Monday, November 24, 2014

Grace under pressure

Tonight both girls are in a horrid mood. There is screaming from one, then the other, then together. Little Monster is cutting molars and the kid is... Herself? Something is wrong but she has no idea what and is a terror because she's upset. We went out to dinner because the house is a disaster and we host thanksgiving Thursday and exhaustion and long commute are winning. At dinner the kid didn't eat until we were ready to leave and she was suddenly ready to eat enough so she could have dessert. This rotation's 2.5 hour daily commute is decidedly taking its toll on me especially, but all of us at least some.

I never understood grace before this year. I mean, I'd heard the word over and over. I'd heard it defined as poise, as the free pass we get when we are forgiven for something. I'd heard about giving yourself grace as a way to cut yourself some slack. I don't know about you, but I am terribly hard on myself. In many ways it's deserved; I'm a person and therefore imperfect, and I'm a particularly ordinary person with some reasonably common flaws that run riot in my life if I don't work hard to keep them in check. Most of the time, I am too hard on myself and I attack my flaws perhaps more than I ought. It's easy to dwell on how nothing is ever right.

In the past little while, I've been practicing forgiving myself for being human. It works sometimes and others it doesn't. Grace is there if I want or need it. Well, when I want and need it. All I can ever do is my best.

But then there is life. Everything crowds my little tiny bubble of "I don't have to be right, I don't have to have all the control, it will be fine probably so stick to the next right thing" affirmations. I yell. I curse a great deal. I lose my temper after the first test of my boundaries instead of the tenth (my goal). It is so hard to find grace in the screaming (usually not me for too long) that I lose faith in the whole exercise of allowing myself to be imperfect. In an awful lot of messy situations, I have been collected and said and done sane things, the right things even. I know that I have access to that grace within myself. I just don't know how to operate day after day with children prodding at my weak points constantly and still find that place where I can think and act from a place that allows them grace too.

Little Monster is sure she is 2 and yells and tantrums to demand things. For the most part, that I cope with all right. I get so frustrated with myself when I can't cope with the kid doing much the same thing. After all, we have had the best part of 5 years to adapt to her tantrums and screaming... and yet it is impossible lately for me to cope. That makes me think I totally missed the mark learning about grace and that I have a very long way to go before I can hang onto any semblance of grace under child-inspired pressure. 

The best part is that I have tomorrow to try again to be a smidgen better than I was today. And please, all that is holy, let there be less screaming tomorrow.

Thursday, October 23, 2014

There and back again

It's strange to go home after a month away.

I can tell you I have learned the value of having a pharmacist in your healthcare team. From chatting with patients in this clinic pharmacy, I know it takes an hour or more sometimes to check in to see a doctor and that they only see walk-in appointments for a few hours a day. It takes at least 2 hours and sometimes much longer to get a call back if you leave a message for the nurse of a provider. If a patient called the pharmacy, they spoke to a pharmacist within 3 minutes. Sometimes we could triage what was wrong (go to the hospital if you take a blood thinner and fell and now you have a headache, go to the ER if you are throwing up blood after taking a new medication, try taking your medicine with food or on an empty stomach if it makes you sick or isn't working, you are supposed to take 3 every day and not just one so see if that works, etc) sometimes we couldn't (make an appointment if you need a refill on that medication that was stolen... again...) but at least people got their questions answered rather than waiting hours. That accessibility of pharmacists is sure valuable. Then again we are often too accessible. No other healthcare provider is as likely to work overnights as a pharmacist. Doctors take turns covering nights but not regularly working them, we have a regular rotation of night pharmacists in hospitals and community pharmacies. It's really easy for people to demand to see us too, and they sure do, often to ask silly questions like:
  • "I want a flu shot. Where do I sign up?" while standing under a sign that points to "Check in for your flu shot here!"
  • "Where are the paper towels?"
  • "I need a refill of my medication." "OK, you can talk to my technician over there." SuperTech: "Which medication would you like refilled?" Patient: "The little green one." ST: "What do you take it for?" Patient: "Because my doctor says I need to take it."
  • "Why won't you vulcanize my tires while I wait?" 
So maybe that last one is a Clerks reference, but you get the gist. Because you can see the pharmacist in a community pharmacy and because we answer our own phones in the hospital, people make demands on a pharmacist that they would never dream of making on a doctor and yet we have similar educational backgrounds. Somehow pharmacists let themselves be used by everyone else, helping out people and getting nothing in return to the point that we make ourselves miserable.

Anyway, home. I've learned a lot and I'm really glad I had this experience, but it is so hard to be home. While I was gone, Little Monster learned to say "I love you." She wouldn't say it to me when we video chatted for the first few days after she learned it, but then she did it with no coaching or prompting at all, for like 3 minutes straight. She's so big. It boggles my mind.

Sunday, October 19, 2014

Compromised values

I'm getting ready to apply to residencies and this brings to the forefront a few things.

First, I really don't want to work for a religious institution. I think. Probably. Or at least not a particularly prevalent one that runs an awful lot of health care establishments. Think hospitals named after saints and you've got the right idea. I'm too lazy to disguise the name of this particular religion and I don't want to invite a legion of angry commenters here by using its name.

My major reason for not wanting to work for one of these institutions is the disservice done to women in the face of obstetric problems. Nobody with pPROM who wants labor induced should have to wait until signs of infection to do so. Nobody with an ectopic should have her tube removed because using the standard of care medication amounts to an "indirect ab.orti.on." I'm perfectly content to let anyone think whatever they want and use their own thoughts to decide on appropriate obstetric treatments for themselves, but I absolutely don't want a hospital to prevent a woman from getting appropriate care for any reason.

It gets a bit more complex though. I live in an area where the closest non-this-faith-based hospital is an hour and a half away across state lines. I don't think the hospitals nearer are doing any terrible things most of the time. They're just the only hospitals around and they happen to be run by some extension of this particular faith. The level to which they subscribe to the official doctrine varies but it isn't one of those things it's easy to ask before you work somewhere.

My personal job acceptance line has been "absolutely no job is worth having at a certain big blue box store" and "if at all possible, a job at a giant red pharmacy chain should be avoided." Beyond that I'd consider myself open but I continue to have mixed feelings about even considering such a religious institution while finding that an awful lot of the places that are otherwise appealing are also religiously affiliated... I'm continuing to consider the merits of maintaining my line as previously defined or to change my values to allow for working for a health system that has a faith-based sponsor.

Then I wonder if I'm compromising too much. There are lots of places similar to this one that we could move to that have secular health systems where I could work.

Second is that I am more likely to get a really satisfying job in a community pharmacy if I take a job offer sooner rather than later. Specifically the job interviewing season is starting in November and my classmates who work for a big chain are starting to be offered jobs there already. I really feel like we live in a decent place now and it would be nice to stay put if we can manage it, but that means working for a faith-based hospital system or getting a job with a chain community pharmacy.

Third is that I'm trying to avoid just going with the flow, or seeming to just go with the flow. My plan is to cultivate a few possible paths, to explore even the ones that are scary and that I'm likely to fail at, and to be on the look out for the ideal opportunity that is the right fit. I'm sure that I will know it when it arrives but I am impatient as ever. I want the certainty of saying, "Here are my career goals and I really want to meet them and I clearly see how I can accomplish that" instead of the liminal space that exists now where I have some pretty good ideas for what I'd like to do but I am unsure which direction is the right one for me, for us. If things go perfectly smoothly, I would love to work in a hospital doing clinical and technical pharmacy. If things go in another direction, I'd be very happy working in a community pharmacy. If things go in a third direction, I'd really enjoy working in an ambulatory setting.

So I guess I know what I'd like most but I'm not sure how to articulate the "I don't commit to one way yet because I don't trust my certainty of my own judgment" place that I'm in. I stick with the next right thing and I do that and then I do the next right thing after that. If I try to plan for years ahead I usually am wrong because I skipped that next right thing in favor of dreaming.

Thursday, October 16, 2014

To scale or not to scale?

I have never personally owned a scale. Not in a great many years now have I even had regular access to a scale. None of my roommates had scales so I haven't had access to one at all since I moved out of my parents' house better than a decade ago.

Lately I've been pondering if a scale would be a useful thing or a detrimental one. Obviously I'm attempting to get into proper shape which should eventually come with a good deal of weight loss. I'm also healthier now than I have been in a long time so I'm not visiting the doctor all too often so I have no accidental/coincidental scale access either.

My memory of having access to a scale is not friendly. The scale was a source of stress and a way to control something in a world that was spiraling out of my grasp. My weight became the only thing I even attempted to control and I did that through very damaging eating patterns.

So on the one hand, I think it would be motivating and helpful for me to know how I am doing in attempting to lose weight. On the other hand, I never want that disordered eating in my life again and I'm afraid of what having a chart of my weight would do to me.

On the third hand, I like to think I'm overall much healthier now than I have been before. Most days I think my mental health is pretty well taken care of and my physical health is improving with exercise. Maybe I'm giving the scale control of my life without it even being present to impact it at all. Maybe it would be no big deal to weigh in once a week or once a day.

But there again, I don't know. I want to make sure my girls develop some kind of healthy relationship with eating and their bodies. The kid eats so little and at most meals, Little Monster eats at least as much if not more (sometimes by double or more) what her older sister eats that I worry their approaches to food are going to set them apart as they get old enough to notice how different they are. We are probably already ruining them by pointing out the good things Little Monster does when presented with a new food ("Look, she's picking it up and smelling it up close! You could try that too! Why don't you just touch the fish stick? Oooh and now she's taking a bite! What a brave Little Monster! See? She likes it! That fish stick might be your favorite food and you are missing it, Kid!") and how great it is that she eats her food instead of ignoring it at meals and demanding 5 desserts afterward (and I'm sure Little Monster will also do that when she has words for it but since nobody ever gets 5 desserts, no matter how much they whine and tantrum, she hasn't tried to develop words for it yet).

I remember times when my mom spent days and weeks weighing herself a couple times a day before giving up or before giving up dessert and then dinner in favor of some fad diet snack she'd eat before we all did. I bet that stuff influenced me more than I realize. It isn't something I consider often but I know my body image is very skewed.

So where do you stand? Scale or no scale? Should I get one? How long of a trial do I give it? How would I even recognize if the scale were a problem?

Sunday, October 12, 2014

The weight of balance

I had a revelation the other week about life-work balance.

First I should explain how I'd always thought about balancing work and non-work life. I'd imagined one of those old torsion balances (we use those in the pharmacy with weights on one side and stuff on the other and a dial in the middle for adjusting it so the plates are even when it's empty) or maybe even just two plates hanging on a point in the middle. I imagined one side labeled "work" and the other either "family" or "non-work" or "life." I envisioned my day split into little identical weights that represented an hour each and I imagined myself putting 8 of them aside as sleeping time and then having the other 16 to divide between the two sides. I always envisioned balancing exactly 2 sides in a zero sum game (zero sum games are ones where there is always one winner and a corresponding loser, where resources go to one person or to the other person, where when someone gets something it is taken away equally from someone else).

It dawned on me the other day that balance can also be a very different thing. In a dance we balance too, weight on one foot or the other or both or neither. I heard an interview with a band talking about how they get people to dance to their unusual music (well, non-western sounding and with very different rhythm patterns). They said they try to dance along too as a way to show people where to put the weight in the dance.

So I realized that work-life balance doesn't have to be zero sum. It isn't choosing work or family or friends over the other where one inherently loses if the other is winning. Instead it can be a dance and I can put weight in different places at different moments but there is no winner or loser, it's all a beautiful mess together but the parts add up together to be the dance. If you never change where you put your weight in a dance, you crash or you are standing still. The ups and downs mix together and sometimes we need someone to show us where to put the weight but the dance is never meant to be a zero sum game. A leap in the air doesn't mean the ground is less important or less valuable or less important to keeping the dance going.

I feel like an important part of this is mentors. Someone who is already dancing who shows you how it might be done, who displays balance so you can emulate them at first and then do your own thing later. I think that's an important thing we can and should be sharing with each other - how are we actually making it work or not. That's one reason I am an avid blog reader of real blogs and not commercial ventures that pretend to be blogs. I like to hear how other people make life work with all the everything that happens to complicate what seems so straightforward.

I've added to my list of questions I ask myself every day now. It went from just "What are you doing to help other people today?" to include "What would you do if you weren't afraid?" and then "How are you being vigilant today?" Now I'm asking myself "Where are you putting the weight today? How do you stay in balance?"

Wednesday, October 8, 2014

Sandwiched

Have I mentioned how much I dislike being in the sandwich generation? It is so much. SO MUCH.

In case you're unfamiliar with those in the sandwich generation, it's folks who are adults caring both for parents and children. I'm a double sandwich in that I help a bit in caring for my grandma in addition to keeping an eye on what my parents are up to.

There's someone in my life who has a chronic condition that can be kept in check pretty well with medication. Medications need to be refilled and then picked up from the pharmacy for this to work. Once every now and again an appointment with a doctor needs to be made for more refills to happen. These sorts of resource-management and scheduling tasks are ones I could do with no problem. Many people do these sorts of things for parents and grandparents all the time.

Of course providing care for another adult isn't that simple. If the patient doesn't want to take their medications or if they are too busy to pick up a refill for a week or a month, it becomes the care provider's problem to deal with.

Thus far, I am opting out of managing anyone else's medications for a couple of reasons. Firstly, this person hasn't asked me to help and I am not going to offer. I am a busy person and I don't need to be stupidly signing up for more work than I already have. It's a way of preemptively saying no to work I don't really have time for, to just not offer to help.

Secondly, I want to encourage the maximum independence possible. I am part of an extended family that gets really codependent and way too involved in each other's business. It is healthy for everyone to take care of themselves. It keeps them from playing the victim if they don't get exactly the care they expected (which would inevitably spiral from "please make sure my medication refills get ordered" into "but why didn't you pick up the other 10 things I didn't tell you I needed from the pharmacy that I won't pay you back for despite them being expensive?") and it gives them control over a part of life that it's possible to control. It's rewarding to know you can influence your life. In this case, it's rewarding to know that taking medications improves life so dramatically.

It honestly starts to feel like I'm teaching or parenting every time I set the expectation that, despite it being easy for me to just order refills for someone online, I will let medication management be this person's thing for as long as possible. I am getting really fed up that there are no consequences I can levy if this person does a terrible job taking care of medications and makes noises like "this would never happen if you just took care of me!" I think that's the real trap of being sandwiched between elders and children, caring for both. You have to set boundaries and expectations and clearly divide up jobs, but there are few consequences you as child/grandchild/niece get to give to your elder if they behave badly.

Not that I'm totally convinced that giving misbehavior a consequence is convincing my kid to behave one bit better. Maybe it does but mostly I think that well-timed, brief, loud expressions of my feelings about something she did that was out of line seem to work better. Example: we had a several month stretch where she would get frustrated, be sent to her room "until she was steady," and would get upstairs and immediately start throwing things down at us. Most of the things in the girls' room aren't breakable so it was mostly annoying and irritating. Her consequence was to have to come pick up all the things she had thrown (which entailed much whining and complaining and more throwing of the very same things) and then losing some privilege (TV the next day, story before bed, dessert, TV the next day, a trip planned for the weekend, etc). One day she actually broke a thing and hit me in the head doing it while I stood at the bottom of the stairs listening to hear her actually step into her room. I yelled that I was very upset because she was disrespecting property, that she hurt me by throwing the thing, that it was now ruined and she wouldn't get a new one, if anything else was thrown down the stairs it was going straight into the trash, and that she had lost TV for the week and was also not allowed to play outside of our back yard for the same week.

Since then, she's thrown things down the stairs maybe twice and we haven't made her clean up the things but I did discard them all (I think it was some flashcards or crayons or something). The throwing hasn't been aimed at anyone's head and nothing heavy has been thrown. When she cooled down that first time, we talked about how to use words and explain what was wrong and to use words even if she didn't know what was wrong to say she was upset. Some of that has helped but mostly we established a firm boundary (this behavior is NOT acceptable) and she recognized that no further testing was needed.

Adults though, they know your weaknesses implicitly enough to exploit them and to know that it's hard to keep up a new boundary. Maybe that's just my family, but it is so hard to have my new boundaries poked at all the time. That's really what makes it so hard to be sandwiched, that the boundaries are shifting and the aging parent has to allow more care (and hopefully confess what's really going on) while the adult child has to figure out where to set the boundary for how much care can be given before it's too much.

Monday, September 29, 2014

Meditations on "first, do no harm"

I've been wondering lately if it makes me either a bad person or a terrible almost-pharmacist (or both) if I think death would be the most humane outcome for a patient. 

I would like to take a moment to frame this musing with a patient vignette. His is a totally made-up story but it reminds me of a number of patients I have cared for already. The patient is in his 30s, has a traumatic car wreck but walks away unscathed... until a few days later when massive internal bleeding is discovered in the ER when he turns up dizzy and then stops breathing. But despite what becomes a sudden cardiac arrest, he lives. Kind of. He can't swallow or breathe alone or respond to the world, has constant seizures that require him to be restrained, and shows zero improvement after a month in the hospital. Or maybe she's in her late 70s, has a big blood clot in her lungs and loses consciousness a few minutes before her daughter finds her. The clot was caused by cancer. She has been in a coma for 3 weeks and the family wants aggressive chemo. Or maybe he is in his late 60s, just had a third heart attack, and is now taking 15 medications a day to combat heart failure but is not improving and his decline is only marginally being slowed by all the medications and the frequent short trips to the hospital.

I should also add that my routine is to pray and/or think good thoughts about every patient I come across every day with every prescription I fill and every one I hand out. It helps me keep it in perspective, that everything I do counts and is for someone with a family and friends who matters. This gives me a lot of opportunities to think about what would be the best outcome (I hope this patient gets better or gets to go home or isn't in pain any more or gets a good diagnosis soon or... dies soon so the suffering ends?).

When we enter a healthcare profession, there's a code of honor or ethics or whatever it's called in that profession. Here's a copy of the Pharmacists' Oath. http://www.pharmacist.com/oath-pharmacist I often think about the Hippocratic Oath too, the Declaration of Geneva being the modern version that I find keeps the spirit of the original well. http://www.wma.net/en/30publications/10policies/g1/ Of course I also consider the idea that in the health professions, we might want to  or ought to "first do no harm."

I worry that too often we get busy doing everything we can to extend life and we forget to consider what kind of life it is we are extending. If it's a life that requires multiple machines to permanently sustain and there's no ability to interact with the world, I'm not sure it is one I want for anyone. In some ways I'm disappointed that any ethics committee anywhere lets families lobby for this. In other ways, I get it. It's hard to think about death and harder still to accept that the time for letting death happen has come for someone you love. But I keep asking myself if we are harming patients and their families by preventing death at such great lengths with such extraordinary measures. (You will note that I don't mention about if we should offer assisted suicide to terminal patients, and I think that's a separate issue and maybe I'll write about that eventually but not now.)

This year for the Festive Winter Holiday, I'm asking my extended family for copies of their advanced directives and living wills. I don't want to find myself sitting in a hospital room with an almost-dying loved one who had a stroke and not know if they want the full court press to live the maximum number of days even with some or severe cognitive impairment or if they'd rather have no intervention and jut be allowed to die. I don't have lots of siblings or siblings-in-laws to consult about parents and grandparents or each other if we have really bad luck. I spent many hours considering my choices about what I want and what I'd want for my girls if I were unable to make decisions for them and they were still under 18. Now that I have seen more patients with end of life stalling interventions, I am updating a few things but for the most part, I'm feeling secure in my choices. I want no treatments that extend my life unless they extend my capacity to be me as well. I want only palliative care if I have stage 4 cancer or a cancer with a low increased survival with treatment. If there is no chance of recovering nearly all of my mental faculties, I want no feeding tube or ventilator.

But above all, I hope that we all talk more about the choices we can make at the end of life and that we do so well in advance of needing to make them so it's simpler and family and friends don't have to feel guilty if they don't demand full code (all the resuscitation possible) for a patient who is unconscious, on dialysis, a ventilator, and has a feeding tube permanently placed.

If you are curious about how to write a legal document for your state, here is a link to a wealth of resources that can help you and your loved ones puzzle through it all. If there's one thing I've learned from working in hospital and clinic pharmacies, it's that it is never too soon to consider what you want the end of your life to look like because it might come remarkably soon. http://www.nhdd.org/public-resources