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


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. 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. 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.

Saturday, September 27, 2014

Firsts, lasts, and middles

Last Sunday as we left a building to go retrieve the kid and spouse from a nearby playground via the parking lot, I asked Little Monster to hold my hand. Just like that, she did. She held on tight and walked beside me across the parking lot and down the path to the playground.

I got a first out of her. Most of her firsts have been shared between us parents or ignored while I was busy or happened at daycare but this time, just me. I bet if I asked around she's done this before but it was a little triumph anyway. First time walking In the parking lot holding my hand.

This evening I was tampering with something on the computer and I heard someone say "hi mommy" just out of sight over my shoulder. I turned and started to say "hi there Kid" but saw Little Monster instead. Sneaky baby, growing into a toddler. She owns a tiny plastic potty now and she can drink from a real cup and eat ice cream with a spoon and little mess.

It's easy to see now that there are so many lasts piling up too. Last time she calls a fox KITTY! Last time she screams about a bath (now she demands them often and splashes with glee). As cute as it is that she has mixed up "on," "off," "down," and "up," I'm not sure I will miss her shouting OFF! while struggling to zip her sweatshirt or put on socks. The hands outstretched to reach for me while shouting "down, Mommy?" will certainly be missed though.

It's interesting because I don't see any leaps in the kid's development lately. She's plowing along toward reading and adds a couple of words a week but no leap yet. Practicing her violin was too boring and yet too hard and there was never a proper time for it so we've given up for a bit. I keep hoping today is the last time she does one of her infuriating things (you know the things that make you nuts about your 3 year old? All that stuff only she's taller, stronger, and has more words to argue) but I'm sure it won't be so I'd be content to stretch the interval between moments.

I'm in the middle of rotations and it's scary how fast it's all going by. From this end I might buy the "oh, pharmacy school went so fast!" story I've heard from many pharmacists. Maybe. I suppose it's like parenting a preschooler. The hours take forever but the months fly by. I'm trying to gather all the lists of things I need to do and lists I need to make so I can try to keep it together. It isn't working so I'm going back to keeping my head above water. This next rotation is absolutely out of town so that's exciting and terrifying and all levels of panic to elation.

Thursday, September 4, 2014

Hidden work or why I can be abnormally stressed

Let's talk about hidden work. When you are in the realms of parenting especially but really any long-term relationship where you are both working toward a common goal, there is the risk of doing hidden work. There isn't any complex definition to hidden work as it's defined in the social science literature beyond "work that goes unrecognized by those who aren't doing it." Usually in parenting hidden work describes all the things that (stereotypically) are done by women that men seem totally surprised need doing.

A good example from my life is scheduling well child visits. I keep track of them for the most part by entering them in my digital calendar and inviting my spouse to them. I have been away from home more or less from May until August and didn't attend Little Monster's 15 month appointment back in May so I didn't schedule her 18 month appointment afterward. With the kid I usually took her to well child visits by myself since usually my spouse was working, and with Little Monster we have gone together up until the 15 month appointment during which I was working (my spouse was very underemployed last year and thus had plenty of time to come with). I had never explicitly stated that at the end of every well child visit, I walked over and scheduled the next well child appointment. I just always did that, and for what is still a majority of the well child visits our girls have attended, I did it with nobody else knowing it's what I always did. It was hidden work from the other person in the relationship who needed to be working on the same parenting project as me. As you might imagine, I mentioned when Little Monster was 17 months old that I was curious about when her 18 month appointment was since I'd be in town then and might be able to attend it if it were in the afternoon... and there was no appointment yet. It meant that she just had that visit this week when she is now 18.75 months old. Is that the end of the world? No. But it's representative of the sort of trouble a lot of couples run into.

For us specifically, playing Chore Wars is a way for us to explore ALL the work and to make it all explicit. We don't have much hidden work but it's important that we keep working at it so we are both aware of the silent contributions the other person is making to keep things going smoothly. The other night, the baby woke up and I slept through it (nights aren't my thing because I get up much earlier than my spouse so I wouldn't have gotten up even if I had known she was up). Without a way to communicate that happened, I would never have known that Little Monster held a baby party from 1am to 1:40am in the living room. We have a weekly family meeting now where we all share something that's going well, something that could go better, and something we personally are going to improve. This week we've split it so I should be emptying the dishwasher and my spouse should be loading it. I actually think we need a white board where we write what everyone is doing to improve this week so we don't lose sight of it.

I have heard from a variety of folks that my spouse and I have such a good relationship. From my seat inside it, I'd say it's pretty typical and nothing especially great. We struggle just like everyone else but in different ways, some of which won't be appearing on this blog, most of which are about our non-traditional division of labor and how weird that is for everyone else. What is different about our relationship compared to those around us is that we have very little hidden work so nobody feels like they get no recognition for the great things they do. When you earn points for doing the dishes, it adds a little oomph to get it done AND your spouse knows you did it, even if there is no evidence. Say I empty the dishwasher and then reload it and then run it again before my spouse gets home from an evening meeting or my spouse does the same while I'm at work one day. Without Chore Wars, it's easy for my spouse to completely miss that I did anything because the dishwasher went from full of clean dishes to... still full of clean dishes! Obviously this means we need to be diligent and add all the parts of the various tasks we work at around the house to Chore Wars so we can record what we do. The reporting aspect keeps us accountable to each other as well.

It's my natural instinct to take on more hidden work than my spouse. I like to organize things and plan and have my living space tidy while my spouse values this much less and would rather relax. I have a hard time relaxing when it's a mess. This means that I have to be diligent about not hoarding that sort of job, that I have to let my spouse do some of it and trust that it will be done adequately even if it gets done totally differently than I had envisioned. We had our office full of boxes, with one wall floor to ceiling boxes from when we moved 2 years ago that was blocking a closet full of MORE boxes. I'd always meant to put shelves into the closet once the boxes were gone or to hold the things that were in the boxes, but my spouse decided to hang some sweater organizers and pile in some totes of stuff, and that's fine. It doesn't matter how that work of organizing the closet happened, just that it happened. PLUS the boxes are out of the office. It's a lovely space now that there's room to move without dodging the boxes. The danger of me taking on all of the work is twofold: if I don't get something done, nobody knows and so whatever it is can get to a critical level of neglect since nobody else is checking in, and I can make sure I never sleep while I get the house organized totally and spotlessly clean. Neither of those is good so it's important that I give up tasks. I explain all the steps I have been taking completely and don't assume my spouse will know one thing about how the job is done (there is much eye rolling usually but sometimes there's a moment of surprise where something I have been doing is explained and my spouse can then more fully do the job), then trust it will be done.

Trust is tricky and building it is still a work in progress (I ask if my spouse can do something, the response is affirmative, the thing is still not done after what I deem to be far too long, I point this out, it either gets done by me or my spouse... or we repeat). I still feel, despite getting let down often, that it's worth it to give up control of some things. We have a much happier relationship if I sleep and if we both pitch in to keep things running smoothly.