this was as huge landmark for us. Asher is officially a little boy, freed of the constraints of infancy. We don't have to pack a bag full of diapers. Wherever there is a toilet, we're fine. Huge change from the newborn days when a weekend away meant a SUV bursting at the seams with baby equipment. Bittersweet in some ways, but mostly just awesome. Having potty-trained one kid, I am certainly no expert in the matter, but reflecting on it and talking with a lot (basically every mother I know, which is a lot of moms considering what I do for a living) of people about it, I think there are some basic concepts that parents need to get in order to get the job done.

 First off, don't worry so much about whether or not your kid is ready. Very few kids come out and just start using the potty consistently on their own.  If this happens, you are very lucky, but you also might be waiting until that child is almost ready to start kindergarten, which is not a reasonable option for most of us.  For the rest of us, we just have to jump in. If your kid can follow simple directions reasonably well, there is a very good chance, he can figure it out. If you are actually considering potty training, he is certainly ready (I am convinced we underestimate our kids' abilities all the time). It's really a question of whether or not YOU are ready. Seriously. This is a big deal. Your baby is no longer a baby. There are GREAT things ahead, but that's a big emotional speed bump to get over.

When Asher first showed up to his "mommy and me" classes (which he attends with the nanny...more on that in the future, I'm sure), after missing just one week, everyone was sure we had failed in our endeavor.  He was a bit of a phenomenon among the not-quite-two crowd.  None of the other kids had attempted this, and it was a shock to everyone when it worked.  And I think that is mostly because no one wanted to admit that our kids are growing up.  Admittedly, I cried the first day (I cried a lot the next few days too, but for different reasons--even when training goes well, it is not easy).  I couldn't believe he was ready for this, and yet, there he was sitting on the potty and running around diaper-less.

Beyond the emotional aspects, you've got to commit the time. I don't care what some books say, three days of "boot camp" are not going to have your kid potty-trained sufficiently put undies on him and just let him go. You've really got to clear your calendar, I mean REALLY clear it, for at least a week. Which means that you take a day or two off of work, or you get your partner or some other relative to stay home with your child. You use vacation time. Yes, I mean that. This is way more life-altering than that trip to Disney you were prepared to take a week off for. And you clear your weekends for a while after that. No birthday parties or weekend trips or any other unbreakable plan. You keep things low-key and close to home (and familiar potties) as long as it takes.

And you've got to accept that there WILL be accidents.  And that's OK, just messy.  The accidents are learning opportunities, not failures.  At some point, you'll feel like there are so many accidents that it's not working.  You will be wrong.  Stick with the program, and it will work.  Trust me, we've all been there.

As for the particulars, there are a lot of different methods, and I can't have an opinion about any aside from the one we used. In fact, I'm not sure it really matters. We used the "Oh Crap" method, chosen as much for its name as for a big two thumbs up from a good friend (  I personally don't think that big rewards or peeing on Cheerios does it.  I like the matter-of-fact approach, the concept that doing your business in the potty is the way all of us do it and now a child is mature enough to handle that too.  But if stickers or drowning the Cheerio works for your kid, go for it.  Whatever you do, just be consistent and put in the time.

Eventually, you will be rewarded in ways you never imagined.
  (Photo taken on Day 1, which happened to be Valentine's Day--note the monster with hearts on Asher's shirt and daddy love.)

New Blog? Why???

This has to be at least the 4th blog that I've started.  We'll see if it sticks.  The reality is that it's hard to keep up with a blog whose topic isn't staring you in the face every day.  When I was training for a marathon, a running blog made sense.  Then the marathon was over, and I had a stress fracture (self-diagnosed, of course) in my foot, and I had to take a break.  So then work took over and my work blog became the blog of the hour.  And then little Asher came along and for a few short weeks (7 weeks and 6 days, to be exact), he was the only thing on my mind.  Then I went back to work....

Now we're coming up on Asher's second birthday.  He has learned a lot, and so have I.  And an unintended consequence of his existence is that his mother is a MUCH better OB/GYN than she was before he was born.  I've realized that I have a lot of "wisdom" to pass on, not just as a doctor and not just as a working mom but also as a mother and a woman in general.  

My job gives me unique insights because I'm talking to women of all backgrounds who have children of all ages all the time. 30 women a day times 4 days a's a pretty easy word problem.  It's an amazing opportunity for me to learn, and I realize more and more that I apply that new knowledge to my own life and pass it on to my patients during everyday office visits.  I'm definitely not a expert in parenting or pediatrics or life in general, but since I spend a lot of time every day sharing thoughts with other women, it seems fitting that I pass on those thoughts to others as well.

The first few posts of this blog will be getting us caught up with topics pertinent current life and the pregnancy and babyhood that preceded it.   From there, who knows?  Buckle up--it's going to be a bumpy ride...'cuz that's how parenthood is!