Becoming an attendier attending and fighting the system.

Have you ever witnessed a bald eagle in-flight?  This view is one of the many benefits to our new accommodations in the wintery north. I have also done double takes realizing that in place of expected turkey vultures, here, eagles feast at roadside.  Few words describe the animal as easily as majestic.  The first time you see an eagle in-flight, you’re in awe of the symbol of our nation’s freedom.  The wingspan can be up to 90in and the bird stands up to 3ft tall. 

Each time is the same; I stare with wonder.  I watch it soar through frigid air.  I watch it slowly beat massive wings against a blue sky.  Oh, to be so free.  The eagle does not know how it is envied. The freedom that it represents is envied. All for a price.

Everything is obtainable for a price.  The freedom represented by the eagle, the family, the education, the house with the picket fence, the car, the job….shucks sometimes even the love interest. We’ve all seen An Indecent Proposal. The price though, often comes in the form of pain.  Pain of work, effort, and hustle. I’m currently reading Leadership Pain, The Classroom for Growth.  Within the text, Dr Chand (doctor of philosophy, not medicine), states there is a concept called “liminal space”. This is a concept in theology and psychology that covers the in-between.  The “transitional state where you cannot go back to where you were because a threshold has been crossed, and you have yet to arrive where you are going”.  This is a very common state in medicine.  Once training is complete, you cross the threshold as an attending.  However, the common lay-misconception is that this is the goal.  The attending physician is not the final destination but another liminal space where often the attending is looking for “an attendier attending”.  We practice medicine learning constantly from other physicians, nurses, and patients in an apprentice-style model.  Until one day, without realizing it, we arrive and become the teachers.  

However, with the administrative pressures placed on physicians today, medicine is moving away from the apprentice-style model and focusing on business practice to ensure a happy customer, formerly known as a patient.  The price for happiness in customers is no longer just health, but inappropriate antibiotics and testing, inappropriate pain medication, and seeing more customers-faster!  This additional stress and loss of freedom has left many physicians in the liminal space unable to persist through and unable to turn back. In an effort to find my threshold between attending and attendier attending, this week has been a long one. A pseudocyesis, a threatened preterm labor, a preterm labor – all in a budding obstetrics practice.  A host of new patients and follow-ups in a developing family clinic.  Hours covering emergency rooms across our frozen tundra under a winter-storm advisory – IN SPRING!  Dr Chand states that “tenacity is laudable, but people, like cars, run out of fuel, need new tires, and sometimes need major repairs.”  How do we take medicine back across the threshold before it became a business to ensure that we are able to care for our caregivers?  The price that health care professionals are paying is too great.  The prices our families pay is too great.  Soon, we too will be the way of the eagle, threatened with extinction, if the business of medicine does not return to a focus on health. 

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The snow has melted. We are in the thaw phase now.  The last year has been a blur.  Watching flakes swirl, dive, float, and finally rest upon the mounds of white.  We have lived in a snow globe.  We have worked to build a practice and a life.  We have completed projects and tasks.  We have been top in our fields, classes, and activities.  We have succeeded.  Then the globe was shaken.  As we settled, we again started the work of building among falling flakes.  Flakes that shift and move.  Flakes that have no purpose or destination.  Flakes that occasionally rested upon us.  Flakes that blocked the view of the goal, the prize, or the dream.  We built upon shaky foundations at times.  Watching occasionally, our perfectly placed effort slip and crumble upon the pile of flakes that rested at the bottom not noticed until the globe was again shaken. 

What happens when you build in this environment?  What happens when walls of accomplishment are built upon snowflakes?  What happens when the figures designed to “set the scene” are absent?  What happens when you build a house of flakes?  Just ask the three little pigs.  Oh wait. Nevermind, they were delicious over the open flame.

That’s the thing about fire. It cooks.  Combustible.  Out of control.  Fire will destroy everything in it’s path if not tended.  However, if you enclose it, restrict it, smother it – it will dim. It will go out.  It will leave you as cold as a dark, snowy night.  You cannot contain fire in a snow globe.  Neither can we be contained.  Albert Camus, French philosopher understands our plight given his work in absurdism.  He once stated, “In the depth of winter, I finally learned that there was in me an invincible summer.” 

We have broken out. We have pushed the few remaining flakes to the side and are basking in the glow of our own flames.  We are teaching our new friends, coworkers, and community how we burn.   While the flakes melt around us and fade away, we rise to the challenge and score the winning point, complete projects, and explore new opportunities to provide care where we are appreciated.  I promise more fodder for the flames in the near future!

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It’s important to stir the pot.  Otherwise, the stuff on the bottom burns; the stuff in the middle is mush; the stuff on the top is not done. And, everyone goes hungry.

I’m not a chef. Anyone who really knows me, understands I am a foodie by nature but have no idea how the magic works to take glorious ingredients and combine them into the tasty dishes we love to eat. My middle swears I make a mean sandwich. The oldest is fond of my charcuterie platters. The youngest is excited when I make popcorn. Thank God for medicine and for a husband that cooks!

I’ve taken a break from writing as I’ve been busy stirring the pot. The misconception is that stirring the pot has been from a place of malice instead of what it was, an effort to effect change and awareness.

I have been growing, learning, and changing.  I have bubbled up, boiled over, and stewed.  I have clarified, mixed things up, and now am refreshing.  At times, I’ve been on the bottom. Feeling the weight of the world pressing, drowning, and burning. At times, I’ve been in the middle.  Mushed into someone even my inner circle doesn’t recognize. At times, I’ve been on the top. Tough, raw, and undone.

Over the last two years – I’ve fought. I’ve learned. I’ve laughed. I’ve delivered. I’ve rounded. I’ve repaired. I’ve transferred. I’ve cut. I’ve set. I’ve coded. I’ve cried. I’ve held. I’ve comforted. I’ve run.  I’ve pushed that boulder up the hill so many times I have smoothed, polished shoulders where chips used to be.

However, I’m not Sisyphus. I’m not doomed to repeat the same lesson for eternity for bad behavior.  Instead, we’ve been given a remarkable opportunity to create something amazing.  Look for the adventures to come, as we continue to stir the pot and are not afraid of a little change!

“This is my invariable advice to people: Learn how to cook (or in my case, practice medicine – we all know I’m not going to learn to cook!). Try new recipes, learn from your mistakes, BE FEARLESS, and above all have fun!” ~Julia Child

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On the eve of my firstborn’s ninth birthday, I sit straddling the precipice that is working motherhood. The tenuous balance should not be lost on anyone, especially those that have experienced the climb.  For those that haven’t, do not pretend to understand.

Nearly a decade of wondering how to balance. Nearly a decade of second guessing.  Nearly a decade of compromising.  Nearly a decade of growing.  Nearly a decade of living a double life.

Each child gifts their parents with unique rewards. Number one’s amazing abilities astound all those that she meets.  A perfect blend of parental stubbornness, determination, humor, and approach.  Learning milestones as a med-student with her as my guide set me up for failure.  A lesson learned the hard way; patients do not follow the books from which we learn our trade.  I anchored my skills as a mother on my knowledge as a physician.  Occasionally, my hold crumbled beneath my hands.

At times, feeling like a failure for being unable to advance, reach further, or even maintain. At times, feeling judged by how she (and the littles) developed. She has been pushed to the edge, secured only by the thin, no longer present cord, which still binds us.  As she develops, becomes, and blooms in the inhospitable role of a physician’s daughter, she inspires the world around her.  Her abilities to bloom where she is planted inspired me to dive into a free-fall of truly rural medicine.

Our recent relocation: in part for a job of a lifetime, in part for a family-friendly community, has been a near insurmountable task for all of us. Daily, I am exposed to new or previously limited cases. We suffered enough through intern year; yet, I chose to essentially repeat the experience by now practicing emergency medicine, hospital medicine, outpatient medicine, and obstetrics – often all in the same day.  Daily, the littles face challenges of how to blossom in the now fertile soil of a quaint community.  Daily, the firstborn accepts her rights with “all other duties as assigned” as the inheritance.  Daily, the hubs, our rock, quietly ensures our suns rise in the east, our food is on the table, and our house still provides shelter.  Through adversity, we have moved together.  We have grown.  Our blood has thickened.

The cold permeates everything at this time of night in the ER. However, the sunrise on the day of my daughter’s birth is enough to warm even the Iowa winter day.  Happy birthday, Sunshine.

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I have so many things to be thankful for this year. This time of Thanksgiving allows us to share with others the bounty that we have received. Of love, three beautiful girls that greet me with hugs and exclamations of “Mom’s home!” at the end of a hard day. Of love overflowed, a husband, who has spent all day cleaning, cooking, and caring for said girls. The smell of a home cooked meal that evokes all the feelings of the holidays in one breath.

In medicine, at the end of a tough case that had a great outcome, it’s hard to be anything but thankful. You don’t feel successful. You don’t feel triumphant. You are just thankful that the patient survived and so did you. I did my first crash cesarean. Living in small town America, it was bound to happen. This is how and why I chose the rural training and subsequent attending life I chose. The call came just minutes before my 24-hour holiday ER shift started. Decision to incision was 37 minutes. Incision to baby was 1 minute. Many of those 38 minutes had the father on his knees. I interrupted his prayers as I rounded the corner to scrub. He stood and apologized. I begged him to continue. For now, I could not be on my knees praying. I had to stand at the table, scalpel in hand, in an effort to save not one but two lives. But what he did not know, was that I too was frantically seeking guidance from God to watch over us, guide us, and protect the lives of mom and baby. I found him there, after I closed with the final counts correct, still praying. Thankfully, we had a healthy mom and babe to celebrate.

Thankfully, I had an OR staff at the ready, called from the warmth of their homes with their families. Thankfully, I had a partner, not on call, but at the ready to scrub and support an infant who was not quite ready to be born. Thankfully, I had another partner, willing to eat a cold meal to cover my ER shift while my OB patient took precedence. Thankfully, I had a hospital that was willing to let me be the kind of doctor I want to be.   Thankfully, I had training that prepared me to succeed. Thankfully, I have faith, that at the end of the day, God has put me here for a reason.

At the end of the day, I have not gotten so busy making a living that I’ve forgotten to make a life. No, I am busy making a life worth living. So thankful to be busy doing it!

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Lawyer: Even for a surgeon, wouldn’t you call that kind of schedule grueling?

Miranda: YOU could say that. I wouldn’t. I would say it’s wildly successful. But then, I would never put a woman’s success in the “con” column.

~Grey’s Anatomy

The first thirty days. The learning curve is as sharp as Sisyphus’s mountain. The holes in my training and short attending tenure are evident. The new experiences bound off my shoulders as I push the boulder with each new patient encounter. I have arrived. I am not hiding behind the outpatient clinic sign. No longer sending patients that are too sick to the ER to be managed by another physician. No longer delegating the responsibilities of hospital management. No longer desperate for obstetric patients, as there is clearly ‘something in the water’.

The first thirty days. Emergency management of STEMIs, septic patients, fractures. More OPERATIVE deliveries than ALL of my deliveries for the last year! Twins. Twice. VBACs. Breech deliveries. Inpatient management. An outpatient clinic that has been as busy in my first month as in the last months of my previous practices.

The first thirty days. Living in a community of glass houses has also been quite the intimidating summit. As the latest local novelties, our every detail is in the paper and on the Internet. Strangers know details of our family, previously restricted to our circle of friends. Details of our family have been creatively changed resulting in giggles among those that know the truth.

The first thirty days. Infinite sunrises. Sunny afternoons. Sipping wine. Reconnecting. Girls on bikes and scooters. A dog beneath the oaks. New friends. Smores. Fire pits. Deliveries of corn, beans, brownies, cookies, cakes, and plants.

The first thirty days. It has been grueling. More importantly, it’s wildly successful.

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The fields lay in the distance full of ripe soy beans and corn. Nearly ready for harvest. The sun rests just beyond in a burning orange as it begins to slip past the horizon. The children’s shrieks of laughter come from behind as they run through our front yard and the yards of our neighbors. Even the fur-child has found a friend and rolls beneath the large oaks in the lush bright green grass.

Our new home. There is magic here. I hope to scoop some of the fairy dust that had been sprinkled on us in the community with gifts of corn, green beans, and tomatoes and place it in my pocket for a rainy day.

The laughter stops briefly, as a princess in heels and jewelry scootering down the street has fought the dragon and lost. She refuses to extend her arm. I know what it is, and how to fix it. Something so satisfying in reducing a nursemaid’s elbow. The faint click as bones go back to their intended spaces. The joy of the bubble returns.

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I spent many summers around a card table with my Gran putting together puzzles. She started at the edges. Instructing me that if you lay a good foundation with the border, all the other pieces are easier to place. I preferred, and still do, the haphazard method.  I find a piece and try to find other pieces that fit. It definitely takes longer my way. I find that as I’m teaching my girls how to complete a puzzle, I encourage them to start at the edges and work from there. However, I still can’t help the urge to pick up any piece and find out where it goes. It is so satisfying to get a run of random pieces together and place that group as one piece in the bigger picture.

Medicine is like that.  You can work from the edges.  We have innumerable panaceas.  There are guidelines and gold standards of care to direct the care. Start from any corner of the world, on any patient, and eventually as you put all the pieces into place, you’ll see the health of the patient bloom. It’s beautiful. Yet, you can also start anywhere. I love that. I love the magic that I feel as I uncover the pieces that were previously scattered now snapped into place. Perfection. Still longer my way.

Life is also like that. Hungrily, I have grasped at the pieces that seemed to fit together. I have pressed and at times tried to force the pieces that didn’t quite fit. Like square pegs into round holes. But it didn’t work. Now, as I find that pieces that glide into place, it seems as if I have been guided into that rhythm that allows first one piece then another, then another, then another…you get the idea. I have now gotten to take that large section and place it into the border that has defined the edges of my life. The structure. My family. My friends. I cannot quite make out the final image yet, but that’s okay. It’s cheating if you look at the front of the box anyhow. And it’s more fun to watch it develop as every piece falls perfectly in place.

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Alice fell down the rabbit hole chasing the white rabbit. Many allusions have been made to falling down before finding success. We all have a rabbit we are chasing. And time is always running out. Medicine is no different.

Medical students find their passion. They chase that passion through fields of angry flowers. In a world of peonies and roses, I’m a wildflower. Headstrong and driven, I’ve always known where I was going, just not sure how to get there. I’ve grown and flourished in good times and bad. Residency is no tea party, but the first years as an attending is like playing croquet with the queen of hearts. At any moment, you could lose your head!!

The transition to attending from resident is one that some do with grace. Others, myself included, land a giant belly flop and wake up the next day with a bruised ego and a hesitancy to reenter the water. But, “we are all mad here”. So, we suit up and try again. The next attempt may hurt. Or it may be, just maybe, that we finally worked out the kinks and land that perfect 10 dive.

Residency prepared me for many things. It did not reveal, however, what truly awaited on the other side of my final June 30. No. THAT is left for life (and death) to teach you. As a new physician, I have struggled with what I desire and what I have before me.

Like Alice, I was too quick to take a bite of the cookie and found myself unable to attain what I wanted. Then, too quick to take a drink, again found myself unable to chase MY rabbit. However, persistence has led me to finally have the magic ratio.

Here we go, into Wonderland. Full of magic, fear, and ferociousness.  A new adventure waits.

“Decide. Is this the life you want to live? Is this the person you want to love? Is this the best you can be? Can you be stronger? Kinder? More compassionate? Decide.”

~Grey’s Anatomy

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Dementia is a terrible disease. Defined as senility, it covers a ‘broad category of brain diseases that cause a long term and often gradual decrease in the ability to think’. It robs you, like a thief in the night of the person that you once knew. Dementia robs the patient of their independence, personality, skills, memories, and ‘selfness’.  It spares the consciousness.

This is what haunts me the most. 

Globally, dementia affects 36 million people.¹ I have seen so many patients over the years with the disease feeling a deep connection to them, their struggles, and the struggles of their loved ones. Because of one patient. The one that belongs to me. The one that I would’ve given anything to develop a cure to save. Except. There is no cure for dementia.¹

This is the woman that could not swim and was deathly afraid of the water, but kept me from drowning as a child when I was too tired to bathe before bed. That ensured I survived after throwing rocks at Pop’s camper. One. Too. Many. Times. She was a saint that mailed me cookies, cakes, brownies, muffins an innumerable number of times in college. Feeding my dorm, my sorority and me by sheer volume. Her baked goods reaching far and wide not just across the US, but across the Atlantic, comforting and feeding the Spaniards as well!

Mrs Fields, Betty Crocker, and Paula Deen have nothing on this woman.

She served as my guide on how to cook, providing recipes, secret tips – you must bang it on the counter to get the air out – no, seriously, bang it! She served as my role model for what a wife should be: a partner, made from his rib, to stand by his side. She served as a map when I had lost my way and my faith.  She served so many roles; the void will never be filled.

But that’s how doctors are made. Like clay in potter’s hands, every patient, every loved one, every experience in life molds a doctor. There are cracks here and there. Sometimes the vase folds and returns to the lump of clay from which it started. Sometimes, once we have been made, we are broken, and we are forced to reexamine what made us, ‘us’ to begin with.  I am so thankful she cared for me so tenderly and helped me become who I am today.  I will continue to see her in every sweet-no-holds-barred firecracker that comes to my office refusing to slow down. I will continue to fight the thief that robs my patients of their memories and selves.  Hoping, against hope, for a cure.

My favorite memories, in no particular order:

1) lying on the sofa with my head in her lap

2) word searches

3) love/hate relationships with Matlock and Jessica Fletcher

4) on pledging my sorority, learning she too pledged: ‘eata byta pi’

5) always kiss him goodnight; it’s not worth yelling

6) if you spray bees with water over your head, you will get wet

7) don’t pray for patience and strength; God will answer your prayers

8) dancing is a lot of work and takes practice

9) buy the green properties in monopoly

10) i love you a bushel, a peck, and a hug around the neck

¹http://www.who.int/mediacentre/factsheets/fs362/en/

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