A Family Reunion in Seattle and Newton’s Law of Attraction

Doc, I don’t see why I need all these meds. Can’t I stop them? Any of them?”

I hear this often from my patients. Sometimes they are right. They are on too many meds and don’t need them all. But sometimes it takes removing a medication for a period of time in order to truly appreciate its benefits.

It’s a crisp morning in Seattle. The sun is trying to break through the scattered clouds and there are waning remnants of fog coming off the harbor. I walk the three blocks to Pike’s Place and the public market, which is half empty as the fishmongers are making their way in. The rest of my family is still asleep, having all slept under the same roof for the first time in months. Months. That is what’s on my mind as I walk this morning. Thinking about plane rides, hugs, siblings and reunions.

I grab a few essentials for my sleeping crew: gluten free breakfast food for my daughter, a razor for my son, my own Venti Americano, Coke Zero for Becky, milk and cereal. I make my way back to our rental unit, buzzing for the start of our day. Our family of four. Four individual orbits that have come together here in the Pacific Northwest for a precious forty-eight hours.

We take the Link Light Rail across the city away from the harbor and skyscrapers, and make our way to the University of Washington and its traditional campus architecture. It is truly a picture-perfect fall day for a college tour. As I walk with Maya, I try to picture her among the students walking through the quad, the red square, and the union. Becky and Madison head in a different direction to enjoy some time together.

While Maya is occupied listening to our tour guide, my mind is free to wander. The day is truly magnificent. A perfect mix of cool temperatures, warm sun, a light breeze and a backdrop of trees with leaves full of fall colors. Discrete patches of thick white clouds move quickly across the sky. Not as static shapes, but dynamically altering their form as they twist and tumble, with a three-dimensional complexity I find fascinating. On the surface so simple, but with depth and layers that are mesmerizing. Their future as unpredictable as Madison and Maya’s.

We all meet back outside the Union. There is silly chatter, pictures and piggy-back rides. We joke and tease and smile. Yesterday’s travel to get here, and tomorrow’s departure, forgotten for the moment. There is a levity surrounding all of us, with no expectation or agenda other than simply enjoying each other’s company. The four of us are not just in close physical proximity to each other. The rhythms of our interactions are in sync in a way that has been missing for quite a while. Our individual orbits, for now, have become one.

Newton’s law of universal gravitation states that a particle attracts every other particle in the universe. In high school physics, I struggled with this concept, that the person ten feet away was exerting a gravitational force on me. But now I do appreciate the pull of my family’s orbits. A few months ago, the intensity and depth of our connection was present but not felt. Similar to my patients who appreciate the impact of their medicine  only in its absence, I am now more aware of the forces that bind and connect my family. And for the moment my world is perfect.

 

 

My wife miscarried while I was on call. What this medical resident chose to do.

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The day began the same as yesterday. As well as every day prior to that for the last few months. I was tired. Exhausted. The type of fatigue that envelops your brain in a dense fog, altering the way you see and hear the world around you. The type that impairs your ability to think clearly and process efficiently. It was the cumulative fatigue from too many nights of disjointed and ineffective sleep. My two children the culprits at home, my pager when at the hospital. The alarm clock told me it was 5:00 am and time to start moving. I was the senior resident on call for a busy general medicine service. I got ready mindlessly and drove to work, leaving my three-year-old son, ten-month-old daughter and pregnant wife behind.

The page from my wife would come a few hours later, while in the middle of hearing about a new admission. I called her back, expecting a generic morning update on the kids.

“I think I’m miscarrying.”

In my worn-out state, there was no reflexive response. Like the origin of a wave as a swell forms and the water gently rises, confusion first surfaced in my head. As the swell of emotions picked up momentum and power, sadness and feelings of loss crashed in. Then guilt over fleeting thoughts of being saved from even more sleepless nights another baby would bring. As the waves passed, I was left with loneliness. So far away from my wife at the moment when she needed, WE needed, to be together. I did something in that moment I had never done before. I called the chiefs and asked them to call in the resident on jeopardy to cover for me. Within a few hours, I was home at my wife’s side.

We sat together. We talked. We cried.

But as a few hours passed, the fact that someone else was covering for me caused increasing tension. Someone was doing my work for me. Admitting patients with my team, because I wasn’t there to do it. And as the sun set on the day, my wife turned to me and said, “It’s ok. Go back to the hospital. I’m alright.”

And I went back.

Thinking back to that moment, my stomach still twists in knots. How could I have walked away? How did the culture of medicine lead a fatigued, and emotionally exhausted, young doctor to leave his wife, who had just miscarried hours ago, to care for two young children on her own?

Did it start in medical school? Initial thoughts of self-doubt, and feeling like an imposter, slowly faded as we internalized subtle, and some not so subtle, comments from faculty. “You deserve.” “You belong.” We were told we were on a path to a higher and more noble calling, with great purpose and responsibility. Something bigger then ourselves. Whether from self-doubt or self-importance, we were driven to study. We spent hours reading and learning, dissecting and memorizing. We prepared for finals, mini-boards and shelf exams. And while doing so, our friends of old, no longer enmeshed in academic studies, enjoyed the perks and freedoms that came with new jobs and real incomes. We were too tired and too immersed in our narrowly focused world to connect with our friends. And as the dynamics started to shift in those friendships, we became a little more isolated.

Did it continue when we began our clinical rotations? The residents we looked up to as role models were always present and available. They taught us clinical pearls, ran codes confidently, and handled emergencies calmly. They were described as “strong.” So we emulated them, making ourselves present and available as well. For our assigned patients or a potential procedure. To be noticed. To be evaluated. To be appreciated. Those traits were deemed positive, earning merit. Never mind life outside the hospital walls. Reading a book for pleasure, enjoying a run along the lake, and being emotionally and physically available for our partners and children weren’t skills that made it into letters of recommendation.

Did it continue in residency? We took on more responsibility for our patients. Admit them, document them, draw their blood, administer antibiotics, check the labs, update their families, and plan their discharges. “To do” lists to be checked off before we could sign out and go home. In one month we would work twenty-six days. Seven of those were spent working overnight, non-stop into the next. Four days a month we were allowed to keep for ourselves. But those four days did not make up for being absent physically and emotionally for twenty-six. Not there to take out the garbage or help with laundry. A no-show for a friend’s birthday party. Too tired to take a turn rocking a child back to sleep in the middle of the night. Exercise or making a home cooked meal was off the table, when just keeping your eyes open for the car ride home from work was considered a win.

Did it continue in fellowship? Being on service or working in the clinic was not enough. There were patients to recruit for trials, night-classes to attend, and research to do. We needed to write another chapter and apply for another grant. That’s what our mentors and department chairs did. In the meantime, we weren’t there for our own children’s scarlet fever, chicken pox, recurrent strep throat, first steps and first words. What free time we had was spent moonlighting, as we tried to keep up with ballooning school loans, mortgages, and college savings for our kids.

 At every step on the path to becoming physicians, the messages were clear. Be present. Be available. Leaving early was weak. The students, residents and fellows who stayed were dedicated and serious. Impressions were formed based on being visible. Evaluations were determined by our perceived dedication. But if, in the process of being ever present and available, we struggled to make it through the day, how could we be there for ourselves? To rest and recuperate. To think and process. And if not able to care for ourselves, how could we care for others?

It’s no wonder that in a 2015 JAMA systematic review, average depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2%. In a similar article in JAMA 2016, the prevalence of depression or depressive symptoms among medical students was 27.2%, and the overall prevalence of suicidal ideation was 11.1%. And these numbers don’t address other mood disorders, such as anxiety, or the dysfunctional and harmful coping mechanisms of alcohol and drug use. It’s not surprising that there are so many struggling or failed marriages among physicians, as well as rampant burnout.

In medical school, we are taught about cells, tissues, organs and systems. We learn to write histories and perform physicals. We are preached to about antibiotics and anti-hypertensives. But where in the curriculum are we taught to care for ourselves? When in residency were we told to go home and make sure to be there for our families? When in fellowship was physician wellness placed on the same level as grant writing and lab techniques? Why is focus on family merely tolerated by our peers, instead of modeled and emulated? Too be fair, there have been a few mentors and role-models who showed us how to not only set appropriate limits and boundaries, but taught us that it was acceptable to protect our home lives from our work lives. But they have been outliers. Exceptions. Too often their solitary voices drowned out by the masses.

For too long, the culture of medicine has promoted this choice as binary. Spending time in the hospital to learn and care for patients versus spending time with our families. A zero sum game. But it doesn’t have to be. Why can’t there be a culture that promotes both? So far, attempts to normalize and humanize training have narrowly focused on specific issues such as work hours and work environment. But the culture of training new physicians also needs to change. Setting appropriate limits and boundaries, as well the concept of physician wellness, should be as prominent in the curriculum as human pathophysiology. We talk about developing the skills required to be a life-long learner in today’s internet-connected fast paced world. So too should we talk about promoting clinical excellence and dedication, but not at the expense of their families or their own happiness. Spouses and children should not bear the consequences of a flawed system.

There are only a handful of things in my life that, given another chance, I would do differently. My choice to pursue a career in medicine is not one of them. I love this profession and the unique opportunities it provides to help people in powerful and meaningful ways. But I do wish I could go back to that day during my residency when my wife miscarried. I wish I had stayed home with her.

Throw back Thursday

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If I knew then, what I know now…

I would hug them more. For longer. Squeeze harder.

I would listen more and react less.

I would be sillier and goofier with them and pay less attention to the thoughts of others.

I would cave in more often when they would ask for “one more” bedtime story or book to read or batting practice pitch thrown.

I would write and share with them just how beautiful they are.

Faces and Futility

The patient, previously a John Doe, is now known. Family now present, when before there was none. A spouse, siblings, and young kids all around. Despite seventy-two hours in the ICU, his lungs have failed, his heart has failed, his liver has failed, his kidneys have failed. Too unstable for dialysis, his potassium level climbs higher and higher, despite attempts to slow down and mitigate its lethal effectCardiac arrest is no longer an “if” but a “when”, having reached medical futility.

Kids at the bedside, so young. Unaware. Watching. The face of their dad distorted by tubes in his mouth, IV tubing tugging on his neck, eyes yellow from jaundice, skin all swollen and puffy from edema. Family tension between his siblings and his wife percolates, as his heartbeat becomes more erratic and slow.

In the hallway outside his room, I have a hurried discussion with his wife. She is overwhelmed. Burdened by feelings of guilt competing with anger. Her sadness and despair are palpable. Their last words, their last fight, was days ago, before he was found in a locked motel room, with alcohol around him. Inside him. Poisoning him.

His heart stops while we are talking. We go into his room.

Kids at the bedside, so young. Unaware. Watching. The face of their dad distorted by tubes in his mouth, IV tubing tugging on his neck, eyes yellow from jaundice, skin all swollen and puffy from edema. His heartbeat no longer erratic and slow, because it is no longer beating. This outcome was already determined hours ago.

Compressions will not lower his potassium. IV’s have been pouring adrenaline non-stop into his heart and veins. All to no avail.

I tell the wife to hold his hand and say goodbye. We are not doing compressions. She does not argue.

Is it assent or consent? Medical futility? All of the above?

She holds his hand. She yells. She cries.

Kids at the bedside, so young. Unaware. Watching.

Years pass. I no longer see his face, distorted by tubes in his mouth, IV tubing tugging on his neck, eyes yellow from jaundice, skin all swollen and puffy from edema.

I still see their faces. The kids. They have not left me. I doubt they ever will.