Thursday, October 31, 2013

Happy Halloween!

Having a child yourself brings back memories of childhood. I’ve found myself singing scraps of old songs learned in elementary school and not thought of for decades, like the one I found myself singing out loud earlier:

“Jack-O-Lantern, Jack-O-Lantern
You are such a funny sight
As you sit there in the window
Looking out at the night

Once you were a yellow pumpkin
Growing on a sturdy vine
Now you are a Jack-O-Lantern
See your candle light shine.”

I learned that when I was about seven years old, I think. I don’t think I’ve thought about it since, until it sprang to mind (and voice) while I was walking down a corrider at work today. I’m grateful that no one was around to hear me. Although I’m disappointed that no one noticed my Halloween socks. We are allowed to wear costumes to work on Halloween but the guidance is that if you might need to talk to a patient about something serious you really shouldn’t be wearing a costume. Since my job as a psychiatrist is pretty much always and only about talking seriously with people, I thought I would refrain from dressing up.

I was remembering my old Halloween costumes today. When I was little my mom made Halloween costumes for my sister and I, and for my dad too when we were really little. I have picture of us in matching lion outfits from when I was three or four. I can remember the blue fairy costume and the angel costume and the Native American princess costume from my early elementary years. I remember how beautiful I felt, all dressed up for the evening. I remember walking around the neighborhood with my sister trick-or-treating and becoming so weary.  When we had passed every house we would head for home, bringing the candy back for my parents to inspect before being allowed to eat two pieces.

My daughter and I went trick-or-treating around our little neighborhood early this evening. She wore a princess costume that my mom had bought her for her birthday, and I was grateful she had decided on that instead of insisting on being a ghost, which was her original plan. I couldn’t find a ghost costume in her size and I was nervous about her ability to move around safely with her head and body covered in a cut up sheet. She was a charming princess though, particularly with her plastic tiara nestled in her curly hair. We smiled and said “Happy Halloween!” and discussed which houses might have people at home (looking for the houses with lights, of course). We had just made it around the cul-de-sac when it started to lightly rain and she announced that she had plenty of candy and that it was time to go home. My husband and I inspected her candy (for peanuts, since she is allergic) and let her eat two pieces. Then she helped us give out candy to the older kids before she had to go to bed.

I’m glad I have so many happy memories to enjoy when they come drifting back on the wings of my daughter’s childhood. I hope that I am helping her make her own lovely memories to haunt her life to come.

Monday, October 28, 2013

Compassion is Caught, Not Taught

I read these words today and this is the story I remembered.

In the early morning at the end of a twenty-four hour shift I stood over a newborn boy in the cold, brightly lit newborn nursery. His heart rate was fine, he was breathing easily, and he was moving his arms and legs. But his nurse had called me because his blood oxygen saturation stayed stubbornly at seventy percent, instead of the normal ninety-nine. What could be wrong? We tried giving him some oxygen, which didn’t help. We tried rubbing his feet and back, which sometimes stimulates deeper breaths. That didn’t help. As a senior resident I hated to do it, but I turned to the nurse and asked her to please call the attending physician for help. While we waited for him we tried suctioning the baby’s mouth and nose. His heart rate was still fine, so I wasn’t panicking.

My attending stepped into the room and said, “Why haven’t you tried positive pressure ventilation?”

I immediately grabbed the mask and the pressure bag and started giving the baby breaths. Positive pressure ventilation! Why hadn’t I thought of that? Within 3 breaths the little boy’s oxygen saturation was back where it belonged. We stayed next to him, monitoring until we were reassured, then retreated back to the on-call room.

“Tell me what you were thinking.” my attending said.

Now I wanted to panic. Words tumbled out of my mouth. “His heart rate was fine, and he was breathing and moving, and usually I don’t go to positive pressure ventilation unless the heart rate is less than 100.” Inside my mind I thought “Oh my God. Obviously that was wrong. I could have killed that baby. I should have known better. Oh my God.” I started to cry. Not quiet tears rolling down my face that I could discreetly wipe away. Huge sobs, choking off my breath and constricting my chest and sending a knife through my throat. Tears that left me gasping, unable to hide my distress. Now I had “Stop crying you blubbering idiot.” crashing around in my mind in addition to “Oh my God.” All I could force out between the sobs was “I’m sorry, I’m sorry, I’m sorry.”

My attending, a reserved and distant man I didn’t know particularly well looked at me calmly. “You’re really hard on yourself, aren’t you?” he said quietly. “It’s okay. Nobody died. Just learn from it. You don’t have to be perfect.”

Doctors are perfectionists. Graduation from medical training is built on decades of relentless hard work, at times brutal self-denial in service of learning, achieving, perfecting, succeeding. Doctors are the best of the best of the best, and failure is not permitted because it could kill someone. It doesn’t matter how 
tired, hungry, sick or in pain you might be. Mistakes are not tolerated.

I wish I could say that my attending’s gentle words freed me instantly. Instead, I slowly calmed down, we talked a few more minutes analyzing the mistake in my thinking, and I went home at the end of my shift to rest. But those soft words have echoed and grown through my years as a doctor. Now mine is the voice that murmurs to my students, my colleagues, and my own face in the mirror. “It’s okay. Nobody died. Just learn from it. You don’t have to be perfect.”

Saturday, October 26, 2013

Airlines Don't Care

On our flight home from San Francisco my husband and I encountered a two-hour delay. Generally I would not find this dreadful, but since we had chosen an overnight flight I was already tired and wanting to fall asleep. A delay from leaving at 11pm to leaving at 1am felt pretty painful. It was even more painful because it felt completely preventable. We were about 15 minutes late getting onto the runway. Unfortunately, the runway at that airport closed at 11pm. Which was apparently a huge surprise to our flight crew, although it really shouldn’t have been. It’s their business to know about details like when the runways close. So the 15 minute delay turned into a 2 hour delay.

In the end I have to admit that’s not really terrible. We still got home, we still travelled safely and it’s still amazing to be able to travel cross country and back in a weekend. I think what really bothers me though is that airlines just don’t care. You can hear it in the perfunctory apologies from the crew and the gate agents. Their “I’m sorry” has a ring of “Please shut up and don’t bother me, I don’t really care about your life and don’t want to waste time on you.” You can hear it in the form e-mail I received in response to my complaint that essentially said “You’ll hear from us if you decide you deserve some money back but otherwise don’t expect a response.”

I’m not naming airlines here because I’ve flown them all and the experience is about the same. I usually fly about 4 times a year, some years more (which I think is a lot for a non-b, and most airlines are happy to boast about their customer service and show you a video about how happy they are that you’re flying with them. But when it comes down to owning up to mistakes and even just honestly apologizing, forget about it. I think this is because the airlines know they are all about the same. You can say “I’ll never fly such and such airline again!” and maybe you won’t but if you fly anywhere, on any airline, you’re likely to have the same experience in the future.

I acknowledge that I keep this system going. I keep choosing to fly, because I love to travel. I love to get across the country and see friends. I have lots of good friends on the west coast, some of whom I didn’t even get a chance to see this time and many others who I’d like to see again. With the amount of vacation time I’m allowed, I can’t make it to the west coast by bus, train or car and back again with enough time left over to actually see my friends or even do anything fun along the way. It really is amazing that it only takes a day to go from Washington D.C. to San Francisco or Seattle and in the end I can’t resist. So I know I’ll keep choosing to fly and putting up with the inconveniences.
I suppose the only thing I can do is learn to stop fighting reality. I can expect and plan for delays by booking flights early in the day and well before I need to be where I want to go. I can acknowledge that airlines don’t have much incentive to change because they are the best alternative for most trips and so people aren’t going to stop flying – that lets me let go of the demand that airlines be something other than how they are. I can try to be more zen about the whole thing. It’s just hard to be zen at 1 in the morning.

Thursday, October 24, 2013

The Fine Art of Bargaining With A Three-Year-Old

My husband and I don’t usually fight with our daughter about what clothes she wears. She wants to wear a brown and orange flowered dress with florescent yellow, green and pink striped leggings? Sure, go for it (yes, that was a recent outfit). Part of this is that my husband, as a stay-at-home dad, is responsible for getting her dressed in the morning. He’s colorblind, so it makes fighting a daily battle over ensembles truly pointless, since there’s no guarantee that his choice will work any better than hers. He does the laundry too, so outfits don’t tend to stay together. Hence the decision that clothing choice is a pretty reasonable area for her to start having some control. We do reserve a veto for hygiene and weather appropriateness but otherwise we let her pick out what she’s going to wear that day. Except yesterday was school picture day.

I’m a sucker for school pictures. I always end up buying them to send to grandparents and to tuck in cards and for my own wallet. So I really wanted her to wear matching clothes yesterday, something to compliment her basic adorableness. I discussed this with her and she picked out a nice tunic with purple and black and white flowers. I told her she needed leggings and she let me pick out the black ones for her. So far, so good. Unfortunately, then she decided to add the dark blue skirt with red and yellow flowers over the leggings under the tunic. Arrgh! Now I feel stuck, because we have told her that she’s allowed to pick her clothes. I don’t want to take that back when really, she’s mostly doing a good job. Plus I am trying to get ready for work myself and am not eager to inspire a tantrum. But I really, really don’t want her to wear that skirt.

“Sweetie, can you take the skirt off?” I say.

“No!” says my daughter.

“Please? I want you to look pretty in the pictures at school.” I say.

“I think the skirt is pretty! It’s very pretty!” she says back.

Having an articulate child is not always a blessing. It’s hard to argue with taste I guess, but I still don’t want her to wear that skirt. I want the pictures to look good to MY taste. So I decide to offer a deal.

“Please?” I say. “I’ll let you pick out my clothes this morning.”

“Okay!” she says.

I know this sounds risky, but I don’t have that many different work clothes so I didn’t think she could go too far wrong. Tan, brown, blue and black pants pretty much go with anything, after all. Plus I know she loves picking out my clothes; when I get home from work she often asks if she can pick a T-shirt for me or pick a pair of jeans out of my drawer. I think that might be because I usually let her borrow one of my shirts to play in at the same time. Or maybe she just enjoys the chance to be the one in charge sometimes.  

My strategy worked like a charm. She went to school in her tunic and leggings sans clashing skirt. I went to work in black pants and a pink sweater instead of tan pants and a black sweater. Both of us were happy and looking good. That’s what I call a win-win situation!

Monday, October 21, 2013

Motherhood = Guilt

I wrote this over the weekend while my husband and I were away. I couldn't post it due to internet access issues. Then my guilt became a lot worse this morning when we returned home to find that our daughter had been ill with a fever all day yesterday…. I suppose it just proves the point.

This isn’t an astonishing new insight, but being a mother means feeling guilty. When you take that tiny person home from the hospital they don’t tell you that you’ve also just brought home your very own automatic infinite supply guilt dispenser. You get to figure that part out on your own. It doesn’t take long. Right around the first time you start desperately wishing someone else would take over so you and your husband can go out for a nice walk together you realize that guilt is now going to be a constant companion.

I don’t know any mothers who don’t feel guilty on a regular basis. My friends who work feel guilty about being away from home, about missing out on different events, about putting their careers first. My friends who stay home feel guilty about not working and giving their children more of a financial advantage and about not modeling feminine independence and career mindedness. All of us feel guilty for not enjoying our kids more, for being impatient, for wanting some time to ourselves again, and for generally letting our kids down. Pretty much whatever you do, you can doubt yourself. The internet makes it worse because in a few clicks you can access information telling you that you should be doing something else – sleep with your kids in your bed. No, make them sleep in their bed. Play with them and give them attention. No, make them learn to play independently. It’s enough to make you pull your hair out.

My particular guilt this weekend is that my husband and I are away. We are away and pretty far away at that, since my boss was kind and allowed me to take leave (the government reopened anyway, but we didn’t have to cancel our plans two weeks ago) so we could attend the wedding of a very dear friend. We decided a long time ago that the trip was too long-distance and too short-time-frame to be reasonable for a three year old, and my mother graciously agreed to come up and babysit. So this morning we woke up early, kissed our daughter good-bye, and headed for the airport.

Mind you, I don’t have any rational reason to feel guilty. My daughter absolutely adores my mother, and I know they are having a ball together. I called home when we arrived and my ears were filled with stories about playing princess and cooking and legos and a great day at preschool. They are going to a pumpkin patch with pony rides tomorrow. If that isn’t enough, my daughter’s other beloved grandparents are coming down on Sunday to spend time with her and my mom as well. She’s going to be spoiled completely rotten with three doting grandparents on the job and no Mom and Dad around to set limits on the fun. I suspect she’s probably not even missing us, to be honest.

My rational mind also knows that a trip like this is good for my husband and I. We haven’t had an extended period of time to relax together in almost a year. 2013 has been filled with injuries, moves, work and the daily routines of home and parenthood. We’ve been overdue for some time to reconnect as a couple. I’m definitely a believer in the idea that happy parents create happy families, and that means keeping the relationship between my husband and I strong. We also wouldn’t have wanted to miss our friend’s wedding; we are so happy for him and for his fiancĂ©, who is absolutely wonderful herself, and we had a chance to visit with some old college friends we haven’t seen in way too long.

Rationality has very little to do with feeling guilty. No matter what I tell myself, I feel guilty being away from my daughter. I’m still having fun, but I feel guilty. 

Tuesday, October 15, 2013

Segway Tour: It's fun! Don't judge!

Have you ever been on a Segway tour? I went for the first time this past weekend with my husband, my mom, and my sister. My sister had bought us the tickets for a guided tour of Washington D.C. last Christmas but between my broken ankle and my mom’s foot surgery and all of our busy schedules it took us until October to schedule the tour. My mom and sister arrived at our house Thursday night and all day Friday we prayed the rain would stop in time for our tour on Saturday. Which, thankfully, it did. So we headed out to the city with cheerful hearts while my daughter stayed home with her favorite babysitter.

Segways are not hard to ride, but it took me a while to get used to it. You use your body weight to move forward and backwards. Lean forward and the Segway rolls forward. The more you lean the faster it rolls, up to 12 mph. Lean left and right to turn and lean backward to slow down or move backwards. If you want to hold still stand perfectly upright and balanced (not easy). I’ve noticed that since I broke my ankle I am anxious about unstable surfaces and the possibility of falling. So at first I was scared stepping up and down off the platform and rolling back and forth. Fortunately our guide was patient and kind and the company (Capital Segway in downtown D.C. is the company we toured with: gives you a little lesson in the store and then takes you to a nearby park to practice before you hit the streets. By the time we really got going I had mastered the controls although my feet were cramping from tension at first. After about the first hour I felt comfortable with it and was able to relax and enjoy the stories our guide was telling via headset.

Touring D.C. by Segway during a government shutdown is still fun. The monuments and museums are closed but you can’t go into them on a Segway anyway, and you can still look at the buildings. We were able to cover about 7 miles of touring in 2 hours, which is much more than we’d have managed walking in that time. We zipped past the White House, the Vietnam memorial, the Lincoln Memorial, the Martin Luther King Jr. Memorial (which we slipped inside to see while our guide watched the parked Segways… I think Congress needs to take a field trip down there and read the words engraved on the walls). Then back up past the Washington Monument (covered in scaffolding) and up the streets that line the National Mall. Which are currently open to pedestrians and bikes but not cars, so we were able to take the Segways up to their top speed of 12mph and cruise up the empty streets. We stopped in front of the Capitol building, which is still beautiful despite the people who work there. Then back up through D.C. streets to our starting point.

About the only sour note in the entire outing was the bystander who felt called upon to call out “Nice exercise!” in a sarcastic sneering tone as we guided the machines up a ramp onto a sidewalk. Since I was still focused on staying on the Segway (ramps were a little nerve wracking throughout the tour) I didn’t respond. I probably wouldn’t have anyway, since I don’t typically engage in arguments with strangers on the street. But what I wanted to say is “Hey buddy, back off. I’m not stupid. I know I’m not getting any exercise here. That isn’t the point of today’s adventure. I’ll take a walk later today for exercise, but the point of this tour is to spend some time with my family doing something fun that I’ve never done before. So don’t judge!”  

Obnoxious pedestrians aside, it was an outstanding outing. I learned some things I didn’t know about the city I live in (the National Gallery of Art has a tunnel connecting the East and West wings! I will have to check that out if the government ever opens up again!), I shared a mild adventure with my family, and I learned a new (albeit somewhat useless) skill. That’s a great way to spend a Saturday.

Friday, October 11, 2013

Don't Reward Bad Behavior - Temper Tantrums for Kids and Politicians

I’ve heard plenty of references to the government having a “temper tantrum” when people talk about the government shutdown. Usually when some says “do what I want or I’ll hurt you” we call that extortion and it’s considered a crime, but okay. Let’s talk about temper tantrums. As a parent of a three-year-old I can tell you quite a lot about tantrums.

My daughter threw a tamper tantrum the other night. She did something wrong, we told her to stop, she didn’t stop, we gave her a consequence, she had a tantrum. This isn’t an uncommon sequence of events, because three-year-olds don’t have a whole lot of emotional control. So my husband and I have agreed on a way to cope with tantrums. First and foremost, we never, ever, ever give in to or reward a tantrum. The very fact of the tantrum means that she loses whatever it is she wanted, even if we normally would have given it to her. We agreed on that rule before she was born and we’ve stuck to it so far. Second, we don’t give her attention for a tantrum. If she has a tantrum at home she goes to her room and she can come out when it’s done. If she has one in public we stay with her (for safety) but don’t speak to her until she’s done. These tactics work pretty well; my daughter has temper tantrums but they tend to be short and not very frequent. Even at the very young age of three, she’s learning that temper tantrums don’t pay off. It’s a lot of effort for not much reward.

A key principle of human behavior is that we do what works. Human beings are results oriented. I first learned these ideas in my psychology 101 class back when I was a sophomore in college. Behavior that results in positive consequences, or a reward, will continue. In psychology terms we would say that behavior has been “reinforced.” Behavior that results in unpleasant consequences, or punishment, will cease. A psychology class will go into all kinds of permutations on this theme, talking about reward schedules (how frequently the behavior earns a reward – unpredictable intermittent rewards are actually the most reinforcing – hence gambling becomes such a problem - while unpredictable intermittent punishments don’t do much to stop behaviors) and positive vs. negative reinforcements but the core idea is really simple. If the behavior gets a result you like, you’re going to do it again.

In psychiatry we use these ideas about reward and reinforcement all the time. They are an important part of how we think about habits, addictions, learning, parenting, interpersonal relationships and many other aspects of behavior. Apparently we can apply these ideas about behavior, motivation and reward to politics as well. Right now congress is not doing its job by passing a budget and the government shutdown is hurting the entire country. A default on our debt, if it happens, will hurt us even more. I would call that bad behavior. And so the last thing anyone should do is reward it.

I agree with the president’s position that he won’t negotiate while the government is shut down. I don’t ever want Congress to do this again, and if it works for them, if they get what they want through refusing to pass a budget or raise the debt ceiling, then you can be certain that eventually the government will shut down again over some new issue. Remember, behavior that is rewarded is repeated. Therefore you don’t negotiate with toddlers having temper tantrums. You send them to their rooms to calm down.

But I hope the American people will take it further. In my more cynical moments, I think the reason this fight is happening now, in 2013, is because congressional elections aren’t until 2014. Which gives the American people a whole year to forget how badly our elected officials have behaved before they have to stand for re-election. I suspect our congress people are betting that we can’t sustain our focus and anger for that long, and that they will get away with their tantrum. I can see why they might think that. As a collective we do seem to have pretty short attention spans when it comes to major public outrages. But Congress, I promise you that I will remember. And when election time 2014 rolls around I will be reminding other people. Because I don't reward bad behavior.

Thursday, October 3, 2013

Government Shutdown: A Personal Perspective

There are plenty of people writing about the government shutdown. I’m reading articles about how it’s affecting people in different ways and how it’s affecting all of us as a society. I’m reading about the President’s stance and the House Republican’s stance and how the prospects of the government opening up soon don’t look too good. And this evening I’m reading about a woman who, according to current news reports, died on Capitol Hill today after ramming her car (!!with a child inside!!) into a barrier. I have no idea if that’s connected to the shutdown or not. It’s just terrible, no matter what the story.

With all that, I wonder if it’s even worth writing about the shutdown in a personal way. And yet as I read the news it seems like there are still people who don’t get how big and real this is to so many of us. There are still people who are saying that this is okay. I don’t know if those people will read this. Probably not, right? But the shutdown is not okay with me. It’s real and it is making a big and personal impact.

I’m a federal employee. I’m one of the fortunate ones whose work was deemed essential, which means I’m still working this week and that I will eventually get paid for the work. The key word here is eventually; I won’t get paid until Congress passes a budget so that there is money to pay my salary. Like the all rest of the federal civilians I’ll be living off savings until then. I’m very blessed that I have some savings to do this, because not everyone does. I also count myself fortunate that at least I will get that money back again, unlike my mom, my brother-in-law, and several friends who are involuntarily sitting at home this week. They aren’t celebrating or having fun, they are worrying about how they will get the bills paid. They have no assurance that this loss of pay will be made up to them eventually. I’m worried about them.

Because the furlough is going on, I’m not allowed to take my earned vacation time from work right now. My work was deemed essential, remember? That means I have to be there, even though I had previously been approved for a few days vacation in a few weeks. So that trip in a few weeks to attend a good friend’s wedding, the trip I paid for months ago and have been looking forward to for those months? I may not be able to go at all. It depends on my director granting permission for me to be furloughed without pay for a couple days. It’s not a matter of obtaining coverage, because I’ve worked those issues out. It’s just a matter of policy. I know my friends will understand, but it’s not the kind of event you get a second chance to attend.

My daughter has been asking to go to the zoo. We live near Washington D.C. and the National Zoo is one of our favorite destinations. We also love the Natural History Museum which has dinosaur bones and a butterfly pavilion. Both of those are closed right now. Have you tried explaining to a three-year-old that the government is shut down and that’s why she can’t go to the zoo? And then that she can’t go to her favorite museum? It didn’t go over well.

At work I’ve seen several patients now who have been suicidal because of the financial stress of the furlough. These are hard working, middle class people who won’t be able to pay their mortgages until Congress gets its act together and passes a budget so they can go back to work. Even then they will be scrambling to catch up and make up for that missed pay. If the shutdown continues it becomes the kind of blow that can wreck a family financially. People do kill themselves in despair over financial problems. I can try to help but I know I can’t save everyone. Those lives aren't replaceable. You can't measure them in dollar amounts because they are of infinite worth. But if this keeps going on, some lives are going to be lost.

Some of those issues, particularly the ones that are just mine, are small, I know. I do count myself as someone who is very lucky. If you are in agreement with the shutdown, I guess you could read this and shrug. You could say “so what?” or “big deal!” or “you made your choices, live with them.” And I would say you’re right. My problems aren’t huge. I mention them because they are mine, and they are real, and I want you to understand that this isn’t a game or a story. This isn't some minor blip that will quickly be forgotten. 

You're right to say my choices are my own. I made a choice to serve my country, both as an active duty military member in the past and now as a federal employee. I made that choice with the expectation, which I think is reasonable, that my country would hold up its end of the bargain and continue to function. I think it’s not unreasonable for me to expect Congress, whose members are also paid to serve, to honor its own responsibilities by passing a budget.

I blame Congress for the shutdown. The passing of a budget to keep the country running should never, ever be a bargaining chip. It should never be a tool for a minority to terrorize the majority into giving them what they couldn’t win through elections and legislation and courts. It’s too important and too many lives are affected. Members of Congress, please be aware that you are hurting real people with your actions. As you posture and play games and insist that you be given your own way, you are damaging real lives. And if you can’t act with wisdom and compassion, you might consider acting with your own self-interest in mind. After all, even if you don’t care about me, I will remember you. And I vote.